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. 2024 Apr 30;11(3):e12024.
doi: 10.1002/jeo2.12024. eCollection 2024 Jul.

Impact of unplanned second debridement, antibiotics and implant retention on long-term outcomes in knee exchange arthroplasty: Elevated risk of failure and reinfection

Yu-Chih Lin  1   2   3 , Wei-Cheng Chen  1   2   3 , Shih-Hui Peng  1   2   3 , Chih-Hsiang Chang  1   2   3 , Sheng-Hsun Lee  1   2   3 , Sheng-Hsuan Lin  4
Affiliations

Impact of unplanned second debridement, antibiotics and implant retention on long-term outcomes in knee exchange arthroplasty: Elevated risk of failure and reinfection

Yu-Chih Lin et al. J Exp Orthop. .

Abstract

Purpose: This study investigates the outcomes of two-stage exchange arthroplasty (EA) for periprosthetic joint infection (PJI) following initial or unplanned repeat debridement antibiotics, and implant retention (DAIR).

Methods: We retrospectively reviewed cases of knee arthroplasty infection treated with two-stage EA after DAIR, spanning from January 1994 to December 2010. A total of 138 patients were included, comprising 112 with initial DAIR and 26 with an unplanned second DAIR. Data on demographics, comorbidities, infection characteristics and causative organisms were analyzed. The primary outcome was implant failure or reinfection, observed over a minimum follow-up of 10 years.

Results: The overall success rate for two-stage EA was 87% (119/138 patients). Factors identified for treatment failure included reinfection with the same pathogen for unplanned second DAIR (hazard ratio [HR] = 3.41; 95% confidence interval [CI] = 1.35-4.38; p = 0.004), higher reinfection rates in patients undergoing EA after an unplanned second DAIR, especially with a prior history of PJI within 2 years (HR = 4.23; 95% CI = 2.39-5.31; p = 0.002), pre-first DAIR C-reactive protein (CRP) levels over 100 mg/dL (HR = 2.52; 95% CI = 1.98-3.42; p = 0.003) and recurrence with the same pathogen (HR = 2.35; 95% CI = 1.32-4.24; p = 0.007). Additional factors such as male gender (HR = 3.92; 95% CI = 1.21-5.25; p = 0.007) and osteoporosis (T score < -2.5; HR = 3.27; 95% CI = 1.23-5.28; p = 0.005) were identified as risk factors for implant failure in all EA cases.

Conclusions: This study identifies key risk factors for worse knee EA outcomes following DAIR, including a pre-first DAIR CRP level over 100 mg/L, same pathogen recurrence, and PJI history within 2 years. It shows implant failure rates remain constant across EA cases, regardless of DAIR sequence, particularly with risk factors like male gender and severe osteoporosis (T score < -2.5). These results underscore the need for careful evaluation before an unplanned second DAIR, given its significant impact on EA success.

Level of evidence: Level III.

Keywords: debridement, antibiotics and implant retention (DAIR); implant failure; periprosthetic infection; reinfection; staged exchange arthroplasty.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Flowchart of study selection and treatment protocol. Excluded cases are indicated by the grey background. DAIR, surgical debridement, antibiotics and implant retention; EA, exchange arthroplasty; PJI, periprosthetic joint infection.
Figure 2
Figure 2
Survival curve of staged exchange arthroplasty free from reinfection by times of debridement, antibiotics and implant retention (DAIR). Follow‐up time was defined as the time from the final staged EA (reimplant date for staged EA) to the date of reinfection, death or study end date (31 December 2020), whichever came first. Censored data (vertical spikes) revealed reinfection. Death was treated as a competing event, while reinfection and study end date were censoring events. Groups: ‘First DAIR with subsequent PJI > 2 years interval’; ‘First DAIR with subsequent PJI < 2 years interval’; ‘Second DAIR with subsequent PJI > 2 years interval’; ‘Second DAIR with subsequent PJI < 2 years interval’; EA, exchange arthroplasty; PJI, periprosthetic joint infection; *p value < 0.05.
Figure 3
Figure 3
Survival curve of staged exchange arthroplasty free from revision by times of debridement, antibiotics and implant retention (DAIR). Follow‐up time was defined as the time from the final staged EA (reimplant date for staged EA) to the date of revision surgery, death, or study end date (31 December 2020), whichever came first. Censored data (vertical spikes) revealed revision surgery. Death was treated as a competing event, while revision and study end date were censoring events. Groups: ‘First DAIR with subsequent PJI > 2 years interval’; ‘First DAIR with subsequent PJI < 2 years interval’; ‘Second DAIR with subsequent PJI > 2 years interval’; ‘Second DAIR with subsequent PJI < 2 years interval’. EA, exchange arthroplasty; PJI, periprosthetic joint infection. *p value < 0.05.
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References

    1. Abdel Khalik, H. , Wood, T.J. , Tushinski, D.M. , Gazendam, A. , Petruccelli, D.T. & Bali, K. et al. (2023) Routine use of antibiotic‐laden bone cement in total knee arthroplasty is a cost‐effective practice in the single‐payer healthcare system. Knee Surgery, Sports Traumatology, Arthroscopy, 31(9), 3847–3853. Available from: 10.1007/s00167-023-07364-5 - DOI - PubMed
    1. Argenson, J.N. , Arndt, M. , Babis, G. , Battenberg, A. , Budhiparama, N. , Catani, F. et al. (2019) Hip and knee section, treatment, debridement and retention of implant: proceedings of international consensus on orthopedic infections. The Journal of Arthroplasty, 34, S399–S419. Available from: 10.1016/j.arth.2018.09.025 - DOI - PubMed
    1. Blom, A.W. , Brown, J. , Taylor, A.H. , Pattison, G. , Whitehouse, S. & Bannister, G.C. (2004) Infection after total knee arthroplasty. The Journal of Bone and Joint Surgery British Volume, 86, 688–691. Available from: 10.1302/0301-620x.86b5.14887 - DOI - PubMed
    1. Blom, A.W. , Taylor, A.H. , Pattison, G. , Whitehouse, S. & Bannister, G.C. (2003) Infection after total hip arthroplasty. The Avon experience. The Journal of Bone and Joint Surgery British Volume, 85, 956–959. Available from: 10.1302/0301-620x.85b7.14095 - DOI - PubMed
    1. Brimmo, O. , Ramanathan, D. , Schiltz, N.K. , Pillai, A.L.P.C. , Klika, A.K. & Barsoum, W.K. (2016) Irrigation and debridement before a 2‐stage revision total knee arthroplasty does not increase risk of failure. The Journal of Arthroplasty, 31, 461–464. Available from: 10.1016/j.arth.2015.08.044 - DOI - PMC - PubMed