It has generally been believed that the infection rate after revision TKA is substantially higher than the infection rate after primary TKA [12, 27, 41]. However, the rate of infection after revision TKA varies greatly between 0% and 10% according to different studies [10, 11, 13, 14, 25, 29, 34, 35, 37]. The majority, if not all, of previous studies evaluate the incidence of infection after revision for aseptic failure. We conceived this study to examine the rate of periprosthetic infection after revision TKA, to identify the current microorganisms involved in infections after revision, and to determine risk factors for infection after revision TKA.
We acknowledge some limitations of our study. First, because of the retrospective design, the study is likely to have been affected by confounding variables that could not be controlled, including variability in data collection, potential bias, and missing data for some patients. Despite all efforts, some data could not be collected. However, we did not believe the missing data were critical to influence the conclusions of this study. The prospective and strict data collection process that was in place, however, should have reduced the influence of some the aforementioned variables in the analysis. Second, because of the relatively low incidence of infections after revision TKA, our analysis may have failed to detect some important risk factors. However, the study is based on a relatively large cohort of patients who underwent revision arthroplasty in one institution over a relatively short period of time and who were subjected to the same care protocols. Third, because it was not our intention to report all-time incidence of infection, but merely to follow patients for at least 2 years after revision, the true incidence of infection in this cohort is likely underestimated. Fourth, the limitation of current diagnostic methods to identify infection or isolate the infecting organism may result in erroneously categorizing these patients into aseptic failures. Finally, we didn't evaluate postoperative risk factors for infection. The adverse influence of perioperative complications such as hematoma and wound problem on the subsequent infection is well-known.
Our data demonstrate the rate of infection after revision arthroplasty at 9.2% is considerably higher than the rate of infection after primary TKA at 0.5% to 1% at our institute . It also demonstrates the rate of infection after revision for septic reasons is over fourfold higher than the rate of infection after revision TKA for aseptic reasons. The latter is not difficult to understand because numerous studies have identified history of infection as an important predictor for periprosthetic infection [2, 30]. However, the rate of infection after revision for aseptic reason is still fivefold higher than the rate of infection after primary TKA. It is plausible periprosthetic infection was indeed the cause of failure of TKA in these patients but escaped detection using conventional methods for diagnosis.
We found the Gram-positive organisms S. aureus and S. epidermidis were the most frequently isolated microorganisms from infected revision TKA. The distribution of pathogens was comparable to those causing primary TKA infections [4, 23, 28, 33] (Table 3). In approximately one-fourth of patients who had clinically diagnosed infection, no pathogens could be cultured in infected primary or revision knees. The most important reported reason for negative cultures is the inappropriate administration of antibiotics before aspiration .
Our study also revealed some factors known to predispose patients to infection. Although all the previous studies identifying these risk factors for infection were conducted in cohorts of patients undergoing primary TKA, it is not surprising to observe these factors as being important predictors of infection after revision TKA also [23, 27, 28, 30, 40] (Table 4). Diagnosis other than osteoarthritis and medical comorbidities were among those factors. Other important risk factors for infection such as diabetes and obesity were not independent risk factors in the logistic regression analysis. The latter may relate to the relatively small sample size of patients with events (infection) (ie, Type II error). While operative time or blood transfusion [24, 30] did not predict failure, our findings may relate to the complexity of revision surgery, the relatively long operative times, and the large number of patients who received transfusions; thus, we could not definitely determine the relative importance of these factors. We did not differentiate between early and late infection following revision in the analysis for risk factors for several reasons. First, we think that the presence of risk factors predisposes the patients to infection even as a late event. Additionally, there is no clear cut-off point to categorize acute and chronic infections. Finally, it is possible that some of these patients with late infection may have had contamination during surgery leading to infection that declared itself at a later date. The failure rate of surgical treatment of infected TKA was considerably higher when one-stage exchange arthroplasty or irrigation and débridement together with exchange of polyethylene was attempted. The failure was also higher if the infecting organism exhibited methicillin resistance. Taken together, these issues raise the question as to whether irrigation and débridement or one-stage exchange arthroplasty should be attempted in patients with periprosthetic infection, particularly those caused by resistant organisms. In an analysis conducted by the Periprosthetic Infection Study Group that collates data from multiple centers, failure of irrigation and débridement was higher than 70% for infections caused by methicillin-resistant organisms [6, 17, 31]. Based on these findings, we do not currently advocate irrigation and débridement or one-stage exchange arthroplasty for periprosthetic infection caused by methicillin-resistant organisms, even for early infections. Even with two-stage exchange arthroplasty, reinfection or recurrence of infection still occurs in 9% to 14% of patients . The failure rate of two-stage exchange arthroplasty in our series was somewhat higher at 21%. Of the 80 patients who had a previous infection and underwent revision TKA, 17 experienced a subsequent prosthetic joint infection. One major reason for the higher failure rate in our series may relate to definition of failure, which was described as need for any further surgical intervention or antibiotic treatment. The incidence of initial infection with methicillin-resistant organisms was also much higher in our series, which may have contributed to the higher failure rates observed by other investigators [17, 31]. Our institutional protocols use multiple methods, including serologic tests and aspiration of the joint for cell count, neutrophil percentage, and culture, before reimplantation. Despite these strict protocols, some of the reinfections were caused by the same initial infecting organism pointing to the possibility that persistence of infection was responsible for failure in some of these patients. The latter again highlights the limitations of current diagnostic modality for PJI that fails to detect an organism in some cases. With improvements in diagnosis of periprosthetic infection such as sonication  or the use of molecular techniques , we believe more of these patients with “aseptic” failures will be correctly diagnosed as infected and treated appropriately. In a study by Bongartz et al., the rate of periprosthetic infection was 3.5% in patients with a history of infection in other prosthetic joints . The rate of infection increased to 29.9% in a joint that had previously been treated for periprosthetic infection. The authors concluded reinfections are the result of undetected persistence of bacteria and not the result of general host susceptibility to infections . One drawback of the latter study, however, is it did not consider revision surgery as a potential confounding factor for increased risk of infection.
It appears that the risk of infection after revision TKA is considerably higher than infection after primary TKA. Treating periprosthetic infection following revision TKA remains challenging. All efforts should be made to minimize this complication. Thorough preoperative evaluation of all patients undergoing revision TKA is an important strategy if unexpected infections following revision TKA are to be minimized.
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