Skip to main content

Advertisement

SpringerLink
Log in

Repeat revision TKR for failed management of peri-prosthetic infection has long-term success but often require multiple operations: a case control study

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

Abstract

Background

Prosthetic joint infection (PJI) is associated with poor outcomes and catastrophic complications. The aim of this study was to present the outcomes of re-revision surgery for PJI of the knee following previous failed two-stage exchange arthroplasty.

Materials and methods

A retrospective analysis was performed of 32 patients who underwent re-revision knee arthroplasty, having already undergone at least one previous two-stage exchange for PJI with a minimum follow-up of two-years for alive patients. Outcomes were compared to a matched control of two-stage revisions for PJI of a primary knee replacement also containing 32 patients. Outcomes investigated were eradication of infection, re-operation, mortality and limb-salvage rate.

Results

Successful eradication of infection was achieved in 50% of patients following re-revision surgery, compared with 91% following two-stage exchange of primary knee replacement for PJI (p < 0.001). Fourteen (44%) patients required further re-operation compared with three (9%) patients in the primary group (p = 0.006). Amputation was performed in one case (3%) with thirteen patients (92%) who had infection controlled by debridement, antibiotics and implant retention (DAIR), further revision surgery or arthrodesis. Two patients died with infection (6%) and the long-term rate for infection control was 91%. The mean number of procedures following surgery for the re-revision group was 2.8 (0–9) compared with 0.13 (0–1) for the primary two-stage group (p < 0.001). Five-year patient survival was 90.6% (95% CI 77.1–100). The limb-salvage rate for the re-revision cohort was 97%.

Conclusion

Outcomes for re-revision knee arthroplasty for PJI have higher re-operation and failure rates, but no worse mortality than in revisions of primary knee replacements. Failures can successfully be managed by further operation.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. No authors listed: National joint registry: 16th Annual report, 2019. https://reports.njrcentre.org.uk/Portals/0/PDFdownloads/NJR%2016th%20Annual%20Report%202019.pdf

  2. Kurtz S, Ong K, Lau E, Mowat F, Halpern M (2007) Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 89(4):780–785

    Article  PubMed  Google Scholar 

  3. Natsuhara K, Shelton T, Meehan J, Lum Z (2019) Mortality During Total Hip Periprosthetic Joint Infection. J Arthroplasty 34(7S):S337–S342

    Article  PubMed  Google Scholar 

  4. Bongers J, Jacobs AME, Smulders K, Van Hellemondt GG, Goosen JHM (2020) Reinfection and re-revision rates of 113 two-stage revisions in infected TKA. J Bone Jt Infect 5(3):137–144

    Article  PubMed  PubMed Central  Google Scholar 

  5. Zmistowski B, Karam J, Durinka J, Casper D, Parvizi J (2013) Periprosthetic joint infection increases the risk of one-year mortality. J Bone Joint Surg Am 95(24):2177–2184. https://doi.org/10.2106/JBJS.L.00789

    Article  PubMed  Google Scholar 

  6. Yu S, Bolz N, Buzza J, Saleh H, Murphy H, Rathod P et al (2018) Re-revision total knee arthroplasty: Epidemiology and factors associated with outcomes. Orthop Proc. 99-B(Suppl):6

    Google Scholar 

  7. Gundtoft P, Pedersen A, Varnum C, Overgaard S (2017) Increased mortality after prosthetic joint infection in primary THA. Clin Orthop Relat Res 475:2623–2631

    Article  PubMed  PubMed Central  Google Scholar 

  8. Li C, Renz N, Trampuz A (2018) Management of prosthetic joint infection. Hip Pelvis 30(3):138–146

    Article  PubMed  PubMed Central  Google Scholar 

  9. Parkinson RW, Kay PR, Rawal A (2011) A case for one-stage revision in infected total knee arthroplasty? Knee 18:1–4

    Article  PubMed  Google Scholar 

  10. Marchant MH Jr, Viens NA, Cook C, Vail TP, Bolognesi MP (2009) The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty. J Bone Joint Surg Am 91(7):1621–1629

    Article  PubMed  Google Scholar 

  11. Cochran A, Ong K, Lau E, Mont M, Malkani A (2016) Risk of reinfection after treatment of infected total knee arthroplasty. J Arthroplasty 31(9 Suppl):156–161

    Article  PubMed  Google Scholar 

  12. Osmon DR, Berbari EF, Berendt AR et al (2013) Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the infectious diseases society of America. Clin Infect Dis 56:e1–e25

    Article  PubMed  Google Scholar 

  13. Romano CL, Gala L, Logoluso N, Romano D, Drago L (2012) Two-stage revision of septic knee prosthesis with articulating knee spacers yields better infection eradication rate than one- stage or two-stage revision with static spacers. Knee Surg Sports Traumatol Arthrosc 20(12):2445–2453

    Article  CAS  PubMed  Google Scholar 

  14. Workgroup Convened by Musculoskeletal Infection Society (2011) New definition for periprosthetic joint infection. JArthroplasty 26:1136–1138

    Article  Google Scholar 

  15. Diaz-Ledezma C, Higuera C, Parvizi J (2013) Success after treatment of periprosthetic joint infection: a delphi-based international multidisciplinary consensus. Clin Orthop Relat Res 471(7):2374–2382

    Article  PubMed  PubMed Central  Google Scholar 

  16. Magiorakos A, Srinivasan A, Carey R, Carmeli Y, Falagas M, Giske C, Harbarth S (2012) Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect 18(3):268–281

    Article  CAS  PubMed  Google Scholar 

  17. Chalson ME, Pompei P, Ales KL et al (1987) A new method of classifying prognostic co-morbidity in longitudinal studies: development and validation. J Chronic Dis 40(5):373–383

    Article  Google Scholar 

  18. Azzam K, McHale K, Austin M, Purtill JJ, Parvizi J (2009) Outcome of a second two-stage reimplantation for periprosthetic knee infection. Clin Orthop Relat Res 467(7):1706–1714

    Article  PubMed  PubMed Central  Google Scholar 

  19. Jamsen E, Huhtala H, Puolakka T, Moilanen T (2009) Risk factors for infection after knee arthroplasty. A register-based analysis of 43,149 cases. J Bone Joint Surg Am. 91(1):38–47

    Article  PubMed  Google Scholar 

  20. Parvizi J, Zmistowski B, Adeli B (2010) Periprosthetic joint infection: treatment options. Orthopedics 33(9):659

    Article  PubMed  Google Scholar 

  21. Kubista B, Hartzler RU, Wood CM, Osmon DR, Hanssen AD, Lewallen DG (2012) Reinfection after two-stage revision for periprosthetic infection of total knee arthroplasty. Int Orthop 36(1):65–71

    Article  PubMed  Google Scholar 

  22. Kheir MM, Tan TL, Gomez MM, Chen AF, Parvizi J (2017) Patients with failed prior two-stage exchange have poor outcomes after further surgical intervention. J Arthroplasty 32:1262–1265

    Article  PubMed  Google Scholar 

  23. Ibrahim M, Raja S, Khan M, Haddad F (2014) A multidisciplinary team approach to two-stage revision for the infected hip replacement: a minimum five-year follow-up study. Bone Joint J. 96-B(10):1312–1318

    Article  CAS  PubMed  Google Scholar 

  24. Mortazavi J, Vegari D, Ho A, Zmistowski B, Parvizi J (2011) Two-stage exchange arthroplasty for infected total knee arthroplasty: predictors of failure. Clin Orthop Relat Res 469(11):3049–3054

    Article  PubMed  PubMed Central  Google Scholar 

  25. Sadique H, Evans S, Parry M et al (2016) Multidrug-resistant bacteria: an independent predictor of failure in peri-prosthetic joint infection. Bone Joint J 98-B(Supp 23):11

    Google Scholar 

  26. Son M, Lau E, Parvizi J et al (2017) What are the frequency, associated factors, and mortality of amputation and arthrodesis after a failed infected TKA? Clin Orthop Relat Res 475(12):2905–2913

    Article  PubMed  PubMed Central  Google Scholar 

  27. Barton CB, Wang DL, An Q, Brown TS, Callaghan JJ, Otero JE (2019) Two-stage exchange arthroplasty for periprosthetic joint infection following total hip or knee arthroplasty is associated with high attrition rate and mortality. J Arthroplasty S0883–5403(19):31137–31144

    Google Scholar 

  28. American Cancer Society. Cancer facts and figures 2020. 2020. http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/ document/acspc-031941.pdf. Accessed 2020 May 17.

  29. Singh J, Yu S, Chen L, Cleveland J (2019) Rates of total joint replacement in the United States: future projections to 2020–2040 using the national inpatient sample. J Rheumatol 46(9):1134–1140

    Article  PubMed  Google Scholar 

  30. Podmore B, Hutchings A, van der Meulen J, Aggarwal A, Konan S (2018) Impact of comorbid conditions on outcomes of hip and knee replacement surgery: a systematic review and meta-analysis. BMJ Open 8(7):e021784

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Funding

No funding was received for conducting this study.

Author information

Authors and Affiliations

  1. Trauma and Orthopaedic Registrar, The Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Northfield, Birmingham, B31 2AP, UK

    Harshad Rajgor, Huan Dong & Raj Nandra

  2. Consultant Orthopaedic Oncology and Arthroplasty Surgeon, The Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Northfield, Birmingham, B31 2AP, UK

    Michael Parry, Jonathan Stevenson & Lee Jeys

  3. Senior Clinical Lecturer, Aston University Medical School, Aston University, Birmingham, UK

    Michael Parry & Jonathan Stevenson

  4. Professor of Life Sciences, Aston University, Birmingham, UK

    Lee Jeys

Authors
  1. Harshad Rajgor
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Huan Dong
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Raj Nandra
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Michael Parry
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jonathan Stevenson
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Lee Jeys
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

HR: collected and analysed the data, wrote the manuscript. HD: collected and analysed the data, wrote the manuscript. RN: collected and analysed the data, wrote the manuscript. MP: edited the manuscript. JDS: initiated the project, collected and analysed the data, edited the manuscript. LJ: edited the manuscript.

Corresponding author

Correspondence to Jonathan Stevenson.

Ethics declarations

Conflict of interest

JD Stevenson: British orthopaedic oncology society executive board member L Jeys: Paid speaker for Zimmer, Stryker, Implantcast and Depuy. Paid consultant for Zimmer and Implantcast. All other authors have no competing interests to declare that are relevant to the content of this article.

Ethical approval

The study was approved by our institution (Royal Orthopaedic Hospital Birmingham—reference number 19–010).

Informed consent

No consent was required as this was a retrospective review with no patient identifiable information used.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Rajgor, H., Dong, H., Nandra, R. et al. Repeat revision TKR for failed management of peri-prosthetic infection has long-term success but often require multiple operations: a case control study. Arch Orthop Trauma Surg 143, 987–994 (2023). https://doi.org/10.1007/s00402-022-04594-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00402-022-04594-z

Keywords

Search

Navigation