Two-Stage Reimplantation of a Prosthetic Hip Infection: Systematic Review of Long-Term Reinfection and Pathogen Outcomes

Abstract

Background: Although two-stage exchange for chronic periprosthetic hip infections remains an effective option for infection eradication, long-term outcome reporting remains scarce. Compiling outcomes data for this standard of care is necessary to characterize long-term reinfection risk and identify bacteria associated with reinfection. The purpose of our study was to perform a systematic review to determine the long-term risk of reinfection after two-stage reimplantation. The second purpose was to identify the proportion of reinfections caused by the same or different organism(s) relative to the index infection.

Methods: We performed a systematic review of two-stage reimplantation randomized control trials, cohort studies, and case series for the treatment of periprosthetic joint infections, yielding 320 unique citations for abstract review, of which 138 were reviewed in full. We collected reinfection data including the timing of reinfection after successful reimplantation and the bacteria identified at reinfection. Meeting inclusion criteria were 28 studies with 2047 patients and 2055 hips that completed both reimplantation stages with just seven studies having greater than 24 month follow-up.

Results: Studies with longer average follow-up reported significantly higher all-time reinfection rates (P = .042). Among studies with at least 5 years of follow-up, the risk of reinfection was 10.25% (8.21-12.47). Among studies with minimum follow-up of at least 24 months, the 24-month rate of reinfection was 4.58% (2.17-7.66), which increased to 7.34% (4.44-10.82) by final follow-up. Only 12 studies reported index and recurrent pathogen data. In those studies, 3.00% (1.19-5.38) of all hips which completed both reimplantation stages were reinfected by a new pathogen, and 1.70% (0.52-3.35) of patients became reinfected by recurrent pathogens.

Conclusion: While the majority of two stage reimplantation literature follows patients for two years, there is significant risk of reinfection into the long term. Further studies with detailed outcomes and long-term follow-up are needed to identify factors associated with late infections.

Keywords: arthroplasty; periprosthetic joint infection; reinfection; systematic review; two-stage.