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Outcome of Revision Surgery for Infection After Total Knee Arthroplasty

Results of 3 Surgical Strategies

Leta, Tesfaye H. MPhil, PhD1,2,3; Lygre, Stein Håkon L. PhD1,4; Schrama, Jan C. MD, PhD1; Hallan, Geir MD, PhD1,5; Gjertsen, Jan-Erik MD, PhD1,5; Dale, Håvard MD, PhD1; Furnes, Ove MD, PhD1,5

doi: 10.2106/JBJS.RVW.18.00084
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Background: Periprosthetic joint infection (PJI) after knee arthroplasty surgery remains a serious complication, yet there is no international consensus regarding the surgical treatment of PJI. This study aimed to assess prosthesis survival rates, risk of revision, and mortality rate following different surgical strategies (1-stage versus 2-stage implant revision and irrigation and debridement with implant retention) that are used to treat PJI.

Methods: The study was based on 644 total knee arthroplasties (TKAs) that were revised because of a deep infection (i.e., surgically treated PJI) and reported to the Norwegian Arthroplasty Register (NAR) from 1994 to 2016. Kaplan-Meier and multiple Cox regression analyses were performed to assess implant survival rate and risk of revision. We also studied mortality rates at 90 days and 1 year after revision for PJI.

Results: During the follow-up period, 19% of the irrigation and debridement cases, 14% of the 1-stage revision cases, and 12% of the 2-stage revision cases underwent a subsequent revision because of a PJI. The 5-year Kaplan-Meier survival rate with revision for infection as the end point was 79% after irrigation and debridement, 87% after 1-stage revision, and 87% after 2-stage revision. There were no significant differences between 1-stage and 2-stage revisions with subsequent revision for any reason as the end point (relative risk [RR], 1.7; 95% confidence interval [CI], 0.9 to 3.5) and no difference with revision because of infection as the end point (RR, 1.6; 95% CI, 0.7 to 3.7). In an age-stratified analysis, however, the risk of revision for any reason was 4 times greater after 1-stage revision than after 2-stage revision in patients over the age of 70 years (RR, 4.3; 95% CI, 1.3 to 14.8). Age had no significant effect on the risk of subsequent revision for knees that had been revised with the irrigation and debridement procedure. The 90-day and 1-year mortality rates after revision for PJI were 1.2% and 2.5%, respectively.

Conclusions: Irrigation and debridement yielded good results compared with previous published studies. Although the 1-stage revisions resulted in a fourfold increase in risk of subsequent revision compared with the 2-stage revisions in older patients, the overall outcomes after 1-stage and 2-stage revisions were similar.

Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

1Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway

2VID Specialized University, Bergen, Norway

3Haraldsplass Diaconal Hospital, Bergen, Norway

4Department of Occupational Medicine, Haukeland University Hospital, Bergen, Norway

5Institute for Clinical Medicine, University of Bergen, Bergen, Norway

E-mail address for T.H. Leta: tesfaye.hordofa.leta@helse-bergen.no

Investigation performed at the Norwegian Arthroplasty Register, Haukeland University Hospital, Bergen, Norway

Disclosure: The authors indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/A446).

Copyright © 2019 by The Journal of Bone and Joint Surgery, Incorporated
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