Summary

Management of PJI should occur in specialist revision centres

Abstract

Aims: Management of prosthetic joint infection (PJI) is associated with poor outcomes and
catastrophic complications. The aim of this study was to present the outcomes of re-revision
surgery for PJI of the knee following previous failed two-stage exchange arthroplasty.

Methods

We retrospectively analysed 32 patients who underwent re-revision knee
arthroplasty, having already undergone at least one previous two-stage exchange for PJI,
between 2009 and 2018, with a minimum follow-up of two years(mean follow-up 40
months(2 to 99 months)). Outcomes were compared to a matched control of two-stage
revisions for PJI of a primary knee replacement. Primary outcomes investigated were
eradication of infection and re-operation. Secondary outcomes were five-year mortality and
limb-salvage rate.

Results

Successful eradication of infection was achieved in 50% of patients following re- revision surgery at the first treatment episode, compared with 91% following two-stage
exchange of primary knee replacement for PJI (p<0.001). Fourteen(44%) patients required
further re-operation compared with three (9%) patients in the primary group (p=0.006).
Amputation was performed in one case(3%) with thirteen patients(92%) had infection
controlled by DAIR, further revision surgery or arthrodesis. Two patients died with infection
(6%) and therefore the long-term rate for infection control was 91%. The mean number of
procedures following surgery for the re-revision group was 2.8(0-9) compared with 0.13 (0-
1) for the primary two-stage group (p<0.001). Five-year patient survival was 90.6%(95% CI
77.1 to 100). Multi-drug resistant organisms were present in 14(44%) patients in the re-revision group. The limb-salvage rate for the re-revision cohort was 97% at final follow-up.

Conclusion

Outcomes for re-revision knee arthroplasty for PJI have higher re-operation and
failure rates, but no worse mortality than in revisions of primary knee replacements for PJI.
Failures can successfully be managed by further operation. This supports the move to
concentrate expertise for eradicating recurrent knee PJI within specialist MDTs.