Periprosthetic Joint Infection (PJI)-Results of One-Stage Revision with Antibiotic-Impregnated Cancellous Allograft Bone-A Retrospective Cohort Study

Abstract

Controversy exists regarding the optimal treatment of periprosthetic joint infection (PJI), considering control of infection, functional results as well as quality of life. Difficulties in treatment derive from the formation of biofilms within a few days after infection. Biofilms are tolerant to systemically applied antibiotics, requiring extreme concentrations for a prolonged period. Minimum biofilm eradicating concentrations (MBEC) are only feasible by the local application of antibiotics. One established approach is the use of allograft bone as a carrier, granting a sustained release of antibiotics in very high concentrations after appropriate impregnation. The purpose of this study was to determine the rate of reinfection after a one-stage revision of infected hip or knee prostheses, using antibiotic-impregnated allograft bone as the carrier and avoiding cement. Between 1 January 2004 and 31 January 2018, 87 patients with PJI, according to MSIS, underwent a one-stage revision with antibiotic-impregnated cancellous allograft bone. An amount of 17 patients had insufficient follow-ups. There were 70 remaining patients (34 male, 36 female) with a mean follow-up of 5.6 years (range 2-15.6) and with a mean age of 68.2 years (range 31.5-86.9). An amount of 38 hips and 11 knees were implanted without any cement; and 21 knees were implanted with moderate cementing at the articular surface with stems always being uncemented. Within 2 years after surgery, 6 out of 70 patients (8.6%, CI 2-15.1) showed reinfection and after more than 2 years, an additional 6 patients showed late-onset infection. Within 2 years after surgery, 11 out of 70 patients (15.7%, CI 7.2-24.2) had an implant failure for any reason (including infection) and after more than 2 years, an additional 7 patients had an implant failure. Using Kaplan-Meier analysis for all 87 patients, the estimated survival for reinfection was 93.9% (CI 88.8-99.1) at 1 year, 89.9% (CI 83.2-96.6) at 2 years and 81.5% (CI 72.1-90.9) at 5 years. The estimated survival for implant failure for any reason was 90.4% (CI 84.1-96.7) at 1 year, 80.9% (CI 72.2-89.7) at 2 years and 71.1% (CI 60.3-81.8) at 5 years. One-stage revision with antibiotic-impregnated cancellous allograft bone grants comparable results regarding infection control as with multiple stages, while shortening rehabilitation, improving quality of life for the patients and reducing costs for the health care system.

Keywords: antibiotic carrier; antibiotic-impregnated cancellous allograft bone; biofilm; cementless implants; impaction grafting; local antimicrobial therapy; microorganism; one-stage revision; periprosthetic joint infection; single-stage.

Figure 1

Flowchart illustrating the inclusion, exclusion and results of patients in this study. Abbreviations: MI, myocardial infarction; I&D, irrigation and debridement.

Figure 2

Venn diagram (n = 124) demonstrating the overlap of patients diagnosed according to MSIS, EBJIS 2018, IDSA and ICM 2018.

Figure 3

Kaplan–Meier curves with (a) reinfection and (b) implant failure for any reason as events of interest. All 87 patients with PJI according to MSIS are included. The dotted lines are the confidence intervals per x-value, the vertical stripes are censored events.

Figure 4

Radiographs of a 66-year-old male who sustained a femoral neck fracture treated with uncemented total hip arthroplasty. Postoperatively, he complained of unspecific pain with only slightly elevated infection markers. (a) Three years later, loosening of the acetabular component was diagnosed with marked osseous defect periacetabular and signs of osteolysis around the proximal part of the stem. (b) One-stage exchange with uncemented components. The defects were filled with antibiotic-impregnated bone (OSTEOmycin^TM V). Sonication of explanted material revealed growth of two strains of methicillin-resistant S. epidermidis and Propionibacterium sp. The hospital stay was one week, with cefuroxime intravenously, followed by six weeks of amoxicillin/clavulanic acid and rifampicin orally. (c) Six months postoperatively, the patient is pain-free with no sign of infection and unlimited mobility. There is partial remodeling of the allograft. Figures taken from previous publication in EOR Winkler (2017) [67]. (d) 6,5 years postoperatively. Unlimited weight-bearing, no sign of infection. No change of position of implants. The allograft is completely incorporated with seamless ingrowth of cup and stem.

Figure 4

Radiographs of a 66-year-old male who sustained a femoral neck fracture treated with uncemented total hip arthroplasty. Postoperatively, he complained of unspecific pain with only slightly elevated infection markers. (a) Three years later, loosening of the acetabular component was diagnosed with marked osseous defect periacetabular and signs of osteolysis around the proximal part of the stem. (b) One-stage exchange with uncemented components. The defects were filled with antibiotic-impregnated bone (OSTEOmycin^TM V). Sonication of explanted material revealed growth of two strains of methicillin-resistant S. epidermidis and Propionibacterium sp. The hospital stay was one week, with cefuroxime intravenously, followed by six weeks of amoxicillin/clavulanic acid and rifampicin orally. (c) Six months postoperatively, the patient is pain-free with no sign of infection and unlimited mobility. There is partial remodeling of the allograft. Figures taken from previous publication in EOR Winkler (2017) [67]. (d) 6,5 years postoperatively. Unlimited weight-bearing, no sign of infection. No change of position of implants. The allograft is completely incorporated with seamless ingrowth of cup and stem.