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Thorough debridement, sensitive ‘bug’ aid success of one-stage revision for PJI
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PARK CITY, Utah — Although one-stage exchange is not widely used in North America to treat prosthetic joint infection, a presenter at the Joint Arthroplasty Mountain Meeting said it can be a successful way to manage chronic total joint arthroplasty infection in the right circumstances and with appropriate patient selection.
“When we are talking about treating the chronic periprosthetic infections, I am not going to spend a lot of time on two-stage [exchange], but this is the gold standard in North America,” Charles L. Nelson, MD, said. “One-stage revision is an option for selected patients.”
Recurrent infection is common after TJA revision for chronic prosthetic joint infection performed with one-stage or two-stage exchange, according to Nelson. Part of the problem, he said, is biofilms make it difficult to culture the organisms and “routine cultures are not sensitive, partially because of the issue with biofilm.”
Nelson said, “The outcomes have been good with both of these approaches, and there has not been that big of a difference.”
He discussed results of a study in which Fares S. Haddad, FRCS (Tr&O), and colleagues compared results for 102 chronic total knee arthroplasty infections. Of these infections, 27% were treated with one-stage revision and 73% were treated with two-stage revision. There were no re-infections in the one-stage group vs. five re-infections in the two-stage group.
However, Nelson noted, conditions were fairly optimal in the one-stage group, which had “mild to moderate bone loss [and] had a known, sensitive, single organism. They had absence of any immunocompromise, vasculitis, sepsis or re-infection and they had healthy soft tissue, so it was not the same treatment population that were treated with two stages. However, you can look at that selected group. They had 100% success free of infection. So, they did well with their one stages when they limited it to those criteria.”
The protocol Nelson described for one-stage revision for PJI during his presentation includes a thorough “oncologic” debridement during which the components and bone cement are removed, and antimicrobial solution is used. Surgical preparation is then repeated with the use of a new drape, scrub gown and new instruments prior to implanting a new prosthesis in the patient.
“You need to treat this almost like a cancer,” he said.
A course of prolonged postoperative antibiotics may be associated with improved outcome, Nelson said. – by Susan M. Rapp
References:
Haddad FS, et al. Clin Orthop Relat Res. 2015;doi:10.1007/s11999-014-3721-8.
Nelson CL. Single-stage exchange in chronic TJA infection. Presented at: Joint Arthroplasty Mountain Meeting; Feb. 10-13, 2019; Park City, Utah.
Disclosure: Nelson reports he is a consultant for Zimmer Biomet, medical advisor for Acuitive Technologies and receives research funding from PCORI and Zimmer Biomet.