Skip to main content

Advertisement

SpringerLink
Log in

Prosthesis Failure Within 2 Years of Implantation Is Highly Predictive of Infection

  • Clinical Research
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

The outcome of revision surgery depends on accurate determination of the cause of prosthesis failure because treatment differs profoundly among aseptic loosening, mechanical failure, and prosthetic joint infections (PJI).

Questions/purposes

We sought to determine (1) the predictive role of the interval from primary to revision surgery in determining the reason for prosthesis failure of a hip, knee, shoulder, or elbow arthroplasty, and (2) whether positive cultures during revision surgery for aseptic loosening were associated with shorter event-free survival of the prosthesis.

Methods

All patients undergoing revision surgery between July 2010 and January 2012 were included in a prospective cohort of 112 patients, and were classified as having had failure from aseptic loosening (56%), mechanical failure (15%), or PJI (29%). To make the diagnosis of PJI, at surgery we used a standardized enhanced diagnostic approach in all patients including sampling of five periprosthetic tissue specimens, sonication of removed prosthetic components, prolonged incubation of aerobic and anaerobic cultures, and multiplex PCR of sonication fluid in aseptic loosening cases. Kaplan-Meier survival and Cox proportional hazards regression analysis were performed.

Results

The median time from primary to revision surgery was (p < 0.001) longer for patients with aseptic loosening (7.8 years) than for patients with mechanical failure (1.6 years) or PJI (2 years). No difference in the time to revision was observed for patients with aseptic loosening with positive or negative microbiological cultures (p = 0.594). Propionibacterium acnes was cultured below the established microbiological criteria for positivity in 12 (19%) procedures that had been presumed to have been revisions for aseptic loosening.

Conclusions

PJI should be considered in all revisions performed within 2 years of implantation even in the absence of clinical or laboratory findings suggestive for infection. However, the growth of low-virulence microorganisms below the cut-off in revisions for apparent aseptic loosening is not associated with early prosthesis failure.

Level of Evidence

Level II, diagnostic study. See the Instructions for Authors for a complete description of levels of evidence.

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

Similar content being viewed by others

References

  1. Achermann Y, Vogt M, Leunig M, Wust J, Trampuz A. Improved diagnosis of periprosthetic joint infection by multiplex PCR of sonication fluid from removed implants. J Clin Microbiol. 2010;48:1208–1214.

    Article  PubMed  Google Scholar 

  2. Bori G, Soriano A, Garcia S, Gallart X, Casanova L, Mallofre C, Almela M, Martinez JA, Riba J, Mensa J. Low sensitivity of histology to predict the presence of microorganisms in suspected aseptic loosening of a joint prosthesis. Mod Pathol. 2006;19:874–877.

    PubMed  Google Scholar 

  3. Corvec S, Portillo ME, Pasticci BM, Borens O, Trampuz A. Epidemiology and new developments in the diagnosis of prosthetic joint infection. Int J Artif Organs. 2012:35:923–934.

    PubMed  Google Scholar 

  4. Del Pozo JL, Patel R. Clinical practice: infection associated with prosthetic joints. N Engl J Med. 2009;361:787–794.

    Article  PubMed  Google Scholar 

  5. Della Valle C, Parvizi J, Bauer TW, DiCesare PE, Evans RP, Segreti J, Spangehl M, Watters WC 3rd, Keith M, Turkelson CM, Wies JL, Sluka P, Hitchcock K; American Academy of Orthopaedic Surgeons. American Academy of Orthopaedic Surgeons clinical practice guideline on: the diagnosis of periprosthetic joint infections of the hip and knee. J Bone Joint Surg Am. 2011;93:1355–1357.

    Google Scholar 

  6. Dodson CC, Craig EV, Cordasco FA, Dines DM, Dines JS, Dicarlo E, Brause BD, Warren RF. Propionibacterium acnes infection after shoulder arthroplasty: a diagnostic challenge. J Shoulder Elbow Surg. 2010;19:303–307.

    Article  PubMed  Google Scholar 

  7. Harris WH. The problem is osteolysis. Clin Orthop Relat Res. 1995;311:46–53.

    PubMed  Google Scholar 

  8. Havelin LI, Engesaeter LB, Espehaug B, Furnes O, Lie SA, Vollset SE. The Norwegian Arthroplasty Register: 11 years and 73,000 arthroplasties. Acta Orthop Scand. 2000;71:337–353.

    Article  PubMed  CAS  Google Scholar 

  9. Holinka J, Bauer L, Hirschl AM, Graninger W, Windhager R, Presterl E. Sonication cultures of explanted components as an add-on test to routinely conducted microbiological diagnostics improve pathogen detection. J Orthop Res. 2011;29:617–622.

    Article  PubMed  Google Scholar 

  10. Ince A, Rupp J, Frommelt L, Katzer A, Gille J, Lohr JF. Is “aseptic” loosening of the prosthetic cup after total hip replacement due to nonculturable bacterial pathogens in patients with low-grade infection? Clin Infect Dis. 2004;39:1599–1603.

    Article  PubMed  CAS  Google Scholar 

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

    Article  PubMed  Google Scholar 

  12. Kelly JD 2nd, Hobgood ER. Positive culture rate in revision shoulder arthroplasty. Clin Orthop Relat Res. 2009;467:2343–2348.

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  14. Kurtz SM, Ong KL, Schmier J, Mowat F, Saleh K, Dybvik E, Karrholm J, Garellick G, Havelin LI, Furnes O, Malchau H, Lau E. Future clinical and economic impact of revision total hip and knee arthroplasty. J Bone Joint Surg Am. 2007;89(suppl 3):144–151.

    Article  PubMed  Google Scholar 

  15. Malchau H, Herberts P, Eisler T, Garellick G, Soderman P. The Swedish Total Hip Replacement Register. J Bone Joint Surg Am. 2002;84(suppl 2):2–20.

    PubMed  Google Scholar 

  16. Moran E, Byren I, Atkins BL. The diagnosis and management of prosthetic joint infections. J Antimicrob Chemother. 2010;65(suppl 3):iii45–54.

    Google Scholar 

  17. Nelson CL, McLaren AC, McLaren SG, Johnson JW, Smeltzer MS. Is aseptic loosening truly aseptic? Clin Orthop Relat Res. 2005;437:25–30.

    Article  PubMed  Google Scholar 

  18. Paxton EW, Furnes O, Namba RS, Inacio MC, Fenstad AM, Havelin LI. Comparison of the Morwegian knee arthroplasty register and a United States arthroplasty registry. J Bone Joint Surg Am. 2011;93(suppl 3):20–30.

    Article  PubMed  Google Scholar 

  19. Piper KE, Fernandez-Sampedro M, Steckelberg KE, Mandrekar JN, Karau MJ, Steckelberg JM, Berbari EF, Osmon DR, Hanssen AD, Lewallen DG, Cofield RH, Sperling JW, Sanchez-Sotelo J, Huddleston PM, Dekutoski MB, Yaszemski M, Currier B, Patel R. C-reactive protein, erythrocyte sedimentation rate and orthopedic implant infection. PLoS One. 2010;5:e9358.

    Article  PubMed  Google Scholar 

  20. Piper KE, Jacobson MJ, Cofield RH, Sperling JW, Sanchez-Sotelo J, Osmon DR, McDowell A, Patrick S, Steckelberg JM, Mandrekar JN, Fernandez Sampedro M, Patel R. Microbiologic diagnosis of prosthetic shoulder infection by use of implant sonication. J Clin Microbiol. 2009;47:1878–1884.

    Article  PubMed  Google Scholar 

  21. Portillo ME, Salvado M, Sorli L, Alier A, Martinez S, Trampuz A, Gomez J, Puig L, Horcajada JP. Multiplex PCR of sonication fluid accurately differentiates between prosthetic joint infection and aseptic failure. J Infect. 2012;65:541–548.

    Article  PubMed  Google Scholar 

  22. Portillo ME, Salvado M, Trampuz A, Plasencia V, Rodriguez-Villasante M, Sorli L, Puig L, Horcajada JP. Sonication versus vortexing of implants for diagnosis of prosthetic joint infection. J Clin Microbiol. 2013;51:591–594.

    Article  PubMed  CAS  Google Scholar 

  23. Rieger UM, Pierer G, Luscher NJ, Trampuz A. Sonication of removed breast implants for improved detection of subclinical infection. Aesthet Plast Surg. 2009;33:404–408.

    Article  CAS  Google Scholar 

  24. Rohacek M, Weisser M, Kobza R, Schoenenberger AW, Pfyffer GE, Frei R, Erne P, Trampuz A. Bacterial colonization and infection of electrophysiological cardiac devices detected with sonication and swab culture. Circulation. 2010;121:1691–1697.

    Article  PubMed  Google Scholar 

  25. Schinsky MF, Della Valle CJ, Sporer SM, Paprosky WG. Perioperative testing for joint infection in patients undergoing revision total hip arthroplasty. J Bone Joint Surg Am. 2008;90:1869–1875.

    Article  PubMed  Google Scholar 

  26. Sharkey PF, Hozack WJ, Rothman RH, Shastri S, Jacoby SM. Insall Award paper: Why are total knee arthroplasties failing today? Clin Orthop Relat Res. 2002;404:7–13.

    Article  PubMed  Google Scholar 

  27. Sierra JM, Garcia S, Martinez-Pastor JC, Tomas X, Gallart X, Vila J, Bori G, Macule F, Mensa J, Riba J, Soriano A. Relationship between the degree of osteolysis and cultures obtained by sonication of the prostheses in patients with aseptic loosening of a hip or knee arthroplasty. Arch Orthop Trauma Surg. 2011;131:1357–1361.

    Article  PubMed  Google Scholar 

  28. Trampuz A, Hanssen AD, Osmon DR, Mandrekar J, Steckelberg JM, Patel R. Synovial fluid leukocyte count and differential for the diagnosis of prosthetic knee infection. Am J Med. 2004;117:556–562.

    Article  PubMed  Google Scholar 

  29. Trampuz A, Piper KE, Jacobson MJ, Hanssen AD, Unni KK, Osmon DR, Mandrekar JN, Cockerill FR, Steckelberg JM, Greenleaf JF, Patel R. Sonication of removed hip and knee prostheses for diagnosis of infection. N Engl J Med. 2007;357:654–663.

    Article  PubMed  CAS  Google Scholar 

  30. Trampuz A, Zimmerli W. Prosthetic joint infections: update in diagnosis and treatment. Swiss Med Wkly. 2005;135:243–251.

    PubMed  Google Scholar 

  31. Trebse R. The diagnostic protocol for evaluation of periprosthetic joint infection. Hip Int. 2012;22(suppl 8):25–35.

    Article  Google Scholar 

  32. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med. 2004;351:1645–1654.

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgments

We thank Andrej Trampuz MD for comments to the manuscript.

Author information

Authors and Affiliations

  1. Microbiology Laboratory, Laboratori de Referència de Catalunya, Carrer de la Selva, 10, Edifici Inblau A. Parc de Negocis Mas Blau, 08820, El Prat de Llobregat, Barcelona, Spain

    María Eugenia Portillo MD, PhD & Margarita Salvadó MD, PhD

  2. Department of Orthopedic Surgery, Hospital del Mar, Barcelona, Spain

    Albert Alier MD, Santos Martínez MD & Lluis Puig MD, PhD

  3. Infectious Diseases Service, Hospital del Mar, Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Barcelona, Spain

    Lluisa Sorli MD & Juan Pablo Horcajada MD, PhD

Authors
  1. María Eugenia Portillo MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Margarita Salvadó MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Albert Alier MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Lluisa Sorli MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Santos Martínez MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Juan Pablo Horcajada MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Lluis Puig MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to María Eugenia Portillo MD, PhD.

Additional information

Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his or her institution approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.

Surgical and antimicrobial treatments were performed at Hospital del Mar, Barcelona, Spain. Microbiological analyses were performed at the Reference Laboratory of Cataluña, Barcelona, Spain.

About this article

Cite this article

Portillo, M.E., Salvadó, M., Alier, A. et al. Prosthesis Failure Within 2 Years of Implantation Is Highly Predictive of Infection. Clin Orthop Relat Res 471, 3672–3678 (2013). https://doi.org/10.1007/s11999-013-3200-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11999-013-3200-7

Keywords

Search

Navigation