Two-stage revision for prosthetic joint infection: predictors of outcome and the role of reimplantation microbiology

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Abstract

Objectives

We describe rates of success for two-stage revision of prosthetic joint infection (PJI), including data on reimplantation microbiology.

Methods

We retrospectively collected data from all the cases of PJI that were managed with two-stage revision over a 4 year period. Patients were managed with an antibiotic-free period before reimplantation, in order to confirm, clinically and microbiologically, that infection was successfully treated.

Results

One hundred and fifty-two cases were identified. The overall success rate (i.e. retention of the prosthesis over 5.75 years of follow-up) was 83%, but was 89% for first revisions and 73% for re-revisions [hazard ratio = 2.9, 95% confidence interval (CI) 1.2–7.4, P = 0.023]. Reimplantation microbiology was frequently positive (14%), but did not predict outcome (hazard ratio = 1.3, 95% CI 0.4–3.7, P = 0.6). Furthermore, most unplanned debridements following the first stage were carried out before antibiotics were stopped (25 versus 2 debridements).

Conclusions

We did not identify evidence supporting the use of an antibiotic-free period before reimplantation and routine reimplantation microbiology. Re-revision was associated with a significantly worse outcome.

Related collections

Most cited references 28

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The use of the Oxford hip and knee scores.

D. Murray, R. Fitzpatrick, K. Rogers … (2007)

The Oxford hip and knee scores have been extensively used since they were first described in 1996 and 1998. During this time, they have been modified and used for many different purposes. This paper describes how they should be used and seeks to clarify areas of confusion.

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Health-related quality of life in total hip and total knee arthroplasty. A qualitative and systematic review of the literature.

Olivier Ethgen, Olivier Bruyère, Florent F. Richy … (2004)

Total hip and total knee arthroplasties are well accepted as reliable and suitable surgical procedures to return patients to function. Health-related quality-of-life instruments have been used to document outcomes in order to optimize the allocation of resources. The objective of this study was to review the literature regarding the outcomes of total hip and knee arthroplasties as evaluated by health-related quality-of-life instruments. The Medline and EMBASE medical literature databases were searched, from January 1980 to June 2003, to identify relevant studies. Studies were eligible for review if they met the following criteria: (1). the language was English or French, (2). at least one well-validated and self-reported health-related quality of life instrument was used, and (3). a prospective cohort study design was used. Of the seventy-four studies selected for the review, thirty-two investigated both total hip and total knee arthroplasties, twenty-six focused on total hip arthroplasty, and sixteen focused on total knee arthroplasty exclusively. The most common diagnosis was osteoarthritis. The duration of follow-up ranged from seven days to seven years, with the majority of studies describing results at six to twelve months. The Short Form-36 and the Western Ontario and McMaster University Osteoarthritis Index, the most frequently used instruments, were employed in forty and twenty-eight studies, respectively. Seventeen studies used a utility index. Overall, total hip and total knee arthroplasties were found to be quite effective in terms of improvement in health-related quality-of-life dimensions, with the occasional exception of the social dimension. Age was not found to be an obstacle to effective surgery, and men seemed to benefit more from the intervention than did women. When improvement was found to be modest, the role of comorbidities was highlighted. Total hip arthroplasty appears to return patients to function to a greater extent than do knee procedures, and primary surgery offers greater improvement than does revision. Patients who had poorer preoperative health-related quality of life were more likely to experience greater improvement. Health-related quality-of-life data are valuable, can provide relevant health-status information to health professionals, and should be used as a rationale for the implementation of the most adequate standard of care. Additional knowledge and scientific dissemination of surgery outcomes should help to ensure better management of patients undergoing total hip or total knee arthroplasty and to optimize the use of these procedures.

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The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection.

David C Classen, R Evans, Stanley Pestotnik … (1992)

Randomized, controlled trials have shown that prophylactic antibiotics are effective in preventing surgical-wound infections. However, it is uncertain how the timing of antibiotic administration affects the risk of surgical-wound infection in actual clinical practice. We prospectively monitored the timing of antibiotic prophylaxis and studied the occurrence of surgical-wound infections in 2847 patients undergoing elective clean or "clean-contaminated" surgical procedures at a large community hospital. The administration of antibiotics 2 to 24 hours before the surgical incision was defined as early; that during the 2 hours before the incision, as preoperative; that during the 3 hours after the incision, as perioperative; and that more than 3 but less than 24 hours after the incision, as postoperative. Of the 1708 patients who received the prophylactic antibiotics preoperatively, 10 (0.6 percent) subsequently had surgical-wound infections. Of the 282 patients who received the antibiotics perioperatively, 4 (1.4 percent) had such infections (P = 0.12; relative risk as compared with the preoperatively treated group, 2.4; 95 percent confidence interval, 0.9 to 7.9). Of 488 patients who received the antibiotics postoperatively, 16 (3.3 percent) had wound infections (P less than 0.0001; relative risk, 5.8; 95 percent confidence interval, 2.6 to 12.3). Finally, of 369 patients who had antibiotics administered early, 14 (3.8 percent) had wound infections (P less than 0.0001; relative risk, 6.7; 95 percent confidence interval, 2.9 to 14.7). Stepwise logistic-regression analysis confirmed that the administration of antibiotics in the preoperative period was associated with the lowest risk of surgical-wound infection. We conclude that in surgical practice there is considerable variation in the timing of prophylactic administration of antibiotics and that administration in the two hours before surgery reduces the risk of wound infection.

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Author and article information

Journal

Journal ID (nlm-ta): J Antimicrob Chemother

Journal ID (publisher-id): jac

Journal ID (hwp): jac

Title: Journal of Antimicrobial Chemotherapy

Publisher: Oxford University Press

ISSN (Print): 0305-7453

ISSN (Electronic): 1460-2091

Publication date (Print): March 2010

Publication date (Electronic): 6 January 2010

Publication date PMC-release: 6 January 2010

Volume: 65

Issue: 3

Pages: 569-575

Affiliations

[1 ]Bone Infection Unit, Nuffield Orthopaedic Centre, Windmill Road, Oxford OX3 7LD, UK

[2 ]Musculoskeletal Biomedical Research Unit, Nuffield Orthopaedic Centre, Windmill Road, Oxford OX3 7LD, UK

[3 ]Nuffield Department of Medicine, Oxford University, John Radcliffe Hospital, Headley Way, Headington OX3 9DU, UK

[4 ]Department of Microbiology, John Radcliffe Hospital, Headley Way, Headington OX3 9DU, UK

Author notes

[* ]Corresponding author. Bone Infection Unit, Nuffield Orthopaedic Centre, Windmill Road, Oxford OX3 7LD, UK. Tel: +44-(0)1865-741841; Fax: +44-(0)1865-738027; E-mail: pbejon@ 123456well.ox.ac.uk

Article

Publisher ID: dkp469

DOI: 10.1093/jac/dkp469

PMC ID: 2818105

PubMed ID: 20053693

SO-VID: 219b834e-a76e-40ed-8076-c3e2798166a6

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/2.5/uk/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 13 October 2009

Date revision requested : 15 November 2009

Date revision received : 22 November 2009

Date accepted : 29 November 2009

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Two-stage revision for prosthetic joint infection: predictors of outcome and the role of reimplantation microbiology

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Abstract

Objectives

Methods

Results

Conclusions

Related collections

Karger: Oncology

Most cited references 28

The use of the Oxford hip and knee scores.

Health-related quality of life in total hip and total knee arthroplasty. A qualitative and systematic review of the literature.

The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection.

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Cited by 54

Most referenced authors 543