An often-unrecognized entity as cause of recurrent infection after successfully treated two-stage exchange arthroplasty: hematogenous infection
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Reinfection after two-stage exchange arthroplasty is a difficult clinical scenario with limited data on adequate treatment algorithms. Beside the possibility of treatment failure and a new intraoperative infection at the time of reimplantation, hematogenous seeding could play an up to date underestimated crucial role as another cause of an infection after two-stage exchange. The aim of this study was to evaluate its incidence and treatment possibilities in a prospectively followed case series.
All consecutive hip and knee periprosthetic joint infection cases (93 hips and 89 knees) treated according to a standardized diagnostic and therapeutic algorithm at our institution with a two-stage exchange arthroplasty from 2013 to 2015 were included and followed prospectively to identify recurrent infections due to hematogenous seeding.
Six percent from our septic revision hip and knee arthroplasties (11 of 182, including 5 hips and 6 knees) were identified with a hematogenous reinfection after a mean follow-up of 31.8 months (range 14–48 months). The mean time to reinfection after reimplantation was 12.2 months (range 3.1–35.1). In all but two cases was the causative microorganism different than isolated at the time of initial two-stage exchange. In 5 of 11 patients, the primary focus of infection was identified.
Hematogenous infection after a successful two-stage exchange arthroplasty is a rare but very important cause of a reinfection. With our work, we aim at raising the awareness for this entity and recommend consideration of irrigation and debridement with implant retention in these cases, as well as possibly the identification of a primary infection source.
KeywordsHematogenous Periprosthetic joint infection Two-stage exchange arthroplasty Failure
DA: designing the study, data analysis, and drafting paper. CP: critically revising paper and approval of the final version. MM: interpretation of data, critically revising paper, and approval of the final version. TW: interpretation of data, critically revising paper, and approval of the final version.
- 13.Ochsner PEBO., Bodler PM, Broger I, Eich G, Hefti F, Maurer T, Nötzli H, Seiler S, Suva D, Trampuz A, Uckay I, Vogt M, Zimmerli W (2016) Infections of the musculoskeletal system. Basic principles, prevention, diagnosis and treatment. Swiss orthopaedics in-house publisher, GrandvauxGoogle Scholar
- 14.Akgun D, Trampuz A, Perka C, Renz N (2017) High failure rates in treatment of streptococcal periprosthetic joint infection: results from a seven-year retrospective cohort study. Bone Jt J 99-B(5):653–659. https://doi.org/10.1302/0301-620X.99B5.BJJ-2016-0851.R1 CrossRefGoogle Scholar
- 16.Akgun D, Muller M, Perka C, Winkler T (2017) A positive bacterial culture during re-implantation is associated with a poor outcome in two-stage exchange arthroplasty for deep infection. Bone Jt J 99-B(11):1490–1495. https://doi.org/10.1302/0301-620X.99B11.BJJ-2017-0243-R1 CrossRefGoogle Scholar
- 17.Krenn V, Morawietz L, Perino G, Kienapfel H, Ascherl R, Hassenpflug GJ, Thomsen M, Thomas P, Huber M, Kendoff D, Baumhoer D, Krukemeyer MG, Natu S, Boettner F, Zustin J, Kolbel B, Ruther W, Kretzer JP, Tiemann A, Trampuz A, Frommelt L, Tichilow R, Soder S, Muller S, Parvizi J, Illgner U, Gehrke T (2014) Revised histopathological consensus classification of joint implant related pathology. Pathol Res Pract 210(12):779–786. https://doi.org/10.1016/j.prp.2014.09.017 CrossRefPubMedGoogle Scholar
- 18.Rodriguez D, Pigrau C, Euba G, Cobo J, Garcia-Lechuz J, Palomino J, Riera M, Del Toro MD, Granados A, Ariza X, Group R (2010) Acute haematogenous prosthetic joint infection: prospective evaluation of medical and surgical management. Clin Microbiol Infect 16(12):1789–1795. https://doi.org/10.1111/j.1469-0691.2010.03157.x CrossRefPubMedGoogle Scholar
- 22.Bejon P, Berendt A, Atkins BL, Green N, Parry H, Masters S, McLardy-Smith P, Gundle R, Byren I (2010) Two-stage revision for prosthetic joint infection: predictors of outcome and the role of reimplantation microbiology. J Antimicrob Chemother 65(3):569–575. https://doi.org/10.1093/jac/dkp469 CrossRefPubMedPubMedCentralGoogle Scholar
- 25.Martinez-Pastor JC, Munoz-Mahamud E, Vilchez F, Garcia-Ramiro S, Bori G, Sierra J, Martinez JA, Font L, Mensa J, Soriano A (2009) Outcome of acute prosthetic joint infections due to gram-negative bacilli treated with open debridement and retention of the prosthesis. Antimicrob Agents Chemother 53(11):4772–4777. https://doi.org/10.1128/AAC.00188-09 CrossRefPubMedPubMedCentralGoogle Scholar
- 26.Fink B, Schuster P, Schwenninger C, Frommelt L, Oremek D (2017) A standardized regimen for the treatment of acute postoperative infections and acute hematogenous infections associated with hip and knee arthroplasties. J Arthroplasty 32(4):1255–1261. https://doi.org/10.1016/j.arth.2016.10.011 CrossRefPubMedGoogle Scholar
- 28.Uckay I, Lubbeke A, Emonet S, Tovmirzaeva L, Stern R, Ferry T, Assal M, Bernard L, Lew D, Hoffmeyer P (2009) Low incidence of haematogenous seeding to total hip and knee prostheses in patients with remote infections. J Infect 59(5):337–345. https://doi.org/10.1016/j.jinf.2009.08.015 CrossRefPubMedGoogle Scholar
- 33.Murgier J, Laffosse JM, Cailliez J, Cavaignac E, Murgier P, Bayle-Iniguez X, Chiron P, Bonnevialle P (2016) Is the prognosis the same for periprosthetic joint infections due to Staphylococcus aureus versus coagulase-negative staphylococci? A retrospective study of 101 patients with 2-year minimum follow-up. Arch Orthop Trauma Surg 136(10):1357–1361. https://doi.org/10.1007/s00402-016-2533-6 CrossRefPubMedGoogle Scholar
- 35.Balato G, Franceschini V, Ascione T, Lamberti A, Balboni F, Baldini A (2018) Diagnostic accuracy of synovial fluid, blood markers, and microbiological testing in chronic knee prosthetic infections. Arch Orthop Trauma Surg 138(2):165–171. https://doi.org/10.1007/s00402-017-2832-6 CrossRefPubMedGoogle Scholar
- 36.Parvizi J, Zmistowski B, Berbari EF, Bauer TW, Springer BD, Della Valle CJ, Garvin KL, Mont MA, Wongworawat MD, Zalavras CG (2011) New definition for periprosthetic joint infection: from the workgroup of the musculoskeletal infection society. Clin Orthop Relat Res 469(11):2992–2994. https://doi.org/10.1007/s11999-011-2102-9 CrossRefPubMedPubMedCentralGoogle Scholar
- 37.Lisboa T, Seligman R, Diaz E, Rodriguez A, Teixeira PJ, Rello J (2008) C-reactive protein correlates with bacterial load and appropriate antibiotic therapy in suspected ventilator-associated pneumonia. Crit Care Med 36(1):166–171. https://doi.org/10.1097/01.CCM.0000297886.32564.CF CrossRefPubMedGoogle Scholar