February 01, 2015
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No link seen between delayed reimplantation after resection arthroplasty and outcome

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DALLAS —Despite a commonly held notion that surgeons should delay reimplantation after the first resection arthroplasty in patients undergoing two-stage exchange arthroplasty for periprosthetic joint infection, results of a recently presented study showed the timing between the first and second stage procedures did not influence the outcome of infection control.

“This is a retrospective study and the timing between the first and second [stage] was at the discretion of the surgeon who was operating on the patients,” Javad Parvizi, MD, FRCS, of the Rothman Institute, said during his presentation at in his presentation the American Association of Hip and Knee Surgeons Annual Meeting. “But it does appear [that] delaying reimplantation in this group of patients did not seem to confer better benefit in terms of the success rate of the two-stage exchange.”

Javad Parvizi

Javad Parvizi

Two-stage exchange

Using data from the Rothman Institute and the Rush University Medical Center, Parvizi and his colleagues identified 607 patients with periprosthetic joint infection (PJI) who were treated with two-stage exchange arthroplasty between 2002 and 2012. Researchers determined the time between resection and reimplantation, and defined delayed reimplantation as one that occurred after 3 months from the first resection arthroplasty. They defined failure as the need for further surgical intervention for the treatment of PJI. From the time of reimplantation, the mean duration of follow up was 2.4 ± 1.9 years.

Overall, the investigators found a 22% failure rate. “The predictors of failure were infection with antibiotic-resistant organisms, obesity and also the need to undergo an interim spacer exchange between the first and the second stage,” Parvizi said. “Time to reimplantation was not a predictor of failure of the two-stage exchange.”

Patients in the delayed group had more spacer exchanges and were more likely to be infected with antibiotic-resistant organisms or polymicrobial infections than the comparison group. However, the groups had a similar Charlson Comorbidity Index (CCI).

“The time to reimplantation did not appear to make a difference to the success rate of two-stage exchange arthroplasty,” Parvizi said noting the 22% failure rate was higher than others reported in the literature due to the researchers’ strict definition of success.

Immunocompetence

While the CCI is related to higher risks of complications after joint replacement, Parvizi noted that research has not shown whether it is related to immunocompetence of the patient.

“There are patients who suffer from primary immune deficiency who, despite having no other severe comorbidities, are at very high risk of developing infection,” Parvizi said during the paper discussion session. “There has to be some sort of metric to assess the immunocompetence of these patients. At this point, I do not know what the metric is but hopefully, with time and more patients in the cohort, we should be able to assess how to subject our immunocompromised patients to elective arthroplasty or at least try to optimize them preoperatively.” – by Casey Tingle

Reference:

Tokarski AT. Paper #27. Presented at: American Association of Hip and Knee Surgeons Annual Meeting; Nov. 6-9, 2014; Dallas.

For more information:

Javad Parvizi, MD, FRCS, can be reached at the Rothman Institute, 925 Chestnut St., Philadelphia, PA 19107; email: parvj@aol.com.
Disclosure: Parvizi is a consultant for CeramTec, ConvaTec, Medtronic, Smith & Nephew, TissueGene and Zimmer; received other financial or material support from CD Diagnostics, Hip Innovation Technology and PRN; has stock or stock options in 3M, Cempra, CeramTec, DePuy, National Institutes of Health, OREF, Smith & Nephew, StelKast, Stryker and Zimmer; received departmental or institutional support from Datatrace, Elsevier, Jaypee Publishing, SLACK Incorporated and Wolters Kluwer Health – Lippincott Williams & Wilkins; received financial support from Journal of Arthroplasty, Journal of Bone and Joint Surgery – American, Journal of Bone and Joint Surgery – British; and received department research or institutional support from the Eastern Orthopaedic Association, Muller Foundation and Philadelphia Orthopaedic Society.