High Rate of Reinfection With New Bacteria Following One-Stage Exchange for Enterococcal Periprosthetic Infection of the Knee: A Single-Center Study

Roßmann, Markus; Minde, Thore; Citak, Mustafa; Gehrke, Thorsten; Sandiford, Nemandra A; Abdelaziz, Hussein

doi:10.1016/j.arth.2020.08.015

Cited by 14 publications

(13 citation statements)

References 22 publications

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“…In a study examining single-stage exchange for Enterococcus PJI, Rossmann et al showed a reinfection rate of 37.5% at 22 months, with older age and male sex associated with higher risk of failure in this cohort 53 . Massive femoral bone loss (greater than Paprosky IIIA) and previous revision surgical procedures were also associated with a higher risk of subsequent septic failure following a single-stage exchange in a different study; thus, a 2-stage exchange is recommended in these instances 54 .…”

Section: Surgical Treatmentmentioning

confidence: 68%

What’s New in Musculoskeletal Infection

Otero

Brown

Courtney

et al. 2022

Journal of Bone and Joint Surgery

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Periprosthetic joint infection (PJI) remains the most dreaded complication after total joint arthroplasty (TJA). As reimbursement for joint replacement continues to decline [1][2][3] , fewer orthopaedic surgeons take on this challenging and timeconsuming practice. Indeed, in a recent study, Keely Boyle et al. found that 16% of knee arthroplasty revisions, including revisions for infection, were performed at a different center than the one in which the index procedure was performed. Illgen et al. used the American Joint Replacement Registry (AJRR) to show that, in hips, the migration rate for PJI ranges from 28.6% to 46.6%, depending on the size of the hospital 5 . This places a major portion of the responsibility of PJI care on a few specialized surgeons. Therefore, understanding the economics of PJI care has been a hot topic this year.In a study utilizing the National Inpatient Sample (NIS), Premkumar et al. projected that, by 2030, the annual hospital costs related to PJI of the hip and knee will equal $1.85 billion in the United States 6 . In another study from a single institution, the cost of care for a PJI after a 2-stage total knee arthroplasty (TKA) was more than 5 times the cost of care of an uncomplicated primary TKA for an age-matched and body mass index (BMI)-matched cohor t 7 . Comparing the cost of operative treatment for PJI of the hip and knee with that of aseptic revision, Yao et al. 8 showed that the PJI treatment had costs that were double those of the aseptic treatment. Unintended hospitalization during the 2-stage exchange process was shown to add >$20,000 in costs to patient care, which is concerning because less than one-half of the patients who underwent resection for PJI had a successful 2-stage exchange within 1 year 9 . Using a Markov model, Antonios et al. showed the costeffectiveness of adding a planned second debridement, antibiotics, and implant retention (DAIR) procedure to treat PJI 10 . Efforts to reduce failure in PJI treatment will continue to be an important topic in research. PreventionAlthough originally spoken to Philadelphians to increase fire awareness in the 1700s, Benjamin Franklin's famous quote, "An ounce of prevention is worth a pound of cure," certainly still applies to PJI. With the substantial clinical and financial burden of PJI, resources should be focused, not just on treatment, but on optimizing strategies to prevent infection. Many studies published on this topic at this time will help to guide orthopaedic surgeons and their perioperative management of patients undergoing total hip arthroplasty (THA) and TKA, while prompting more prospective studies to answer important questions.Preoperative Staphylococcus aureus screening is controversial. In a recent systematic review and meta-analysis with 32 studies, Ribau et al. identified a marked reduction in infection with decolonization prior to elective THA and TKA 11 . However, in a randomized controlled trial (RCT) of 613 patients, Rohrer et al. did not find a difference in PJI rates with nasal decolonization, but...

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Section: Surgical Treatmentmentioning

confidence: 68%

What’s New in Musculoskeletal Infection

Otero

Brown

Courtney

et al. 2022

Journal of Bone and Joint Surgery

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“…After excluding duplicates, 343 studies were included, and after evaluation of the title and abstract, 21 studies were analyzed. After assessing the eligibility of the full-text articles according to the inclusion and exclusion criteria and screening the bibliography of each article to find additional relevant publications, 18 clinical studies were selected and included in this systematic review [22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39]. The PRISMA flowchart with the research strategy is shown in Fig.…”

Section: Search Strategy and Study Screeningmentioning

confidence: 99%

Characterizing recurrent infections after one-stage revision for periprosthetic joint infection of the knee: a systematic review of the literature

Bosco

Cacciola

Giustra

et al. 2023

Eur J Orthop Surg Traumatol

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Background Periprosthetic joint infection (PJI) of the knee represents a severe complication after 1.5% to 2% of primary total knee replacement. Although two-stage revision was considered the gold-standard treatment for PJI of the knee, in the last decades, more studies reported the outcomes of one-stage revisions. This systematic review aims to assess reinfection rate, infection-free survival after reoperation for recurrent infection, and the microorganisms involved in both primary and recurrent infection. Material and methods A systematic review of all studies reporting the outcome of one-stage revision for PJI of the knee up to September 2022, according to PRISMA criteria and AMSTAR2 guidelines, was performed. Patient demographics, clinical, surgical, and postoperative data were recorded. PROSPERO ID: CRD42022362767. Results Eighteen studies with a total of 881 one-stage revisions for PJI of the knee were analyzed. A reinfection rate of 12.2% after an average follow-up of 57.6 months was reported. The most frequent causative microorganism were gram-positive bacteria (71.1%), gram-negative bacteria (7.1%), and polymicrobial infections (8%). The average postoperative knee society score was 81.5, and the average postoperative knee function score was 74.2. The infection-free survival after treatment for recurrent infection was 92.1%. The causative microorganisms at reinfections differed significantly from the primary infection (gram-positive 44.4%, gram-negative 11.1%). Conclusion Patients who underwent a one-stage revision for PJI of the knee showed a reinfection rate lower or comparable to other surgical treatments as two-stage or DAIR (debridement, antibiotics, and implant retention). Reoperation for reinfection demonstrates a lower success compared to one-stage revision. Moreover, microbiology differs between primary infection and recurrent infection. Level of evidence Level IV.

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“…Which germs are difficult to treat is a question of available antiinfective agents, resources. Methicillin-resistant Staphylococcus aureus (MRSA) and E. faecalis are considered to be DTT [ 13 , 19 ]. Some revision centres perform single-stage revision even in these cases, but poorer outcomes may be expected [ 5 ].…”

Section: Treatment – General Considerationsmentioning

confidence: 99%

Diagnosis and management of the infected total knee replacement: a practical surgical guide

Zahár

Sarungi

2021

J EXP ORTOP

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Purpose Prosthetic joint infection (PJI) after total knee arthroplasty (TKA) is a significant burden in health care. Diagnosis and proper management are challenging. A standardised procedure for the diagnostic workup and surgical management provides clear benefits in outcome. Methods Several diagnostic protocols and definitions for PJI were established in recent years. Proper PJI diagnosis remains critical for success and for choosing the optimal treatment option. A distinct workup of diagnostic steps, the evaluation of the results in a multidisciplinary setup and the meticulous surgical management of the infection are the key factors of successful treatment. Results The management of PJI after TKA consists of early revision with debridement and implant retention (DAIR) in early cases or staged revision in late infections beyond 30 days postoperative or after onset of acute symptoms. The revision is performed as a two-stage procedure with the use of a fixed or mobile antibiotic spacer, or in selected cases as a single-stage operation with the use of local and systemic antibiotic treatment. Conclusions This paper reflects the opinion of two revision surgeons who follow the same protocol for diagnosis and treatment of PJI after TKA, highlighting the key steps in diagnosis and management. Level of evidence Expert’s opinion

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High Rate of Reinfection With New Bacteria Following One-Stage Exchange for Enterococcal Periprosthetic Infection of the Knee: A Single-Center Study

Cited by 14 publications

References 22 publications

What’s New in Musculoskeletal Infection

What’s New in Musculoskeletal Infection

Characterizing recurrent infections after one-stage revision for periprosthetic joint infection of the knee: a systematic review of the literature

Diagnosis and management of the infected total knee replacement: a practical surgical guide

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