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Updated: Aug 13, 2025
Novel Diagnostics in Revision Arthroplasty: Implant Sonication and Multiplex Polymerase Chain Reaction
Published on: December 3, 2017
Clinical impact of microbiological results in two-stage revision arthroplasty with spacer exchange
Bernhard J H Frank1,2, Sebastian Simon1,2, Alexander Aichmair1,2
1Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Speisinger Strasse 109, 1130, Vienna, Austria.
Introduction:
Patients who require a spacer exchange as part of a two-stage procedure for the treatment of periprosthetic hip and knee joint infections (PJI) have high failure rates. Little is known about the clinical impact of microbiological results and changes in the microbiological spectrum and resistance pattern in these patients.
Material And Methods:
Between 01/2011 and 12/2019, 312 patients underwent a total of 327 two-stage revision arthroplasties at our institution. A spacer exchange was required in 52/312 (16.7%) patients (27 knee/25 hip). Microbiological results, antibiotic resistance patterns, patient's host factors as well as re-revision and re-infection rates at a median follow-up of 47.8 months (range 12.2-116.7 months) were analyzed. A propensity score (PS)-matched analysis of patients who underwent spacer exchange and patients treated with standard two-stage procedure was performed.
Results:
We found a high number of microbiological spectrum changes in patients with multiple culture positive procedures between explantations and spacer exchanges (10/12 [83.3%]), spacer exchanges and reimplantations (3/4 [75%]) as well as between reimplantations and subsequent re-revision surgeries (5/6 [83.3%]). In 9/52 (17.3%) patients, same microorganisms were detected repeatedly in two different procedures. We observed changes in the antibiotic resistance patterns in 6/9 (66.7%) of these patients. High re-infection rates were found in patients with culture positive reimplantations (10/12 [83.3%]), and low re-infection rates were found in patients with culture negative reimplantations (2/40 [5%]; p < 0.001). Between patients with and without spacer exchange, no differences were found in the re-revision rates (13/52 [25%] with vs. 13/52 [25%] without; p = 1.00) as well as re-infection rates (12/52 [23.1%] with vs. 8/52 [15.4%] without; p = 0.32).
Conclusions:
Changes in microbiological spectrum and antibiotic resistance patterns between stages are common in patients who require a spacer exchange. If eradication of the microorganism at reimplantation can be accomplished, comparable re-revision rates to standard two-stage procedures can be achieved.
Insights
Spacer exchange in two-stage revision arthroplasty for periprosthetic joint infections (PJI) shows frequent microbiological changes. Successful eradication of infection at reimplantation leads to comparable re-revision rates to standard two-stage procedures.
Area of Science:
- Orthopedic Surgery
- Infectious Diseases
- Microbiology
Background:
- Two-stage revision arthroplasty for periprosthetic joint infections (PJI) has high failure rates, particularly when a spacer exchange is necessary.
- Limited understanding exists regarding the impact of microbiological findings and evolving resistance patterns in patients undergoing spacer exchange.
Purpose of the Study:
- To investigate the clinical significance of microbiological results and resistance pattern changes in patients requiring spacer exchange during two-stage revision arthroplasty.
- To compare re-revision and re-infection rates between patients undergoing spacer exchange and those treated with standard two-stage procedures.
Main Methods:
- Analysis of 312 patients (327 procedures) from 2011-2019, with a focus on 52 patients requiring spacer exchange.
- Evaluation of microbiological spectrum, antibiotic resistance, host factors, and re-revision/re-infection rates.
- Propensity score-matched analysis comparing spacer exchange patients with standard two-stage procedure patients.
Main Results:
- High rates of microbiological spectrum changes (up to 83.3%) were observed between surgical stages in patients with multiple positive cultures.
- Antibiotic resistance patterns shifted in 66.7% of patients with repeated microorganism detection.
- Culture-positive reimplantations had significantly higher re-infection rates (83.3%) compared to culture-negative reimplantations (5%).
- No significant differences in re-revision (25% vs. 25%) or re-infection (23.1% vs. 15.4%) rates were found between patients with and without spacer exchange.
Conclusions:
- Microbiological spectrum and antibiotic resistance pattern changes are common during the interval in patients needing spacer exchange.
- Achieving microbiological eradication at reimplantation is crucial for comparable re-revision outcomes to standard two-stage procedures.
