Friday, September 25, 2015

Managing periprosthetic infections: Is there a place for spacers and the two-stage?

The Fate of Spacers in the Treatment of Periprosthetic Joint Infection.

These authors identified 504 cases of periprosthetic joint infection (326 knees and 178 hips) treated with resection arthroplasty and spacer insertion as part of a two-stage exchange arthroplasty. 

The mean follow-up duration after initial spacer implantation was 56.2 months. Reimplantation occurred in the joints of 83% of 504 cases. Of these 417 cases, 80% had a minimum one-year follow-up, and 82% of these had successful treatment. The mean duration from resection arthroplasty to reimplantation was 4.2 months (range, 0.7 to 131.7 months). 12% of the 504 joints required interim spacer exchange(s). Of the eighty-seven cases that did not undergo reimplantation, 7% required amputation, 6% underwent a Girdlestone procedure, 5% underwent arthrodesis, and 83% underwent spacer retention. Thirty-six patients died in the interstage period.

Thus of the 504 cases, one out of five did not complete the second stage of the planned two-stage treatment. Of those who did, one out of seven had a subsequent infection.

The authors concluded that the commonly held belief that two-stage exchange arthroplasty carries a high success rate for the eradication of periprosthetic joint infection may need to be reexamined. A considerable number of patients undergoing the first stage of a two-stage procedure did not undergo a subsequent reimplantation for a variety of reasons or required an additional spacer exchange in the interim. Reports on the success of two-stage exchange should account for the mortality of these patients and for patients who never undergo reimplantation.

Comment: This is an article about the use of antibiotic impregnated spacers which, for many, is the preferred method for the management of hip and knee periprosthetic infections. We include it on the shoulder blog because the analysis is compelling and it seems reasonable to believe that the results for the use of spacers in the shoulder would be similar.

The culture results of this study (shown below) are interesting. We can wonder if some of the culture negative joints might have had Propionibacterium that could have been overlooked because the challenging culture approaches for this organism were not in place.

We would like to call attention to related study: Comparison of one and two-stage revision of total hip arthroplasty complicated by infection: a Markov expected-utility decision analysis. These authors reviewed the literature on the treatment of patients with infected total hip arthroplasties and used these data to conduct a Markov cohort simulation decision analysis. They found that the 12 month and the 10 year models favored direct-exchange revision over the two-stage approach, regardless of whether surgeon or patient-derived utilities were used. 

We use a single stage primary exchange to a hemiarthroplasty for cases of suspected periprosthetic shoulder infections, recognizing that the diagnosis of an infection may not be made until week after the procedure. Our approach is described in greater detail here.


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