Does the Implementation of the PRO-IMPLANT Foundation Treatment Algorithm Improve the Outcome of Chronic Periprosthetic Knee Infections? Mid-Term Results of a Prospective Study

Abstract

Background Several treatment options for chronic periprosthetic joint infections have been published in the current literature, with an on-going discussion to determine effective management algorithms.

Objectives To compare outcomes of the two-stage exchange procedure in revision TKA prior to and after implementation of the PRO-IMPLANT Foundation treatment algorithm. The primary endpoints were defined as (i) revisions during the interval time, (ii) duration of the interval time and (iii) successful PJI eradication.

Material and Methods Between 02/2013 and 09/2016, 122 patients were included in a single-centre cohort analysis. 55 patients were treated according to the previously used algorithm (K1) and 67 according to the PRO-IMPLANT Foundation algorithm (K2). A minimum follow-up period of 3 years was set as the inclusion criterion. Successful eradication of infection was defined in accordance with the consensus criteria by Diaz-Ledezma et al.

Results Successful eradication was achieved in 42 (67%) patients in K1 and 47 (85.5%) in K2 (p ≤ 0.005). The mean interval time was 88 days (range 51 – 353) in K1 and 52 days (range 42 – 126) in K2 (p ≤ 0.005). In K1, a mean of 0.8 (range 0 – 6) revisions were necessary during the interval period compared with 0.5 (range 0 – 4) in K2 (p = 0.066).

Conclusion Implementation of the PRO-IMPLANT treatment algorithm led to significant improvement in the outcome of periprosthetic joint infections. During mid-term follow-up, infection eradication was highly successful, with decreases in the interval time as well as the number of revisions.

Key words

PJI - revision arthroplasty - TKA - PRO-IMPLANT Foundation - two-stage revision arthroplasty

• References/Literatur

• 1 Schwarz EM, Parvizi J, Gehrke T. et al. 2018 International Consensus Meeting on Musculoskeletal Infection: Research Priorities from the General Assembly Questions. J Orthop Res 2019; 37: 997-1006
• 2 Parvizi J, Tan TL, Goswami K. et al. The 2018 Definition of Periprosthetic Hip and Knee Infection: An Evidence-Based and Validated Criteria. J Arthroplasty 2018; 33: 1309-1314.e2
• 3 Osmon DR, Berbari EF, Berendt AR. et al. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2013; 56: e1-e25
• 4 McNally M, Sousa R, Wouthuyzen-Bakker M. et al. The EBJIS definition of periprosthetic joint infection. Bone Joint J 2021; 103-B: 18-25
• 5 Renz N, Perka C, Trampuz A. [Management of periprosthetic infections of the knee]. Orthopade 2016; 45: 65-71
• 6 Izakovicova P, Borens O, Trampuz A. Periprosthetic joint infection: current concepts and outlook. EFORT Open Rev 2019; 4: 482-494
• 7 Qasim SN, Swann A, Ashford R. The DAIR (debridement, antibiotics and implant retention) procedure for infected total knee replacement – a literature review. SICOT J 2017; 3: 2
• 8 Parvizi J, Zmistowski B, Adeli B. Periprosthetic joint infection: treatment options. Orthopedics 2010; 33: 659
• 9 Aalirezaie A, Abolghasemian M, Busato T. et al. Hip and Knee Section, Treatment, Two-Stage Exchange: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34 (2 Suppl.): S439-S443
• 10 Lieb E, Hanstein T, Schuerings M. et al. [Reduction of Treatment Duration in Periprosthetic Infection with a Fast-Track Concept Is Economically Not Feasible]. Z Orthop Unfall 2015; 153: 618-623
• 11 Parvizi J, Gehrke T, Chen AF. Proceedings of the International Consensus on Periprosthetic Joint Infection. Bone Joint J 2013; 95-B: 1450-1452
• 12 Diaz-Ledezma C, Higuera CA, Parvizi J. Success after treatment of periprosthetic joint infection: a Delphi-based international multidisciplinary consensus. Clin Orthop Relat Res 2013; 471: 2374-2382
• 13 Morawietz L, Classen RA, Schroder JH. et al. Proposal for a histopathological consensus classification of the periprosthetic interface membrane. J Clin Pathol 2006; 59: 591-597
• 14 Rakow A, Perka C, Trampuz A. et al. Origin and characteristics of haematogenous periprosthetic joint infection. Clin Microbiol Infect 2019; 25: 845-850
• 15 Schäfer P, Fink B, Sandow D. et al. Prolonged bacterial culture to identify late periprosthetic joint infection: a promising strategy. Clin Infect Dis 2008; 47: 1403-1409
• 16 Ascione T, Barrack R, Benito N. et al. General Assembly, Diagnosis, Pathogen Isolation – Culture Matters: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34 (2 Suppl.): S197-S206
• 17 Li C, Renz N, Trampuz A. et al. Twenty common errors in the diagnosis and treatment of periprosthetic joint infection. Int Orthop 2020; 44: 3-14
• 18 Peel TN, Dylla BL, Hughes JG. et al. Improved Diagnosis of Prosthetic Joint Infection by Culturing Periprosthetic Tissue Specimens in Blood Culture Bottles. MBio 2016; 7: e01776-15
• 19 Trampuz A, Hanssen AD, Osmon DR. et al. Synovial fluid leukocyte count and differential for the diagnosis of prosthetic knee infection. Am J Med 2004; 117: 556-562
• 20 Aalirezaie A, Bauer TW, Fayaz H. et al. Hip and Knee Section, Diagnosis, Reimplantation: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34 (2 Suppl.): S369-S379
• 21 Boelch SP, Roth M, Arnholdt J. et al. Synovial Fluid Aspiration Should Not Be Routinely Performed during the Two-Stage Exchange of the Knee. Biomed Res Int 2018; 2018: 6720712
• 22 Hoell S, Moeller A, Gosheger G. et al. Two-stage revision arthroplasty for periprosthetic joint infections: What is the value of cultures and white cell count in synovial fluid and CRP in serum before second stage reimplantation?. Arch Orthop Trauma Surg 2016; 136: 447-452
• 23 Ascione T, Balato G, Mariconda M. et al. Continuous Antibiotic Therapy Can Reduce Recurrence of Prosthetic Joint Infection in Patients Undergoing 2-Stage Exchange. J Arthroplasty 2019; 34: 704-709
• 24 Bettencourt A, Calado A, Amaral J. et al. The influence of vacuum mixing on methylmethacrylate liberation from acrylic cement powder. Int J Pharm 2001; 219: 89-93
• 25 Abdel MP, Barreira P, Battenberg A. et al. Hip and Knee Section, Treatment, Two-Stage Exchange Spacer-Related: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34 (2 Suppl.): S427-S438
• 26 Nelson CL, Evans RP, Blaha JD. et al. A comparison of gentamicin-impregnated polymethylmethacrylate bead implantation to conventional parenteral antibiotic therapy in infected total hip and knee arthroplasty. Clin Orthop Relat Res 1993; (295) 96-101
• 27 Bernard L, Arvieux C, Brunschweiler B. et al. Antibiotic Therapy for 6 or 12 Weeks for Prosthetic Joint Infection. N Engl J Med 2021; 384: 1991-2001
• 28 Prendki V, Sergent P, Barrelet A. et al. Efficacy of indefinite chronic oral antimicrobial suppression for prosthetic joint infection in the elderly: a comparative study. Int J Infect Dis 2017; 60: 57-60
• 29 Troendlin F, Frieler S, Hanusrichter Y. et al. Persistent Fistula for Treatment of a Failed Periprosthetic Joint Infection: Relic From the Past or a Viable Salvage Procedure?. J Arthroplasty 2020; 35: 544-549
• 30 Hungerer S, Kiechle M, von Ruden C. et al. Knee arthrodesis versus above-the-knee amputation after septic failure of revision total knee arthroplasty: comparison of functional outcome and complication rates. BMC Musculoskelet Disord 2017; 18: 443
• 31 Balato G, Rizzo M, Ascione T. et al. Re-infection rates and clinical outcomes following arthrodesis with intramedullary nail and external fixator for infected knee prosthesis: a systematic review and meta-analysis. BMC Musculoskelet Disord 2018; 19: 361