Comparison of Risk Factors for 1- and 2-Stage Revisions for Chronic Knee Periprosthetic Joint Infections

With the continued rise of total knee arthroplasties in the United States, chronic knee periprosthetic joint infections (PJIs) have become increasingly common. A 2-stage revision is considered the 'gold standard' first-line treatment, but a 1-stage revision has become an increasingly viable option. Many small-sample, single-institution studies have looked at how patient factors can affect the risk of failure of these first-line treatments. Few have looked at a large, multi-institutional cohort to determine the significant risk factors.

Patients who have chronic knee PJIs were identified in a deidentified records database. Failure after first-line treatment was defined as the need for further surgery, such as irrigation and debridement, rerevision, amputation, or arthrodesis, or the need for suppressive antibiotics. The 5-year risk of failure was evaluated for individual patient factors in order to identify variables for a multivariate Cox proportional hazards model. Overall risk for the individual measures of failure, as well as 90-day mortality, was also reported.

Over 5 years after first-line treatment, 27.8% of 2-stage revisions failed and 40.4% of 1-stage revisions failed. Treatment failure was seen more commonly in patients who had prior methicillin-resistant Staphylococcus aureus infection, a body mass index greater than or equal to 30, or a previous diagnosis of depression. Those patients who underwent 2-stage revision surgeries first were more likely to fail with previous diagnoses of chronic kidney disease, lymphedema, or resistance to other antimicrobials. Those patients who underwent 1-stage revision surgeries were also more likely to fail if they had a previous diagnosis of malnutrition.

Orthopaedic surgeons should strongly consider patient comorbidities when selecting treatment pathways for PJIs.