Orthopaedic Knowledge Update®: Musculoskeletal Infection 2 Print + Ebook (AAOS - American Academy of Orthopaedic Surgeons)

Section 4: Prosthetic Joint Infections

defensin. Alpha-defensin did not change the diagnosis in any case. Level of evidence: IV. 44. Feldman DS, Lonner JH, Desai P, Zuckerman JD: The role of intraoperative frozen sections in revision total joint arthro plasty. J Bone Joint Surg Am 1995;77(12):1807-1813. 45. Della Valle CJ, Bogner E, Desai P, et al: Analysis of fro zen sections of intraoperative specimens obtained at the time of reoperation after hip or knee resection arthro plasty for the treatment of infection. J Bone Joint Surg Am 1999;81(5):684-689. 46. Bori G, Soriano A, García S, Mallofré C, Riba J, Mensa J: Usefulness of histological analysis for predicting the presence of microorganisms at the time of reimplantation after hip resection arthroplasty for the treatment of infection. J Bone Joint Surg Am 2007;89(6):1232-1237. 47. Logoluso N, Pellegrini A, Suardi V, et al: Can the leukocyte esterase strip test predict persistence of periprosthetic joint infection at second-stage reimplantation? J Arthroplasty 2022;37(3):565-573. This study showed promising results for leukocyte esterase strips in predicting persistence of PJI at reimplantation in 76 patients. The retrospective study demonstrated that sensitivity, specificity, positive predictive value, and negative predictive value of the leukocyte esterase assay were 82%, 99%, 90%, and 97%, respectively. Level of evidence: IV. 48. Ma CY, Lu YD, Bell KL, et al: Predictors of treatment failure after 2-stage reimplantation for infected total knee arthroplasty: A 2-to 10-year follow-up. J Arthroplasty 2018;33(7):2234-2239. Retrospective review of 108 knees that underwent two-stage exchange for infection. Authors report obesity, >4 hour OR time, gout, and Enterococcus species as risk factors for failure of two stage treatment. Level of evidence: IV. 49. Wang Q, Goswami K, Kuo FC, Xu C, Tan TL, Parvizi J: Two-stage exchange arthroplasty for periprosthetic joint infection: The rate and reason for the attrition after the first stage. J Arthroplasty 2019;34(11):2749-2756. This study analyzed 111 patients who never went on to reim plantation: 29 patients (26%) did well with their spacer, 23 (21%) underwent salvage procedure, and 59 (53%) were medically unfit. Level of evidence: IV. 50. Fillingham YA, Della Valle CJ, Suleiman LI, et al: Definition of successful infection management and guide lines for reporting of outcomes after surgical treatment of periprosthetic joint infection: From the Workgroup of the Musculoskeletal Infection Society (MSIS). J Bone Joint Surg Am 2019;101(14):e69. This is a workgroup consensus on defining outcomes for consistent reporting after PJI. Level of evidence: V. 51. Houdek MT, Wagner ER, Watts CD, et al: Morbid obesity: A significant risk factor for failure of two-stage revision total hip arthroplasty for infection. J Bone Joint Surg Am 2015;97(4):326-332. 52. Watts CD, Wagner ER, Houdek MT, et al: Morbid obesity: A significant risk factor for failure of two-stage revision

total knee arthroplasty for infection. J Bone Joint Surg Am 2014;96(18):e154. 53. Mittal Y, Fehring TK, Hanssen A, Marculescu C, Odum SM, Osmon D: Two-stage reimplantation for periprosthetic knee infection involving resistant organisms. J Bone Joint Surg Am 2007;89(6):1227-1231. 54. McPherson EJ, Woodson C, Holtom P, Roidis N, Shufelt C, Patzakis M: Periprosthetic total hip infection: Outcomes using a staging system. Clin Orthop Relat Res 2002;403:8-15. 55. Fehring KA, Abdel MP, Ollivier M, Mabry TM, Hanssen AD: Repeat two-stage exchange arthroplasty for periprosthetic knee infection is dependent on host grade. J Bone Joint Surg Am 2017;99(1):19-24. 56. Barton CB, Wang DL, An Q, Brown TS, Callaghan JJ, Otero JE: Two-stage exchange arthroplasty for periprosthetic joint infection following total hip or knee arthroplasty is asso ciated with high attrition rate and mortality. J Arthroplasty 2020;35(5):1384-1389. This retrospective study analyzed 89 patients who underwent resection arthroplasty with a planned second stage. Only 61 patients (69%) underwent reimplantation; of those, 9 (15%) had repeat infection. The mortality rate was 23.6% (21 of 89 patients). Level of evidence: IV. 57. Siddiqi A, Nace J, George NE, et al: Primary total knee arthroplasty implants as functional prosthetic spacers for definitive management of periprosthetic joint infection: A multicenter study. J Arthroplasty 2019;34(12):3040-3047. This study reviewed 137 patients with all-cement dynamic spacers and 57 patients with low-friction spacers and found no significant differences. However, low-friction spacers resulted in decreased rates of infection (14.0% versus 24.1%) and revision surgery (19.3% versus 27.7%), and increased range of motion (106° versus 102°) and improved success rates (78.9% versus 70.8%; P > 0.05 for all). Level of evidence: IV. 58. Nabet A, Sax OC, Shanoada R, et al: Survival and outcomes of 1.5-stage vs 2-stage exchange total knee arthroplasty following prosthetic joint infection. J Arthroplasty 2022;37(5):936-941. This study compared 114 patients who underwent a revision with a low-friction articulating spacer and 48 who underwent a two-stage revision with a traditional spacer. Outcomes were improved in the articulating group; however, the study was biased because not all two-stage spacers were articulating and the two-stage population was evaluated long before the low-friction spacer population was. Level of evidence: IV. 59. Hernandez NM, Buchanan MW, Seyler TM, Wellman SS, Seidelman J, Jiranek WA: 1.5-stage exchange arthroplasty for total knee arthroplasty periprosthetic joint infections. J Arthroplasty 2021;36(3):1114-1119.

Section 4: Prosthetic Joint Infections

This study of 31 patients concluded that 1.5-stage exchange arthroplasty may be reasonable, with 25 patients (81%) hav ing retained spacers at 2.7 years. Level of evidence: IV. 60. George DA, Haddad FS: One-stage exchange arthroplasty: A surgical technique update. J Arthroplasty 2017;32(9 suppl):S59-S62. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2023


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Orthopaedic Knowledge Update ® : Musculoskeletal Infection 2

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