The outcomes of surgical management of failed two-stage revision knee arthroplasty

Main Article Content

Carla Maden
Monketh Jaibaji
Sujith Konan
Luigi Zargra
Matteo Borella
Adrian Harvey
Andrea Volpin

Keywords

Two stage knee arthroplasty, Joint infection, recurrence, revision arthroplasty

Abstract

ABSTRACT


Background


Joint infection following total knee arthroplasty has significant consequences on both the patient and healthcare system. Two stage revision arthroplasties is viewed as the gold standard in management. However, recurrence of infection following this procedure is a growing clinical problem for a multitude of reasons.


Despite a variety of surgical options for management of failure of two-stage revision arthroplasty, the potential for complications and functional limitation remains high, and the optimal strategy is yet to be determined.


Methods


We performed a systematic review of all papers reporting on the outcomes of the surgical management of failure of two-stage revision arthroplasty published up to and including January 2020. Data was extracted on patient demographics, study design, methodological quality, indication for surgery, surgical technique, clinical and functional outcomes, and complications.


Results


Nine papers with a total of 273 patients were found and analysed All surgical techniques had mixed results in term of clinical and functional outcomes, and the rate of complications was high in all studies. Knee arthrodesis had the lower risk of failure than repeat 2 stage revision. Poor patient immunological status and limb status were weakly associated with increased risk of failure.


Conclusion


Despite failure of two-stage revision arthroplasty being a growing clinical issue, we were not able to identify any consistently superior surgical technique for the management of this scenario. Knee arthrodesis appears to provide the best results for improving quality of life and reducing infection recurrence, although the complication rate is high and the functional outcomes appear to be worse. Further larger and prospective studies are needed to elucidate optimal surgical management in different patient subsets.

Downloads

Download data is not yet available.
Abstract 70 |

References

[1] A. Volpin, M. Sukeik, S. Alazzawi, F.S. Haddad, Aggressive Early Debridement in Treatment of Acute Periprosthetic Joint Infections After Hip and Knee Replacements, Open Orthop. J. 10 (2016) 669–678. https://doi.org/10.2174/1874325001610010669.
[2] L. Pulido, E. Ghanem, A. Joshi, J.J. Purtill, J. Parvizi, Periprosthetic joint infection: The incidence, timing, and predisposing factors, Clin. Orthop. Relat. Res. 466 (2008) 1710–1715. https://doi.org/10.1007/s11999-008-0209-4.
[3] B. Kubista, R.U. Hartzler, C.M. Wood, D.R. Osmon, A.D. Hanssen, D.G. Lewallen, Reinfection after two-stage revision for periprosthetic infection of total knee arthroplasty, Int. Orthop. 36 (2012) 65–71. https://doi.org/10.1007/s00264-011-1267-x.
[4] W.A. Jiranek, A.C. Waligora, S.R. Hess, G.L. Golladay, Surgical Treatment of Prosthetic Joint Infections of the Hip and Knee: Changing Paradigms?, J. Arthroplasty. 30 (2015) 912–918. https://doi.org/10.1016/j.arth.2015.03.014.
[5] S.G. Kini, A. Gabr, R. Das, M. Sukeik, F.S. Haddad, Two-stage Revision for Periprosthetic Hip and Knee Joint Infections, Open Orthop. J. 10 (2017) 579–588. https://doi.org/10.2174/1874325001610010579.
[6] T. Mahmud, M.C. Lyons, D.D. Naudie, S.J. MacDonald, R.W. McCalden, Assessing the gold standard: A review of 253 two-stage revisions for infected TKA knee, in: Clin. Orthop. Relat. Res., 2012: pp. 2730–2736. https://doi.org/10.1007/s11999-012-2358-8.
[7] D. Tigani, G. Trisolino, M. Fosco, R. Ben Ayad, P. Costigliola, Two-stage reimplantation for periprosthetic knee infection: Influence of host health status and infecting microorganism, Knee. 20 (2013) 9–18. https://doi.org/10.1016/j.knee.2012.06.004.
[8] K. Azzam, K. McHale, M. Austin, J.J. Purtill, J. Parvizi, Outcome of a second two-stage reimplantation for periprosthetic knee infection, in: Clin. Orthop. Relat. Res., 2009: pp. 1706–1714. https://doi.org/10.1007/s11999-009-0739-4.
[9] B. Zmistowski, M.W. Tetreault, P. Alijanipour, A.F. Chen, C.J. Della Valle, J. Parvizi, Recurrent Periprosthetic Joint Infection, J. Arthroplasty. 28 (2013) 1486–1489. https://doi.org/10.1016/j.arth.2013.02.021.
[10] G.K. Triantafyllopoulos, S.G. Memtsoudis, W. Zhang, Y. Ma, T.P. Sculco, L.A. Poultsides, Periprosthetic Infection Recurrence After 2-Stage Exchange Arthroplasty: Failure or Fate?, J. Arthroplasty. 32 (2017) 526–531. https://doi.org/10.1016/j.arth.2016.08.002.
[11] S.M.J. Mortazavi, D. Vegari, A. Ho, B. Zmistowski, J. Parvizi, Two-stage exchange arthroplasty for infected total knee arthroplasty: Predictors of failure, in: Clin. Orthop. Relat. Res., 2011: pp. 3049–3054. https://doi.org/10.1007/s11999-011-2030-8.
[12] J. Stammers, S. Kahane, V. Ranawat, J. Miles, R. Pollock, R.W.J. Carrington, T. Briggs, J.A. Skinner, Outcomes of infected revision knee arthroplasty managed by two-stage revision in a tertiary referral centre, Knee. 22 (2015) 56–62. https://doi.org/10.1016/j.knee.2014.10.005.
[13] K.H. Wang, S.W. Yu, R. Iorio, A.J. Marcantonio, M.S. Kain, Long Term Treatment Results for Deep Infections of Total Knee Arthroplasty, J. Arthroplasty. 30 (2015) 1623–1628. https://doi.org/10.1016/j.arth.2015.04.008.
[14] I.S. Vanhegan, A.K. Malik, P. Jayakumar, S. Ul Islam, F.S. Haddad, A financial analysis of revision hip arthroplasty: The economic burden in relation to the national tariff, Bone Joint J. 94-B (2012) 619–623. https://doi.org/10.1302/0301-620X.94B5.27073.
[15] B.D. Coleman, K.M. Khan, N. Maffulli, J.L. Cook, J.D. Wark, Studies of surgical outcome after patellar tendinopathy: clinical significance of methodological deficiencies and guidelines for future studies. Victorian Institute of Sport Tendon Study Group., Scand. J. Med. Sci. Sports. 10 (2000) 2–11. https://doi.org/10.1034/j.1600-0838.2000.010001002.x.
[16] A. Del Buono, A. Volpin, N. Maffulli, Minimally invasive versus open surgery for acute Achilles tendon rupture: a systematic review, Br. Med. Bull. 109 (2013) 45–54. https://doi.org/10.1093/bmb/ldt029.
[17] C.Y. Ma, Y. Der Lu, K.L. Bell, J.W. Wang, J.Y. Ko, C.J. Wang, F.C. Kuo, Predictors of Treatment Failure After 2-Stage Reimplantation for Infected Total Knee Arthroplasty: A 2- to 10-Year Follow-Up, J. Arthroplasty. 33 (2018) 2234–2239. https://doi.org/10.1016/j.arth.2018.02.007.
[18] K.A. Fehring, M.P. Abdel, M. Ollivier, T.M. Mabry, A.D. Hanssen, Repeat two-stage exchange arthroplasty for periprosthetic knee infection is dependent on host grade, J. Bone Jt. Surg. - Am. Vol. 99 (2017) 19–24. https://doi.org/10.2106/JBJS.16.00075.
[19] M. Faschingbauer, F. Boettner, R. Bieger, C. Weiner, H. Reichel, T. Kappe, Outcome of Irrigation and Debridement after Failed Two-Stage Reimplantation for Periprosthetic Joint Infection, Biomed Res. Int. 2018 (2018). https://doi.org/10.1155/2018/2875018.
[20] I. Vadiee, D.J. Backstein, The Effectiveness of Repeat Two-Stage Revision for the Treatment of Recalcitrant Total Knee Arthroplasty Infection, J. Arthroplasty. 34 (2019) 369–374. https://doi.org/10.1016/j.arth.2018.10.021.
[21] K. Staats, C. Boehler, S. Frenzel, S.E. Puchner, J. Holinka, R. Windhager, Failed Two-Stage Exchange: Factors Leading to Unachievable Endoprosthetic Reconstruction After Multiple Revision Surgeries, J. Arthroplasty. 33 (2018) 195–199. https://doi.org/10.1016/j.arth.2017.07.049.
[22] M. Robinson, H.I. Piponov, A. Ormseth, C.W. Helder, B. Schwartz, M.H. Gonzalez, Knee Arthrodesis Outcomes After Infected Total Knee Arthroplasty and Failure of Two-stage Revision With an Antibiotic Cement Spacer, JAAOS Glob. Res. Rev. 2 (2018) e077. https://doi.org/10.5435/jaaosglobal-d-17-00077.
[23] M.M. Kheir, T.L. Tan, M.M. Gomez, A.F. Chen, J. Parvizi, Patients With Failed Prior Two-Stage Exchange Have Poor Outcomes After Further Surgical Intervention, J. Arthroplasty. 32 (2017) 1262–1265. https://doi.org/10.1016/j.arth.2016.10.008.
[24] C.H. Wu, C.F. Gray, G.C. Lee, Arthrodesis Should Be Strongly Considered After Failed Two-stage Reimplantation TKA, Clin. Orthop. Relat. Res. 472 (2014) 3295–3304. https://doi.org/10.1007/s11999-014-3482-4.