Prosthesis failure within 2 years of implantation is highly predictive of infection

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.

Fig. 1

The Kaplan-Meier survival analysis is shown for the 112 patients (112 prostheses) stratified to aseptic loosening (n = 63), mechanical failure (n = 17), and PJI (n = 32). The vertical spikes denote censored cases. The survival time of the prostheses was longer in patients with aseptic loosening compared with mechanical failure and PJI (p < 0.001).The vertical line indicates the survival probability 2 years after prosthesis implantation.

Fig. 2

The Kaplan-Meier survival analysis is shown for the 63 patients (63 prostheses) with aseptic loosening stratified according to microbiological findings (48 without growth and 15 with growth of periprosthetic tissue and/or sonication fluid culture). The vertical spikes denote censored cases. The vertical line indicates the survival 2 years after prosthesis implantation.