Does Treatment at a Specialized Prosthetic Joint Infection Center Improve the Rate of Reimplantation

Fehring, Thomas K.; Otero, Jesse E.; Curtin, Brian; Fehring, Keith A.; Metcalf, Rory; Rowe, Taylor; Springer, Bryan D.

doi:10.1016/j.arth.2023.03.082

Cited by 3 publications

(4 citation statements)

References 33 publications

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“…Despite this, the use of single-stage exchange is increasing across the globe, with a single high-volume European center reporting a >30% increase in 1-stage exchange from 2008 to 2021 8 . Fehring et al reported a 99% reimplantation rate after 2-stage exchange at their specialized PJI referral center, which is far better than the previously published reimplantation rates 9 . This work highlights the potential benefit of a national network of specialized PJI centers with experienced revision surgeons performing high-volume procedures to treat infection and with multidisciplinary consultants familiar with the special needs of patients with PJI.…”

mentioning

confidence: 76%

“…Previous research has suggested a high rate of spacer retention in patients who undergo a planned 2-stage exchange for periprosthetic hip or knee infection. Treatment at a specialized PJI center appears to improve the rate of reimplantation to 99% (386 of 390) in these patients 9 . The necessity of intramedullary dowels in knee spacers was clarified by a recent study, which showed a 31% positive culture rate from femoral and tibial canals at the time of resection 36 .…”

Section: A 2-stage Exchangementioning

confidence: 97%

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What’s New in Musculoskeletal Infection

Otero,

Dombrowski,

Brown

et al. 2024

Journal of Bone and Joint Surgery

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Periprosthetic joint infection (PJI) continues to be a devastating complication after total joint arthroplasty (TJA) and remains one of the most common causes for revision TJA. Projections are clear that primary TJA will continue to increase annually and, with it, PJI. In 2022, there was an emphasis on the global economics of PJI management, whereas, in 2023, the literature attempted to provide a more granular look at the financial burden of PJI. Wixted et al. analyzed the direct costs of PJI at a tertiary referral center, including the costs of relevant ancillary services, and demonstrated that the failure of successful reimplantation and the need for additional surgical procedures more than doubled the direct costs of PJI management ($38,865 compared with $79,223) 1 . Additionally, Charalambous et al. assessed cost drivers of 2-stage exchange for PJI treatment and found that age, illicit drug use, the Elixhauser comorbidity index, and number of surgical procedures before reimplantation were all associated with an increased cost of PJI treatment and that failure to clear infection was associated with a >50% increase in total costs at 2 years after treatment 2 . In 2023, the psychosocial impact of PJI was also highlighted. Shichman et al. demonstrated that the sequelae of PJI decreased patientreported quality of life, social satisfaction, and mental health, with approximately 1 of 4 patients regretting their initial decision to undergo primary TJA 3 . Das et al. demonstrated that patients who underwent spacer placement for PJI after TJA had a disproportionately higher incidence of mental health disorders following a surgical procedure compared with aseptic revisions and primary TJA, urging surgeons to consider collaborative management with mental health professionals in the treatment of PJI 4 .Not only are mental health disorders a consequence of PJI, but they are also likely a risk factor. Harmer et al. demonstrated that depression and anxiety were associated with an increased risk of any infection, and specifically with an increased risk of PJI after revision total knee arthroplasty (TKA) 5 .Two-stage exchange continues to be considered the mainstay treatment of PJI, although 1-stage treatment is gaining popularity. In an Australian cost-utility analysis using a Markov model, Okafor et al. found that opting for an index 2-stage revision instead of a 1-stage revision when there is no compelling indication for 2-stage exchange is not likely to be cost-effective 6 . In the United States, most surgeons are utilizing 2-stage exchange, with 75% of American Association of Hip and Knee Surgeons (AAHKS) survey respondents reporting the use of 2-stage exchange rather than 1-stage exchange and with the majority of surgeons handling <20 PJI cases per year 7 . Despite this, the use of single-stage exchange is increasing across the globe, with a single high-volume European center reporting a >30% increase in 1-stage exchange from 2008 to 2021 8 . Fehring et al. reported a 99% reimplantation rate after 2-stage exchange at the...

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mentioning

confidence: 76%

Section: A 2-stage Exchangementioning

confidence: 97%

What’s New in Musculoskeletal Infection

Otero,

Dombrowski,

Brown

et al. 2024

Journal of Bone and Joint Surgery

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“…Lin et al found that a low surgical volume was a risk factor for spacer fractures with dislocation (odds ratio, 8.13) [8]. Moreover, better infection control and reimplantation rates have been reported in patients treated at specialized PKI centers [11]. Superior results have been found for the treatment at subspecialty centers of bone and joint infections [30].…”

Section: Discussionmentioning

confidence: 99%

“…Similarly, HV surgeons have better outcomes and lower re-revision rates following aseptic revision TKA than LV surgeons, and they support the development of revision teams within arthroplasty centers to offer patients the best outcomes [10]. Furthermore, establishing a specialized PKI center with experienced surgeons performing HV infection procedures is recommended to improve the rate of reimplantation [11]. However, the effects of surgeon volume on mechanical complications following resection arthroplasty (RA) using articulating spacers remain unclear.…”

Section: Introductionmentioning

confidence: 99%

Effect of Surgeon Volume on Mechanical Complications after Resection Arthroplasty with Articulating Spacer

Ko,

Tsai,

Fong

et al. 2024

JPM

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Two-stage revision with an antibiotic-loaded cement articulating spacer is a standard treatment for chronic prosthetic knee infection (PKI); however, mechanical complications can occur during the spacer period. There is limited evidence on the association between surgeon volume and mechanical complications after resection arthroplasty (RA) using an articulating spacer. This study aimed to compare the rates of mechanical complications and reoperation after RA with articulating spacers by surgeons with high volumes (HV) and low volumes (LV) of RA performed and analyzed the risk factors for mechanical failure. The retrospective study investigated 203 patients treated with PKIs who underwent RA with articulating spacers and were divided according to the number of RAs performed by the surgeons: HV (≥14 RAs/year) or LV (<14 RAs/year). Rates of mechanical complications and reoperations were compared. Risk factors for mechanical complications were analyzed. Of the 203 patients, 105 and 98 were treated by two HV and six LV surgeons, respectively. The mechanical complication rate was lower in HV surgeons (3.8%) than in LV surgeons (36.7%) (p < 0.001). The reoperation rate for mechanical complications was lower in HV surgeons (0.9%) than in LV surgeons (24.5%) (p < 0.001). Additionally, 47.2% of patients required hinge knees after mechanical spacer failure. Medial proximal tibial angle < 87°, recurvatum angle > 5°, and the use of a tibial spacer without a cement stem extension were risk factors for mechanical complications. Based on these findings, we made the following three conclusions: (1) HV surgeons had a lower rate of mechanical complications and reoperation than LV surgeons; (2) mechanical complications increased the level of constraint in final revision knee arthroplasty; and (3) all surgeons should avoid tibial spacer varus malalignment and recurvatum deformity and always use a cement stem extension with a tibial spacer.

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