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Prognostic Implications of Unexpected Positive Intraoperative Cultures in Two-Stage Knee Arthroplasty
Yu-Chih Lin1, Jui-Ping Chen2, Sheng-Hsun Lee3
1Department of Orthopaedic Surgery, Chang Gung Memorial Hospital (CGMH), Taoyuan, Taiwan; Bone and Joint Research Center, Department of Orthopaedic Surgery, Chang Gung Memorial Hospital (CGMH), Taoyuan, Taiwan; College of Medicine, Chang Gung University (CGU), Taoyuan, Taiwan; Department of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsinchu, Taiwan.
Background:
The clinical challenge of unexpected positive intraoperative cultures (UPICs) persists in 2-stage resection arthroplasty for managing periprosthetic joint infections (PJIs) following total knee arthroplasty.(TKA). This study aimed to investigate the incidence of UPICs during the definitive reimplantation phase of 2-stage resection arthroplasty of the knee and to assess both the infection-free and revision-free survivorship of the implanted prosthesis.
Methods:
This retrospective study included 450 2-stage resection arthroplasties of primary knee prostheses performed between January 2012 and April 2017. Patients were excluded if they: (1) underwent three or more staged resections, (2) had ambiguous clinical documentation or deviated from the 2-stage protocol, or (3) underwent revision arthroplasty prior to the PJI. Additionally, patients presumed aseptic before the second-stage reimplantation were excluded if they lacked joint aspiration or met the 2011 Musculoskeletal Infection Society criteria for PJI before implantation.
Results:
After exclusions, 300 patients were analyzed. Among them, 14% had UPIC during the second-stage reimplantation. The follow-up time was 2,316 (range, 1,888 to 3,737) days and 2,531 (range, 1,947 to 3,349) days for UPIC and negative intraoperative culture (NIC) groups, respectively. Rerevision due to subsequent PJI occurred in 26.2% of UPIC patients and 15.1% of NIC patients. The 2-year infection-free survival rates for the NIC, one UPIC, and ≥ two UPIC cohorts were 99.5, 98.2, and 94.3%, respectively, while the 5-year survival rates were 92.1, 91.1, and 54.3%, respectively. The unfavorable survivorship was significantly different in multiple UPIC cases (P < 0.001). Multiple UPICs with pathogens consistent with the first-stage findings were strongly associated with the risk of reinfection (P < 0.001).
Conclusions:
An UPIC was identified in 14% of second-stage reimplantations. Patients who had multiple UPICs demonstrated truncated survivorship and suboptimal outcomes relative to the NIC and single UPIC cohorts, especially with pathogen consistency to the first-stage surgery.
Level Of Evidence:
III.
Insights
Unexpected positive intraoperative cultures (UPICs) during knee periprosthetic joint infection (PJI) treatment affect 14% of patients. Multiple UPICs significantly reduce infection-free survival, especially when pathogens match initial findings.
Area of Science:
- Orthopedic Surgery
- Infectious Diseases
- Microbiology
Background:
- Periprosthetic joint infections (PJIs) following total knee arthroplasty (TKA) present a significant clinical challenge.
- Unexpected positive intraoperative cultures (UPICs) during 2-stage resection arthroplasty complicate management and affect patient outcomes.
Purpose of the Study:
- To determine the incidence of UPICs during the second stage of 2-stage knee arthroplasty for PJI.
- To evaluate the impact of UPICs on infection-free and revision-free survivorship.
Main Methods:
- Retrospective analysis of 300 patients undergoing 2-stage knee arthroplasty for PJI.
- Exclusion criteria included multiple resections, protocol deviations, or prior revision.
- Follow-up assessed infection and revision rates in relation to intraoperative culture results.
Main Results:
- 14% of patients had UPICs during second-stage reimplantation.
- Patients with multiple UPICs showed significantly lower 5-year infection-free survival (54.3%) compared to negative cultures (92.1%) or single UPIC (91.1%).
- Pathogen consistency between stages in multiple UPIC cases strongly predicted reinfection.
Conclusions:
- UPICs occur in a notable percentage of second-stage knee arthroplasties for PJI.
- Multiple UPICs are associated with poorer survivorship and outcomes, particularly when microbial findings are consistent with the initial infection.
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