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. 2025 Jan 14;37(1):4.
doi: 10.1186/s43019-025-00258-5.

Risk factors of recurrent periprosthetic joint infection of the knee after two-stage reimplantation

Do Weon Lee  1   2 , Hyuk-Soo Han  2   3 , Du Hyun Ro  4   5   6   7
Affiliations

Risk factors of recurrent periprosthetic joint infection of the knee after two-stage reimplantation

Do Weon Lee et al. Knee Surg Relat Res. .

Abstract

Introduction: Prosthetic joint infection (PJI) is one of the most common and detrimental complications of total knee replacement arthroplasty (TKA). Despite extensive efforts, including two-stage reimplantation, to eradicate PJI, it still recurs in a substantial number of patients. However, the risk factors of recurrence after two-stage reimplantation of the knee have not been established. In this study, it is hypothesized that there will be certain risk factors of recurrence after two-stage reimplantation for PJI of the knee.

Materials and methods: From March 2002 to December 2022, 65 knees that underwent two-stage reimplantation for PJIs in a single, tertiary hospital were retrospectively reviewed, and 44 patient-related, laboratory-related, and surgery-related factors, including body mass index, pathogen type, and the usage of transfusions, were selected as the potential risk factors for recurrence. Survival analysis using the Kaplan-Meier method and subsequent Cox proportional hazard regression were performed.

Results: Out of the 65 knees that underwent two-stage reimplantation, infection recurred in 15 knees (23.1%) in a median 11 (range 4-108) months. The Cox proportional hazards regression showed that infection of revision TKA, mixed pathogen-type infection, and higher serum erythrocyte sedimentation rate (ESR, mm/h) level increases the risk of recurrence (p-values < 0.001, 0.04, and 0.009; hazard ratios 40.29, 1.53, and 1.03, respectively).

Conclusions: A significant portion of PJI of the knees recurred after two-stage reimplantation. Revision TKA at the time of initial PJI, mixed pathogen-type infection, and higher serum ESR level were three significant risk factors of PJI recurrence. Surgeons should be more cautious in suspecting PJI relapse for these specific occasions.

Level of evidence: III, retrospective cohort study.

Keywords: Prosthesis-related infection; Survival analysis; Total knee arthroplasty.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: This study was approved by the Institutional Review Board of Seoul National University Hospital (no. H. 0812-019-265). Due to the retrospective nature and anonymity, the study was exempt from the requirement of obtaining informed consent. Competing interests: The corresponding author, D.H.R., is the CEO of CONNECTEVE Co., Ltd. However, this had no effect on the results of our research. No other author reports conflict of interest.

Figures

Fig. 1
Fig. 1
Flow chart of patient selection in the study
Fig. 2
Fig. 2
PJI relapse survival curve of the study patients (whole). PJI, prosthetic-joint infection
Fig. 3
Fig. 3
PJI relapse survival curve of the patients according to the type of surgery before the initial prosthetic joint infection (primary TKA versus revision TKA). PJI, prosthetic joint infection; TKA, total knee replacement arthroplasty
Fig. 4
Fig. 4
PJI relapse survival curve of the patients according to the type of pathogen that caused the initial PJI; comparison between all four pathogen types (a) and non-mixed pathogen type versus mixed pathogen type (b). PJI, prosthetic joint infection; G( +), Gram positive; G(−), Gram negative; non-mixed, non-mixed pathogen type; mixed, mixed pathogen type
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