Barry JJ, Geary MB, Riesgo AM, Odum SM, Fehring TK, Springer BD

J Bone Joint Surg Am. 2020 Oct 20.
doi: 10.2106/JBJS.20.00240
PMID: 33079900

Summary by: Clay Townsend, BS

Periprosthetic joint infection (PJI) is a rare but devastating and costly complication following total knee arthroplasty (TKA).^1.2 Common treatment options include 2-stage exchange or I&D with antibiotic suppression, both of which are widely reported in the literature for the treatment of PJI after TKA.³ Less understood is the treatment of  PJI following revision TKA (rTKA), which can be particularly challenging, especially in the setting of extensive instrumentation.⁴

In this study, Barry et al. retrospectively investigated the outcomes of two different treatment options – 2-stage exchange or I&D with antibiotic suppression – for PJI in patients with rTKA with extensive instrumentation. Extensive instrumentation was defined as having one or more of the following characteristics: metaphyseal cones/sleeves, distal femoral replacement, periprosthetic fracture instrumentation (plate, nail, or both), or fully cemented stems measuring longer than 75 mm. Thirty-one patients were treated with 2-stage exchange and 56 patients underwent I&D with poly exchange and antibiotic suppression. There were no differences between the two treatment groups in duration of follow up, basic demographics, or perioperative characteristics, except for the 2-stage group having longer duration of preoperative symptoms and more patients with loose components.

At 2 and 5 years postoperatively, there were no differences in the rate of survival free of reoperation for infection or in the mortality rates between the two treatment groups. At a minimum of 2 year follow up, there were no differences between the two groups in the rates of reoperation for infection (37.5% in the I&D group versus 32.3% in the 2-stage group; p=0.62). In the 2-stage group, 13/31 (41.9%) patients had successful reimplantation without requiring additional reoperation for infection. In the I&D group, 35/56 (62.5%) patients were treated successfully without requiring additional reoperation for infection. Notably, the I&D group was found to have significantly greater proportions of patients who were ambulatory (76.8%, versus 54.8% in the 2-stage group; p=0.05), and also who had a functional knee arthroplasty (85.7%, versus 45.2% in the 2-stage group; p<0.001) at final follow up.

This study’s findings suggest that 2-stage exchange and I&D with antibiotic suppression result in similar rates of PJI control in patients with rTKA with extensive instrumentation. Additionally, I&D may result in more favorable functional outcomes in this specific patient population. This study’s retrospective nature introduces the inherent selection bias in treatment choice for patients in the two groups. Additionally, this study included patients treated by 8 surgeons over a 12 year period, with potential heterogeneity in treatment and management. Further studies with larger cohorts are needed to substantiate these findings.

References:

1. Kurtz SM, Lau E, Schmier J, Ong KL, Zhao K, Parvizi J. Infection burden for hip and knee arthroplasty in the United States. J Arthroplasty. 2008;23(7):984-991. doi:10.1016/j.arth.2007.10.017
2. Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J. Economic burden of periprosthetic joint infection in the United States. J Arthroplasty. 2012;27(8 Suppl):61-5.e1. doi:10.1016/j.arth.2012.02.022
3. Sherrell JC, Fehring TK, Odum S, et al. The Chitranjan Ranawat Award: fate of two-stage reimplantation after failed irrigation and débridement for periprosthetic knee infection. Clin Orthop Relat Res. 2011;469(1):18-25. doi:10.1007/s11999-010-1434-1
4. Kheir MM, Tan TL, Gomez MM, Chen AF, Parvizi J. Patients With Failed Prior Two-Stage Exchange Have Poor Outcomes After Further Surgical Intervention. J Arthroplasty. 2017;32(4):1262-1265. doi:10.1016/j.arth.2016.10.008