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Updated: Dec 24, 2025
Novel Diagnostics in Revision Arthroplasty: Implant Sonication and Multiplex Polymerase Chain Reaction
Published on: December 3, 2017
Failure analysis of infection persistence after septic revision surgery: a checklist algorithm for risk factors in
Sofia Kilgus1, Daniel Karczewski2, Cindy Passkönig1
1Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité-Universitaetsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
Purpose:
Several studies describe risk factors for primary periprosthetic joint infection (PJI) and general treatment outcome factors like microbe spectrum or patient-specific risk factors. However, these general and patient dependent findings cannot solely explain all cases of infection persistence after a prior septic revision. This study analyzes possible specific and patient independent reasons for failure after revisions for PJI in knee and hip arthroplasty.
Methods:
In a prospective analysis all patients were included that were treated: (1) at our department, (2) with a two-stage exchange, (3) between 2013 and 2017, (4) due to an infection persistence after a previous revision for PJI. Possible reasons for infection persistence were identified using a checklist algorithm, based on international guidelines.
Results:
70 patients with infection persistence could be included (44 knee joints, 26 hip joints). The average age was 71 years, the CCI (Charlson Comorbidity Index) 2.8 and the ASA (American Society of Anesthesiologists) score 2.7. In 85% at least one possible reason for patient independent infection persistence could be identified analyzing the previous infection therapy: (1) 50% inadequate therapy concept (n = 35), (2) 33% inadequate surgical debridement (n = 23), (3) 30% inadequate antimicrobial therapy (n = 21), (4) 13% missed external bacterial primary focus (n = 9). After the individual failure analysis, all 70 patients were treated with a two-stage exchange in our department and in 94.9% infection freedom could be achieved (34.3 ± 10.9 months follow-up).
Conclusions:
In the majority of failed revisions with subsequent infection persistence at least one possible patient independent failure cause could be identified. The entire previous therapy should be critically reviewed following failing revisions to optimize the outcome of septic revisions. By using a checklist algorithm, high rates of infection freedom were achieved.
Insights
Failed septic revisions for periprosthetic joint infection (PJI) often stem from patient-independent factors like inadequate treatment. Critically reviewing prior therapies and using a checklist algorithm can significantly improve infection-free outcomes in revision arthroplasty.
Area of Science:
- Orthopedic Surgery
- Infectious Diseases
- Arthroplasty Revision
Background:
- Periprosthetic joint infection (PJI) is a significant complication following arthroplasty.
- Identifying reasons for persistent infection after revision surgery is crucial for improving patient outcomes.
- Previous studies have focused on general risk factors, but specific causes of treatment failure in septic revisions remain less understood.
Purpose of the Study:
- To analyze patient-independent reasons for infection persistence after revision surgery for hip and knee periprosthetic joint infection (PJI).
- To evaluate the effectiveness of a systematic approach in managing persistent PJI after failed revisions.
Main Methods:
- Prospective analysis of 70 patients undergoing two-stage exchange for persistent PJI between 2013 and 2017.
- Utilized a checklist algorithm based on international guidelines to identify patient-independent failure causes.
- Assessed previous infection therapy, surgical debridement, antimicrobial treatment, and external bacterial foci.
Main Results:
- In 85% of cases, at least one patient-independent reason for infection persistence was identified.
- Common factors included inadequate therapy concepts (50%), surgical debridement (33%), and antimicrobial therapy (30%).
- Following targeted revision, 94.9% infection freedom was achieved at an average follow-up of 34.3 months.
Conclusions:
- Patient-independent factors frequently contribute to the failure of septic revision surgeries for PJI.
- A critical review of all prior treatment steps is essential for optimizing outcomes in revision arthroplasty.
- Employing a structured checklist algorithm can lead to high rates of infection freedom in complex PJI cases.
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