Positive Intraoperative Cultures in Cup Revisions of THA: What Happens to the Stem?

Abstract

Background: Positive intraoperative cultures (PICs) are encountered in some patients undergoing revision of the acetabular cup after a previous THA. It is unknown whether PIC of the cup indicates whether the stem is infected as well and what happens to the stem during follow-up.

Questions/purposes: (1) What proportion of patients undergoing THA who undergo cup revision have PICs? (2) What is the survival of the stem during follow-up in cup revisions with PICs versus that of those with negative cultures? (3) Does antibiotic treatment of PIC of the cup prevent revision THA during follow-up?

Methods: In this retrospective, comparative multicenter study, five surgeons at four centers performed 338 acetabular cup revisions between January 2015 and December 2017. After evaluating the data, we excluded one patient because of an incomplete dataset and 77 patients because fewer than three intraoperative cultures were obtained during surgery, leaving 260 patients for analysis. Follow-up was 2 years. Patients were stratified into three cohorts: no PIC, one PIC, and two or more PICs.

Results: The proportion of patients with one or more PIC was 15% (39 of 260). A total of 8% (21 of 260) had one and 7% (18 of 260) had two or more PICs. Stem survival was lower in patients with two or more PICs, but stem revision for periprosthetic joint infection was similar between groups. Two-year survival, which was defined as freedom from revision for any cause or infection, was 97% (95% confidence interval 95% to 99%) in the group without PICs, 100% (95% CI 95% to 100%) in the group with one PIC, and 86% (95% CI 68% to 100%; p = 0.08) in the group with two or more PICs. None of the patients in the no PIC and one PIC groups were treated with antibiotics. In the two or more PICs cohort, 12 of 18 patients were treated. The stem survived in one of 12 patients treated with antibiotics versus two of six patients who were not treated with antibiotics.

Conclusion: When treated with antibiotics, more than two PICs isolated during cup revision surgery do not have a major impact on survival of the stem during follow-up. A larger cohort of patients with PICs during cup revision might confirm these findings.

Level of evidence: Level III, therapeutic study.

Fig. 1

This flowchart represents eligible patients with aseptic cup revision in four hospitals associated with the Northern Infection Network Joint Arthroplasty. PJI = periprosthetic joint infection.

Fig. 2

These Kaplan-Meier survival curves represent aseptic cup revision for three subgroups and revision for any cause. We performed a log-rank test of equal distribution of survival among the three cohorts (Mantel-Cox test; p = 0.22). A color image accompanies the online version of this article.

Fig. 3

These Kaplan-Meier survival curves represent aseptic cup revision for the three subgroups and revision for periprosthetic joint infection. We performed a log-rank test of equal distribution of survival among the three cohorts (Mantel-Cox test; p = 0.18). A color image accompanies the online version of this article.