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Management of infected extremity endoprostheses: a systematic review

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Abstract

Background

Endoprosthetic reconstructions have become increasingly common in the setting of significant bone loss. Indications include revision arthroplasty, trauma, and reconstruction in the setting of primary malignancies or bony metastases. Although the use of endoprostheses has several advantages, they carry a high risk of infection. The purpose of this review is to determine the success rates of surgical management of infected endoprostheses.

Methods

The authors searched databases for relevant studies and screened in duplicate. Data extracted included overall infection rate, timing of infection, follow-up, isolated pathogen and operative treatment strategy, and subsequent failure rate. The overall quality of the evidence with the Methodological Index for non-randomized studies criteria.

Results

A total of 16 studies and 647 patients met the inclusion criteria. 400 patients had operative management and reported outcomes. Failure rates of patients undergoing debridement, antibiotics, and implant retention (DAIR) were 55.1%. Failure rates of patients who underwent one-stage revision were 45.5%. Failure rates of patients undergoing two-stage revision were 27.3%. Failure occurred at 31.4 months (range, 0–228) postoperatively.

Conclusions

Rates of periprosthetic joint infection remain high in endoprosthetic reconstructions. Although DAIR procedures were found to have a low success rate, they remain a reasonable option in acute infections given the morbidity of staged revisions. There is a lack of comparative data in the current literature and the heterogeneity and low level of evidence does not allow for between group comparisons of results.

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Availability of data and materials

Raw data can be made available upon request. The 276 search strategy is included in the "Appendix".

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Funding

No funding was received in the preparation of this manuscript.

Author information

Authors and Affiliations

  1. Northern Ontario School of Medicine, Thunder Bay, ON, Canada

    Nicholas Nucci

  2. Division of Orthopaedics, Department of Surgery, Center for Evidence-Based Orthopaedics, St. Joseph’s Hospital, McMaster University, Room G522, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada

    Aaron Gazendam, Michelle Ghert & David Wilson

  3. Michael G. Degroote School of Medicine, McMaster University, Hamilton, ON, Canada

    Kyle Gouveia

Authors
  1. Nicholas Nucci
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Contributions

All authors have made substantial contributions to all of the following: (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version to be submitted.

Corresponding author

Correspondence to Aaron Gazendam.

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Conflict of interest

M.G. reports consulting fees from Wright Medical, is on the editorial board of Clinical Orthopaedics and Related Research (CORR) Journal and is an executive committee member of the Musculoskeletal Tumor Society. All other authors (A.G., N.N., K.G., D.W.) report no conflicts of interest.

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Appendix

Appendix

Databases to be searched

  1. 1.

    Medline

  2. 2.

    Embase

  3. 3.

    Web of Science

Sample search strategy

  1. 1.

    Endoprosthesis

  2. 2.

    Megaprosthesis

  3. 3.

    Modular prosthesis

  4. 4.

    1 or 2 or 3

  5. 5.

    Infect*

  6. 6.

    5 or 6

  7. 7.

    Treatment

  8. 8.

    Management

  9. 9.

    8 or 9

  10. 10.

    4 and 7 and 10

  11. 11.

    Limit: Humans

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Nucci, N., Gazendam, A., Gouveia, K. et al. Management of infected extremity endoprostheses: a systematic review. Eur J Orthop Surg Traumatol 30, 1139–1149 (2020). https://doi.org/10.1007/s00590-020-02699-y

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  • DOI: https://doi.org/10.1007/s00590-020-02699-y

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