COMPARISON OF STRATEGIES FOR THERAPY OF HIP AND KNEE PROSTHETIC JOINT INFECTION

Abstract

Aim of the study: Prosthetic joint infection (PJI) is a feared complication of total joint arthroplasties. Several strategies were developed to treat it. The purpose of our study was to compare treatment strategies for PJI treatment presented in the literature.

Materials and Methods: We found more than 5000 documents in databases MEDLINE and EMBASE concerning this topic, published between January 1960 and November 2006. Using two-phase selection, 382 relevant articles were chosen, full texts were obtained for 302 of them (79%), and 77 studies was included into the analysis according to inclusion criteria (a total of 645 hips and 1145 knees). There were compared two-stage surgery, one-stage surgery, removal of prosthesis, and long-term antibiotic therapy in hip PJI, and two-stage surgery, debridement, arthrodesis, and long-term antibiotic therapy in knee PJI. The rate of PJI recurrence was a primary outcome, need for additional surgery was a secondary outcome. Capability index (c), relative risk (RR), and „number needed to treat“(NNT) were calculated for both outcomes under study.

Results:

1. The lowest rate of recurring PJI was reported for two-stage reimplantation (7.4 % in hip, 11 % in knee), followed by one-stage reimplantation in the case of hip PJI (9.2 %), and arthrodesis in the case of knee PJI (15.6 %);

2. The lowest RR for primary outcome of the study was revealed for two-stage reimplantation at both sites of surgery (RR=0.62 and 0.32, for hip and knee PJI, respectively), followed by one-stage reimplantation at the site of hip (RR=1.07) and knee arthrodesis (RR=0.78);

3. NNT was negative for two-stage reimplantation at both sites of surgery (NNT= −21.6 and −4.3, for hip and knee PJI, respectively);

4. Worse outcomes were found for debridement in comparison to long-term antibiotic therapy in terms of recurrence of PJI (RR=4.72 versus 1.20) and need for surgery (RR=4.41 versus 1.31), however, according to capability index (c=0.0317 versus 0.0000) and NNT (2.2 versus 26.3) knee debridement achieved better outcomes than antibiotic therapy.

5. Relative risk for additional surgery was the lowest in the case of two-stage reimplantation (RR=0.47 and 0.36, for hip and knee PJI, respectively), and the highest in the case of long-term antibiotic therapy at the site of hip (RR=6.47).

Conclusion: Two-stage management for treatment of PJI had the smallest risk for both PJI recurrence and need for additional surgery in comparison with all other strategies. One-stage hip reimplantation is a less reliable approach, in which it is necessary to strictly respect the indication criteria. Other methods are either less reliable or are associated with high risk of following surgeries, or unacceptable functional results.