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Failure analysis of infection persistence after septic revision surgery: a checklist algorithm for risk factors in knee and hip arthroplasty

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

Abstract

Purpose

Several studies describe risk factors for primary periprosthetic joint infection (PJI) and general treatment outcome factors like microbe spectrum or patient-specific risk factors. However, these general and patient dependent findings cannot solely explain all cases of infection persistence after a prior septic revision. This study analyzes possible specific and patient independent reasons for failure after revisions for PJI in knee and hip arthroplasty.

Methods

In a prospective analysis all patients were included that were treated: (1) at our department, (2) with a two-stage exchange, (3) between 2013 and 2017, (4) due to an infection persistence after a previous revision for PJI. Possible reasons for infection persistence were identified using a checklist algorithm, based on international guidelines.

Results

70 patients with infection persistence could be included (44 knee joints, 26 hip joints). The average age was 71 years, the CCI (Charlson Comorbidity Index) 2.8 and the ASA (American Society of Anesthesiologists) score 2.7. In 85% at least one possible reason for patient independent infection persistence could be identified analyzing the previous infection therapy: (1) 50% inadequate therapy concept (n = 35), (2) 33% inadequate surgical debridement (n = 23), (3) 30% inadequate antimicrobial therapy (n = 21), (4) 13% missed external bacterial primary focus (n = 9). After the individual failure analysis, all 70 patients were treated with a two-stage exchange in our department and in 94.9% infection freedom could be achieved (34.3 ± 10.9 months follow-up).

Conclusions

In the majority of failed revisions with subsequent infection persistence at least one possible patient independent failure cause could be identified. The entire previous therapy should be critically reviewed following failing revisions to optimize the outcome of septic revisions. By using a checklist algorithm, high rates of infection freedom were achieved.

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Author notes

  1. Sofia Kilgus and Daniel Karczewski contributed equally to this work

Authors and Affiliations

  1. Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité-Universitaetsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany

    Sofia Kilgus, Daniel Karczewski, Cindy Passkönig, Tobias Winkler, Doruk Akgün, Carsten Perka & Michael Müller

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  1. Sofia Kilgus
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  2. Daniel Karczewski
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  3. Cindy Passkönig
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  4. Tobias Winkler
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  5. Doruk Akgün
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  6. Carsten Perka
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  7. Michael Müller
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Contributions

SK, DK, MM: Writing the manuscript and statistical analysis; SK, CP, MM: Acquiring the primary data; SK, DK, TW, DA, CP, MM: Internal review and involvement in septic surgery department.

Corresponding author

Correspondence to Daniel Karczewski.

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The authors have no conflict of interest to report. No specific funding was received. Each author certifies that he or she has no commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements) that might pose a conflict of interest in connection with the submitted article.

Ethical approval

All studies to have been performed in accordance with the ethical standards in the 1964 Declaration of Helsinki. All studies were carried out in accordance with relevant regulations of the US Health Insurance Portability and Accountability Act (HIPAA).

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Kilgus, S., Karczewski, D., Passkönig, C. et al. Failure analysis of infection persistence after septic revision surgery: a checklist algorithm for risk factors in knee and hip arthroplasty. Arch Orthop Trauma Surg 141, 577–585 (2021). https://doi.org/10.1007/s00402-020-03444-0

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