Outcome of Two-Stage Revision Total Hip and Knee Arthroplasty as a Salvage Procedure for Deep Infection of Peri-Articular Fracture Fixation: Propensity Score-Matched Study

Document Type : RESEARCH PAPER

Authors

Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA

Abstract

Background: Failed open reduction internal fixation (ORIF) of peri-articular fractures due to deep infection is associated
with decreased functional outcomes and increased mortality rates. Two-stage revision total joint arthroplasty (TJA) is
often needed as a salvage procedure. The aim of this study was to evaluate the outcome of two-stage revision total
hip and knee arthroplasty as a salvage procedure for the treatment of deep infection of peri-articular fracture fixation.
Methods: Using propensity score-matching, a total of 120 patients was evaluated: 1) 40 consecutive patients were
treated with planned salvage two-stage revision for the treatment of deep peri-articular infection, and 2) a control
group of 80 patients who underwent two-stage revision for periprosthetic joint infection (PJI) after non-IF TJA. An
infection occurred after a fracture of the acetabulum (27.5%), femoral neck (22.5%), intertrochanteric femur (15.0%),
subtrochanteric femur (5.0%), femoral shaft (7.5%), distal femur (5.0%), and tibia (15.0%).
Results: At an average follow up of 4.5 years (range, 1.0-25.8), the overall failure rate was 42.5% for the IF group
compared to 21.3% for the non-ORIF group (P=0.03). There was a significantly higher reinfection rate for the IF group
compared to the non-IF group (35.0% vs. 11.3%, p=0.005). Tissue cultures for the IF patients demonstrated significantly
higher polymicrobial growth (30.0% vs. 11.3%, P=0.01) and methicillin-resistant Staphylococcus aureus (20.0% vs.
7.5%, P=0.04).
Conclusion: Salvage two-stage revision arthroplasty for infected IF of peri-articular fractures was associated with
poor outcome. The overall post-operative complications after salvage two-stage revision for infected IF of peri-articular
fractures was high with 35% reinfection rates associated with the presence of mixed and resistant pathogens.
Level of evidence: III

Keywords

References

  1. Swart E, Roulette P, Leas D, Bozic KJ, Karunakar M. ORIF or arthroplasty for displaced femoral neck fractures in patients younger than 65 years old: an economic decision analysis. JBJS. 2017;99(1):65-75.
  2. Schreiner AJ, Schmidutz F, Ateschrang A, Ihle C, Stöckle U, Ochs BG, et al. Periprosthetic tibial fractures in total knee arthroplasty–an outcome analysis of a challenging and underreported surgical issue. BMC Musculoskeletal Disorders. 2018;19(1):1-8.
  3. Sanal HT, Boulton C, Neyisci C, Erdem Y, Lowe J. Imaging of Pelvic and Femoral Fixation Hardware: Normal Findings and Hardware Failure. InSeminars in Musculoskeletal Radiology 2019 (Vol. 23, No. 02, pp. e1-e19). Thieme Medical Publishers.
  4. Steinmetz S, Wernly D, Moerenhout K, Trampuz A, Borens O. Infection after fracture fixation. EFORT Open Reviews. 2019;4(7):468-75.
  5. Hsieh PH, Chang YH, Chen SH, Shih CH. Staged arthroplasty as salvage procedure for deep hip infection following intertrochanteric fracture. International orthopaedics. 2006;30(4):228-32.
  6. Norris GR, Checketts JX, Scott JT, Vassar M, Norris BL, Giannoudis PV. Prevalence of deep surgical site infection after repair of periarticular knee fractures: a systematic review and meta-analysis. JAMA network open. 2019;2(8):e199951.
  7. Klatte TO, O’Loughlin PF, Citak M, Rueger JM, Gehrke T, Kendoff D. 1-stage primary arthroplasty of mechanically failed internally fixated of hip fractures with deep wound infection: good outcome in 16 cases. Acta orthopaedica. 2013;84(4):377-9.
  8. Mohanty SS, Agashe MV, Sheth BA, Dash KK. Outcome of total hip arthroplasty as a salvage procedure for failed infected internal fixation of hip fractures. Indian journal of orthopaedics. 2013;47(1):87-92..
  9. Haidukewych GJ, Berry DJ. Hip arthroplasty for salvage of failed treatment of intertrochanteric hip fractures. JBJS. 2003;85(5):899-904.
  10. Ebied AM, Elseedy AI, Gamal O. A protocol for staged arthroplasty to salvage infected nonunion of hip fractures. Journal of Orthopaedics and Traumatology. 2017;18(1):43-50.
  11. Duckworth AD, Phillips SA, Stone O, Moran M, Breusch SJ, Biant LC. Deep infection after hip fracture surgery: predictors of early mortality. Injury. 2012;43(7):1182-6.
  12. Parvizi J, Tan TL, Goswami K, Higuera C, Della Valle C, Chen AF, Shohat N. The 2018 definition of periprosthetic hip and knee infection: an evidence-based and validated criteria. The Journal of arthroplasty. 2018;33(5):1309-14.
  13. Rosenbaum PR, Rubin DB. The central role of the propensity score in observational studies for causal effects. Matched Sampl Causal Eff. 2006;70(1):170-184.
  14. McCaffrey DF, Griffin BA, Almirall D, Slaughter ME, Ramchand R, Burgette LF. A tutorial on propensity score estimation for multiple treatments using generalized boosted models. Statistics in medicine. 2013;32(19):3388-414.
  15. Diaz-Ledezma C, Higuera CA, Parvizi J. Success after treatment of periprosthetic joint infection: a Delphi-based international multidisciplinary consensus. Clinical Orthopaedics and Related Research®. 2013;471(7):2374-82.
  16. Stockton DJ, O’Hara LM, O’Hara NN, Lefaivre KA, O’Brien PJ, Slobogean GP. High rate of reoperation and conversion to total hip arthroplasty after internal fixation of young femoral neck fractures: a population-based study of 796 patients. Acta Orthopaedica. 2019;90(1):21-5.
  17. Wasserstein D, Henry P, Paterson JM, Kreder HJ, Jenkinson R. Risk of total knee arthroplasty after operatively treated tibial plateau fracture: a matched-population-based cohort study. JBJS. 2014;96(2):144-50.
  18. Winemaker M, Gamble P, Petruccelli D, Kaspar S, de Beer J. Short-Term Outcomes of Total Hip Arthroplasty After Complications of Open Reduction Internal Fixation for Hip Fracture. J Arthroplasty. 2006;21(5):682-688.
  19. Softness KA, Murray RS, Evans BG. Total knee arthroplasty and fractures of the tibial plateau. World journal of orthopedics. 2017;8(2):107-114.
  20. Pangaud C, Ollivier M, Argenson JN. Outcome of single-stage versus two-stage exchange for revision knee arthroplasty for chronic periprosthetic infection. EFORT open reviews. 2019;4(8):495-502.
  21. Cherney DL, Amstutz HC. Total hip replacement in the previously septic hip. JBJS. 1983;65(9):1256-65.
  22. Kremers HM, Nwojo ME, Ransom JE, Wood-Wentz CM, Melton III LJ, Huddleston III PM. Trends in the epidemiology of osteomyelitis: a population-based study, 1969 to 2009. The Journal of bone and joint surgery. American volume. 2015;97(10):837.
  23. Sakellariou VI, Poultsides LA, Vasilakakos T, Sculco P, Ma Y, Sculco TP. Risk factors for recurrence of periprosthetic knee infection. The Journal of Arthroplasty. 2015;30(9):1618-22.
The Archives of Bone and Joint Surgery
Volume 10, Issue 7
July 2022
Pages 576-584

Files

History

  • Receive Date: 25 August 2020
  • Revise Date: 10 October 2020
  • Accept Date: 02 January 2022

Share

How to cite

Statistics