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An often-unrecognized entity as cause of recurrent infection after successfully treated two-stage exchange
Doruk Akgün1, Michael Müller2, Carsten Perka2
1Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, Berlin, 13353, Germany. doruk.akguen@charite.de.
Introduction:
Reinfection after two-stage exchange arthroplasty is a difficult clinical scenario with limited data on adequate treatment algorithms. Beside the possibility of treatment failure and a new intraoperative infection at the time of reimplantation, hematogenous seeding could play an up to date underestimated crucial role as another cause of an infection after two-stage exchange. The aim of this study was to evaluate its incidence and treatment possibilities in a prospectively followed case series.
Methods:
All consecutive hip and knee periprosthetic joint infection cases (93 hips and 89 knees) treated according to a standardized diagnostic and therapeutic algorithm at our institution with a two-stage exchange arthroplasty from 2013 to 2015 were included and followed prospectively to identify recurrent infections due to hematogenous seeding.
Results:
Six percent from our septic revision hip and knee arthroplasties (11 of 182, including 5 hips and 6 knees) were identified with a hematogenous reinfection after a mean follow-up of 31.8 months (range 14-48 months). The mean time to reinfection after reimplantation was 12.2 months (range 3.1-35.1). In all but two cases was the causative microorganism different than isolated at the time of initial two-stage exchange. In 5 of 11 patients, the primary focus of infection was identified.
Conclusion:
Hematogenous infection after a successful two-stage exchange arthroplasty is a rare but very important cause of a reinfection. With our work, we aim at raising the awareness for this entity and recommend consideration of irrigation and debridement with implant retention in these cases, as well as possibly the identification of a primary infection source.
Insights
Hematogenous seeding is a rare but significant cause of reinfection after two-stage exchange arthroplasty. Early identification and considering irrigation and debridement with implant retention are recommended treatments.
Area of Science:
- Orthopedic Surgery
- Infectious Diseases
- Arthroplasty Research
Background:
- Reinfection following two-stage exchange arthroplasty presents a complex clinical challenge.
- Hematogenous seeding is an underrecognized cause of reinfection after this procedure.
- Limited data exists on effective treatment algorithms for such cases.
Purpose of the Study:
- To evaluate the incidence of hematogenous seeding as a cause of reinfection after two-stage exchange arthroplasty.
- To explore treatment possibilities for hematogenous reinfections in this context.
- To raise awareness of hematogenous seeding as a critical factor in prosthetic joint infection recurrence.
Main Methods:
- A prospective case series included 182 patients (93 hips, 89 knees) undergoing two-stage exchange arthroplasty for periprosthetic joint infection.
- Patients were followed to identify recurrent infections specifically due to hematogenous seeding.
- Standardized diagnostic and therapeutic protocols were applied throughout the study period (2013-2015).
Main Results:
- Hematogenous reinfection occurred in 6% of cases (11 of 182 patients) after a mean follow-up of 31.8 months.
- The average time to reinfection post-reimplantation was 12.2 months.
- In most cases, the causative microorganism differed from the initial infection, and a primary source was identified in 5 patients.
Conclusions:
- Hematogenous infection is an uncommon but crucial cause of reinfection after successful two-stage exchange arthroplasty.
- Increased awareness of this entity is warranted.
- Consideration of irrigation and debridement with implant retention, alongside identifying the primary infection source, is recommended.
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