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Difficult to treat: are there organism-dependent differences and overall risk factors in success rates for two-stage knee revision?

  • Orthopaedic Surgery
  • Published:
Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript

Abstract

Objectives

Failure after two-stage procedure for periprosthetic joint infection (PJI) is a rare, but devastating complication. Some authors assume a correlation of underlying organisms and recurrence rate. Methicillin-resistant Staphylococci (MRS) and other organisms (quinolone-resistant Gram-negative bacteria, rifampicin-resistant Staphylococcus, Enterococcus, and Candida) are meant to be “difficult to treat” (DTT) with an inferior outcome for two-stage revision. In addition to the type of bacteria, some more risk factors seem to be present. The aim of this study was (1) to detect a difference of reinfection rates between reinfection-causing groups of bacteria [“difficult to treat” (DTT), “easy to treat” (ETT) and methicillin-resistant staphylococci (MRS)] after a two-stage procedure, and (2) find overall risk factors for reinfection in a standardized long (spacer insertion for at least 6 weeks) two-stage procedure for periprosthetic knee infection.

Methods

One hundred and thirty-seven two-stage revisions for periprosthetic knee infection were performed at one tertiary referral center. Finally, 96 patients could be included for analyses. Possible risk factors (comorbidities, prior surgery, etc.) and the types of organisms were documented. Quinolone-resistant Gram-negative bacteria, rifampicin-resistant Staphylococcus, Enterococcus, and Candida were classified as “difficult to treat” (DTT). Methicillin-resistant Staphylococci were summarized as “MRS”, all other organism are summarized as “easy to treat” (ETT). Statistical analyses included univariate analysis (t test, Fisher’s exact test, Chi square test) and logistic regression analysis.

Results

There were no statistical significant differences in recurrent infection rates between organism groups (DTT vs. ETT, p = 0.674; DTT vs. MRS, p = 0.705; ETT vs. MRS, p = 0.537). Risk factors seem to be “need of revision after first stage” (p = 0.019, OR 5.62) or completed second stage (p = 0.000, OR 29.07), numbers of surgeries (p = 0.028) and alcohol abuse (p = 0.019, OR 5.62).

Conclusions

Revision needed during or after a two-stage exchange, numbers of surgeries and alcohol abuse are risk factors for recurrence, a different recurrence rates between organism-groups cannot be shown. The absence of significant differences in recurrence rates points to the importance of the individuality of each periprosthetic infection case: a reduction of necessary surgeries (with a thorough debridement, appropriate antibiotic addition to spacers) and the control of comorbidities (alcohol abuse) appear to be essential components of a two-stage exchange.

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Authors and Affiliations

  1. Department of Orthopedic Surgery, RKU, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany

    Martin Faschingbauer, R. Bieger, T. Kappe, C. Weiner, T. Freitag & H. Reichel

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  1. Martin Faschingbauer
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  2. R. Bieger
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  3. T. Kappe
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  4. C. Weiner
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  6. H. Reichel
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Contributions

FM: planning/conception of the study, collection of data, analysis and interpretation, statistical analysis, writing and revising article; (orthopedic surgeon). WC: collection of data, analysis and interpretation, statistical analysis; (student). BR, KT, FT: collection of data, critical revision of the article; (orthopedic surgeons). RH: critical revision of the article, final approval of the article, overall responsibility; (surgeon in chief University of Ulm).

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Correspondence to Martin Faschingbauer.

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Conflict of interest

We certify that we have not signed any agreement with commercial interest related to this study, which would in any way limit publication of any and all data generated for the study or to delay publication for any reason. Dr. Faschingbauer reports personal fees from Deutsche Forschungsgemeinschaft (Research Fellowship, FA 1271/1-1, http://www.dfg.de), during the conduct of the study.

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The authors’ institutional review board approved this study.

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Faschingbauer, M., Bieger, R., Kappe, T. et al. Difficult to treat: are there organism-dependent differences and overall risk factors in success rates for two-stage knee revision?. Arch Orthop Trauma Surg 140, 1595–1602 (2020). https://doi.org/10.1007/s00402-020-03335-4

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  • DOI: https://doi.org/10.1007/s00402-020-03335-4

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