What Is the Mid-term Survivorship of Infected Rotating-hinge Implants Treated with One-stage-exchange?
Aged
Arthritis, Infectious
/ etiology
Arthroplasty, Replacement, Knee
/ adverse effects
Female
Humans
Kaplan-Meier Estimate
Knee Prosthesis
/ adverse effects
Male
Middle Aged
Prosthesis Design
Prosthesis-Related Infections
/ surgery
Reoperation
/ methods
Retrospective Studies
Risk Factors
Treatment Outcome
Journal
Clinical orthopaedics and related research
ISSN: 1528-1132
Titre abrégé: Clin Orthop Relat Res
Pays: United States
ID NLM: 0075674
Informations de publication
Date de publication:
01 12 2021
01 12 2021
Historique:
received:
10
02
2021
accepted:
01
06
2021
pubmed:
22
6
2021
medline:
30
11
2021
entrez:
21
6
2021
Statut:
ppublish
Résumé
Despite the growing number of studies reporting on periprosthetic joint infection (PJI), there is little information on one-stage exchange arthroplasty for the revision of infected rotating-hinge prostheses, which can be among the most difficult PJI presentations to treat. After one-stage direct exchange revision for an infected rotating-hinge TKA prosthesis, and using a multimodal approach for infection control, we asked: (1) What is the survivorship free from repeat revision for infection and survivorship free from reoperation for any cause? (2) What is the clinical outcome, based on the Oxford Knee Score, of these patients at the latest follow-up? Between January 2011 and December 2017, we treated 101 patients with infected rotating-hinge knee prostheses at our hospital. All patients who underwent a one-stage exchange using another rotating-hinge implant were potentially eligible for this retrospective study. During that period, we generally used a one-stage approach when treating PJIs. Eighty-three percent (84 of 101) of patients were treated with one-stage exchange, and the remainder were treated with two-stage exchange. Of the 84 treated with one-stage exchange, eight patients died of unrelated causes and were therefore excluded, one patient declined to participate in the study, and another eight patients were lost before the minimum study follow-up of 2 years or had incomplete datasets, leaving 80% (67 of 84) for analysis in this study. The included study population consisted of 60% males (40 of 67) with a mean age of 64 ± 8 years and a mean (range) BMI of 30 ± 6 kg/m2 (21 to 40). The mean number of prior surgeries was 4 ± 2 (1 to 9) on the affected knee. Fifteen percent (10 of 67) of knees had a preoperative joint communicating sinus tract, and 66% (44 of 67) had experienced a prior PJI on the affected knee. The antimicrobial regimen was chosen based on the advice of our infectious disease consultant and individually adapted for the organism cultured. The mean follow-up duration was 6 ± 2 years. Kaplan-Meier survivorship analysis was performed using the endpoints of survivorship free from repeat revision for infection and survivorship free from all-cause revision. The functional outcome was assessed using the Oxford Knee Score (on a 12- to 60-point scale, with lower scores representing less pain and greater function), obtained by interviewing patients for this study at their most recent follow-up visit. Preoperative scores were not obtained. The Kaplan-Meier analysis demonstrated an overall survivorship free from reoperation for any cause of 75% (95% CI 64% to 87%) at the mean follow-up of 6 years postoperatively. Survivorship free from any repeat operative procedure for infection was 90% (95% CI 83% to 97%) at 6 years. The mean postoperative Oxford Knee Score was 37 ± 11 points. With an overall revision rate of about 25% at 6 years and the limited functional results based on the poor Oxford Knee Scores, patients should be counseled to have modest expectations concerning postoperative pain and function level after one-stage exchange of an infected rotating-hinge arthroplasty. Nevertheless, patients may be informed about a reasonable chance of PJI eradication and might opt for this approach as a means to try to avoid high transfemoral amputation or joint arthrodesis, which in this population often is associated with the inability to ambulate at all. Regarding the relatively high number of patients with aseptic loosening, future studies might focus on implant design of revision knee systems as well. A longer course of oral antibiotics after such procedures may also be warranted to limit the chance of reinfection but requires further study. Level IV, therapeutic study.
Sections du résumé
BACKGROUND
Despite the growing number of studies reporting on periprosthetic joint infection (PJI), there is little information on one-stage exchange arthroplasty for the revision of infected rotating-hinge prostheses, which can be among the most difficult PJI presentations to treat.
QUESTIONS/PURPOSES
After one-stage direct exchange revision for an infected rotating-hinge TKA prosthesis, and using a multimodal approach for infection control, we asked: (1) What is the survivorship free from repeat revision for infection and survivorship free from reoperation for any cause? (2) What is the clinical outcome, based on the Oxford Knee Score, of these patients at the latest follow-up?
METHODS
Between January 2011 and December 2017, we treated 101 patients with infected rotating-hinge knee prostheses at our hospital. All patients who underwent a one-stage exchange using another rotating-hinge implant were potentially eligible for this retrospective study. During that period, we generally used a one-stage approach when treating PJIs. Eighty-three percent (84 of 101) of patients were treated with one-stage exchange, and the remainder were treated with two-stage exchange. Of the 84 treated with one-stage exchange, eight patients died of unrelated causes and were therefore excluded, one patient declined to participate in the study, and another eight patients were lost before the minimum study follow-up of 2 years or had incomplete datasets, leaving 80% (67 of 84) for analysis in this study. The included study population consisted of 60% males (40 of 67) with a mean age of 64 ± 8 years and a mean (range) BMI of 30 ± 6 kg/m2 (21 to 40). The mean number of prior surgeries was 4 ± 2 (1 to 9) on the affected knee. Fifteen percent (10 of 67) of knees had a preoperative joint communicating sinus tract, and 66% (44 of 67) had experienced a prior PJI on the affected knee. The antimicrobial regimen was chosen based on the advice of our infectious disease consultant and individually adapted for the organism cultured. The mean follow-up duration was 6 ± 2 years. Kaplan-Meier survivorship analysis was performed using the endpoints of survivorship free from repeat revision for infection and survivorship free from all-cause revision. The functional outcome was assessed using the Oxford Knee Score (on a 12- to 60-point scale, with lower scores representing less pain and greater function), obtained by interviewing patients for this study at their most recent follow-up visit. Preoperative scores were not obtained.
RESULTS
The Kaplan-Meier analysis demonstrated an overall survivorship free from reoperation for any cause of 75% (95% CI 64% to 87%) at the mean follow-up of 6 years postoperatively. Survivorship free from any repeat operative procedure for infection was 90% (95% CI 83% to 97%) at 6 years. The mean postoperative Oxford Knee Score was 37 ± 11 points.
CONCLUSION
With an overall revision rate of about 25% at 6 years and the limited functional results based on the poor Oxford Knee Scores, patients should be counseled to have modest expectations concerning postoperative pain and function level after one-stage exchange of an infected rotating-hinge arthroplasty. Nevertheless, patients may be informed about a reasonable chance of PJI eradication and might opt for this approach as a means to try to avoid high transfemoral amputation or joint arthrodesis, which in this population often is associated with the inability to ambulate at all. Regarding the relatively high number of patients with aseptic loosening, future studies might focus on implant design of revision knee systems as well. A longer course of oral antibiotics after such procedures may also be warranted to limit the chance of reinfection but requires further study.
LEVEL OF EVIDENCE
Level IV, therapeutic study.
Identifiants
pubmed: 34153008
doi: 10.1097/CORR.0000000000001868
pii: 00003086-202112000-00026
pmc: PMC8726537
doi:
Types de publication
Evaluation Study
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
2714-2722Commentaires et corrections
Type : CommentIn
Informations de copyright
Copyright © 2021 by the Association of Bone and Joint Surgeons.
Déclaration de conflit d'intérêts
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.
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