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Two-Stage Exchange Arthroplasty for Periprosthetic Joint Infection Following Total Hip or Knee Arthroplasty Is Associated With High Attrition Rate and Mortality

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Authors/contributors
Abstract
Background We sought to determine the ultimate fate of patients undergoing resection arthroplasty as a first stage in the process of 2-stage exchange and evaluate risk factors for modes of failure. Methods A retrospective case study was performed including all patients with minimum 2-year follow-up who underwent first-stage resection of a hip or knee periprosthetic joint infection from 2008 to 2015. Patient demographics, laboratory, and health status variables were collected. The primary outcome analyzed was defined as failure to achieve an infection-free 2-stage revision. Univariate pairwise comparison followed by multivariate regression analysis was used to determine risk factors for failure outcomes. Results Eighty-nine patients underwent resection arthroplasty in a planned 2-stage exchange protocol (27 hips, 62 knees). Mean age was 64 years (range, 43-84), 56.2% were males, and mean follow-up was 56.3 months. Also, 68.5% (61/89) of patients underwent second-stage revision. Of the 61 patients who complete a 2-stage protocol, 14.8% (9/61) of patients failed with diagnosis of repeat or recurrent infection. Mortality rate was 23.6%. Multivariate analysis identified risk factors for failure to achieve an infection-free 2-stage revision as polymicrobial infection (P < .004; adjusted odds ratio [AOR], 7.8; 95% confidence interval [CI], 2.1-29.0), McPherson extremity grade 3 (P < .024; AOR, 4.1; 95% CI, 1.2-14.3), and history of prior resection (P < .013; AOR, 4.7; 95% CI, 1.4-16.4). Conclusion Patients undergoing resection arthroplasty for periprosthetic joint infection are at high risk of death (24%) and failure to complete the 2-stage protocol (32%). Those who complete the 2-stage protocol have a 15% rate of reinfection at 4.5-year follow-up.
Publication
The Journal of Arthroplasty
Date
05/2020
DOI
10.1016/j.arth.2019.12.005
URL
https://linkinghub.elsevier.com/retrieve/pii/S0883540319311374
Notes

Level of evidence:

Based on the GRADE system, this study can be assigned a level of evidence of "low." The evidence is downgraded due to the retrospective design, potential biases, small sample size, and limited follow-up duration.

Summary

This retrospective study aimed to determine the outcomes and risk factors associated with failure after resection arthroplasty as the initial stage in a 2-stage exchange protocol for chronic periprosthetic joint infection (PJI). The study included 89 patients who underwent first-stage resection between 2008 and 2015. The primary outcome was failure to achieve an infection-free 2-stage revision, and secondary outcomes were septic failure of second-stage reimplantation and mortality.

The results showed that 68.5% of patients completed the 2-stage protocol, and among them, only 58.4% achieved an infection-free second-stage revision. Risk factors associated with failure to achieve infection-free revision were polymicrobial infection, McPherson extremity grade 3, and prior resection at another hospital. The reinfection rate after successful second-stage reimplantation was 14.8%. Mortality rate during the follow-up period was 23.6%, with McPherson extremity grade and Charlson Comorbidity Index identified as risk factors for mortality.

Important results:

68.5% of patients completed the 2-stage protocol.

58.4% of patients achieved an infection-free second-stage revision.

Risk factors for failure to achieve infection-free revision were polymicrobial infection, McPherson extremity grade 3, and prior resection at another hospital.

The reinfection rate after successful second-stage reimplantation was 14.8%.

Mortality rate during the follow-up period was 23.6%, with McPherson extremity grade and Charlson Comorbidity Index identified as risk factors for mortality.

Citation
1.
Barton CB, Wang DL, An Q, Brown TS, Callaghan JJ, Otero JE. Two-Stage Exchange Arthroplasty for Periprosthetic Joint Infection Following Total Hip or Knee Arthroplasty Is Associated With High Attrition Rate and Mortality. The Journal of Arthroplasty. 2020;35(5):1384-1389.
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