Outcome of prosthesis exchange for infected knee arthroplasty: the effect of treatment approach

Figures & data

Table 1. The inclusion criteria for original papers

The report concerns the results of management of infected knee arthroplasty only with one-stage or two-stage exchange arthroplasty.

The study can be classified into one of the following groups:

– randomized controlled trial

– prospective study comparing two simultaneous treatment groups

– prospective study with historical controls

– prospective case series with no comparison group

– retrospective study comparing two simultaneous treatment groups

– retrospective study with historical control group

– retrospective study with no control group

Study includes more than 5 cases treated.

The paper is written in English or it has an abstract in English.

One or more of the following outcome variables is reported:

– number of all infections appearing after the treatment

– number of reinfections

– clinical status at follow-up, reported using Hospital for Special Surgery or Knee Society knee score

– range of motion at follow-up

Table 2. Original studies included: materials and outcome

Study				Materials					Outcome
		A	B	C	D	E	F	G	H	I
Rosenberg et al.	1988	26	1981–1986	65/31/4	67	2-stage, no spacer	29 (12–57)	100	78	NA
Booth and Lotke ^a	1989	25	1984–1988	NA	67	2-stage, PMMA block	25 (6–59)	96	82	100
Henderson and Booth ^a	1991	28	1984–1989	89/11/0	73	2-stage, PMMA block	27 (12–79)	97	86	90
von Foersteret et al. ^c	1991	104	1976–1985	61/29/10	NA	1-stage	76 (60–180)	73	NA	NA
Göksan and Freeman	1992	18	1979–1989	39/56/5	61	1-stage	60 (12–120)	94	NA	85
Masri et al.	1994	24	1987–1993	75/8/17	66	2-stage, PROSTALAC	26 (6–73)	96	80	86
Whiteside	1994	33	NA	85/15/0	NA	2-stage, PMMA block	24	97	NA	98
Gusso et al.	1995	5	NA	80/NA/NA	NA	2-stage, PMMA block	(4–18)	100	78	105
Goldman et al.	1996	64	1977–1993	70/25/5	67	2-stage, no spacer ^b	90 (24–204)	97	78	94
Gacon et al. ^c	1997	29	1984–1994	97/3/0	70	2-stage, PMMA block	42	83	80	95
Lu et al. ^c	1997	8	NA	NA	NA	1-stage	20	100	NA	NA
McPherson et al.	1997	21	1993–1996	NA	64	2-stage, no spacer	17 (5–33)	95	77	99
Hirakawa et al.	1998	55	1980–1993	75/25/0	67	2-stage, PMMA block	NA	82	79	83
Lecuire et al. ^c	1999	12	1989–1998	NA	NA	2-stage, no spacer	12	100	NA	96
Fehring et al.	2000	25	1986–1995	NA	68	2-stage, PMMA block	36 (24–72)	88	83	98
		15	1996–1999	NA	NA	2-stage, artic. PMMA	27 (24–36)	93	84	105
Haddad et al.	2000	45	1987–1996	80/13/7	69	2-stage, PROSTALAC	48 (20–112)	98	72	95
Kirschner et al. ^c	2000	6	1996–1997	NA	62	2-stage, artic. PMMA	19 (13–21)	100	NA	NA
Mont et al.	2000	69	1989–1993	NA	66	2-stage, PMMA block	63 (36–114)	93	86	96
Lonner et al.	2001	53	1983–1997	NA	NA	2-stage, PMMA block	56 (24–144)	91	NA	NA
Emerson et al.	2002	26	1986–1994	NA	66	2-stage, PMMA block	90 (34–152)	92	NA	94
		22	1995–1999	NA	65	2-stage, RPS	46 (31–77)	100	NA	108
Siebel et al.	2002	10	NA	NA	66	2-stage, artic. PMMA	18 (6–26)	100	64	87
Jhao and Jiang	2003	7	1994–2001	86/14/0	68	2-stage, no spacer	42 (12–84)	100	86	91
Pietsch et al. ^c	2003	24	1999–2002	NA	d	2-stage, RPS	15 (5–33)	96	NA	NA
Haleem et al.	2004	96	1989–1994	77/15/8	69	2-stage, PMMA block	86 (30–158)	96	50	90
Buechel et al.	2004	22	1981–1993	95/5/0	71	1-stage	122 (17–235)	100	80	NA
Durbhakula et al.	2004	24	1998–2001	NA	72	2-stage, artic. PMMA	33 (28–51)	100	82	104
Meek et al.	2004	54	1997–1999	NA	NA	2-stage, PROSTALAC	41	96	76	87
Cuckler	2005	44	1994–2002	NA	68	2-stage, RPS	65 (24–120)	100	84	112
Hofmann et al.	2005	50	1989–2001	NA	67	2-stage, RPS	74 (24–150)	94	89	4–104
MacAvoy and Ries	2005	13	NA	NA	58	2-stage, B&S	28 (15–44)	100	NA	98
Pitto et al.	2005	21	2000–2003	NA	67	2-stage, artic. PMMA	24 (12–43)	100	81	94

OA: osteoarthritis; RA: rheumatoid arthritis; ROM: range of motion; NA: not available; PMMA: polymethylmethacrylate bone cement; PROSTALAC: prosthesis of antibiotic-loaded cement; RPS: resterilized prosthesis spacer; B&S: ball-and-socket spacer;

^a partly overlapping data;

^b includes 7 knees with PMMA block,

^c non-English publications.

^d range 42–78

A No. of knees

B Year(s) of collection

C Diagnosis OA/RA/other, %

D Average age at operation, years

E Revision type, spacer

F Length of follow-up, months (range)

G Rate of eradication of infection, %

H Average clinical knee score postoperatively

I ROM or flexion postoperatively, degrees

Table 3. Quality scores of the 25 studies published in English that were included. Values are number of studies

Quality measure	Measure reported	Measure not reported
Materials
Average age	21	4
Male-to-female ratio	23	2
Primary diagnoses	13	12
ASA or other risk classification	2	23
Pathogens	23	2
Preoperative clinical knee score	9	16
Preoperative range of motion or flexion range	9	16
Intervention
Peroperative antibiotic treatment	19	6
Type of spacer	22	1
Mean time between the two stages	16	7
Postoperative antibiotic treatment	9	16
Rehabilitation	6	19
Results
No. of all new infections	25	0
No. of reinfections/recurrent infections	24	1
No. of other failures	11	14
Postoperative clinical knee score	20	5
Postoperative range of motion/flexion	23	2
	True	False
Methodology
Were both advantages and disadvantages of the treatment described?	8	17
Was the number of patients excluded less than 20% of the number of patients included?	21	4
Was the species of pathogen idenepsied used as an exclusion criterion?	3	22
Was loss to follow-up less than 20%?	25	0

Figure 1. Rates of recurrent and new infections. Studies sorted by length of follow-up.

Figure 2. Rates of recurrent and new infections after revision arthroplasty for infection. Series sorted by publication year.

Figure 3. The effect of treatment approach on the average postoperative range of motion or maximal flexion. Each dot represents one study.

Table 4. Overview of studies published after the literature search

A		B	C	D	E	F	G	H	I
Hart and Jones	2006	48	1998–2003	articulating PMMA	49 (26–85)	88	NA		c
Huang et al.	2006	21	1996–2002	RPS	52 (30–102)	95	85	81 ^a
Jämsen et al.	2006	34	1993–2003	RPS (n = 24)	25 (2–68)	91	104	82 ^a
				static PMMA (n = 10)	49 (2–86)	75	92	79 ^a
Trezies et al.	2006	11	1992–2004	new femoral component + polyethylene tibial insert	65	91	NA
Hsu et al.	2007	28	1996–2004	static PMMA (n = 7)	101 (63–120)	86	78	81 ^a
				articulating PMMA (n = 21)	58 (27–96)	91	95	89 ^a
Mittal et al.	2007	37	1987–2003	articulating or static PMMA	51 (24–111)	75	NA		d
Abstracts
Pietsch et al.	2006	33	2000–2003	RPS	28 (12–48)	91		87 ^b	e
Souillac et al.	2006	28	2000–2003	articulating PMMA	(20–48)	86	NA

NA: not available; PMMA: polymethylmethacrylate bone cement; RPS: resterilized prosthesis spacer

A Study

B No. of knees

C Year(s) of collection

D Spacer

E Follow-up, months (range)

F Infection eradication rate, %

G Range of motion, degrees

H Clinical outcome

a Knee Society score

b Hospital for Special Surgery knee score

I Note

c short-term antibiotic therapy

d resistant organisms: methicillin-resistant Staphylococcus aureus/epidermidis

e prospective study

Appendix 1. Data sources and strategy of the literature review

Literature databases reviewed:

Medline 1966 to present (via Ovid), Medline Daily Update (via Ovid), Medline In-Process and Other Non-indexed Citations (via Ovid), CINAHL (via Ovid), British Nursing Index (via Ovid), Cochrane Central Register of Controlled Trials (via Ovid), Cochrane Database of Systematic Reviews (via Ovid), Database of Abstracts of Reviews of Effects (via Ovid), ACP Journal Club (via Ovid), NHS Health Technology Assessment (via CRD), NHS Economic Evaluation Database (via CRD).

Search strategy for Medline and CINAHL:

1) arthroplasty, replacement, knee/

2) knee prosthesis/

3) “knee prosthes$”.mp

4) “knee arthroplast$”.mp

5) “knee replacement?”.mp

6) reoperation/

7) “revis$”.mp

8) “reimplant$”.mp

9) “exchang$”.mp

10) prosthesis-related infections/

11) infection/

12) wound infection/

13) surgical wound infection/

14) “infect$”.mp

15) (1 or 2 or 3 or 4 or 5) and (6 or 7 or 8 or 9) and (10 or 11 or 12 or 13 or 14)

Search strategy for EBM databases: Cochrane Central Register of Controlled Trials, Database or Abstracts of Reviews of Effects, Cochrane Database of Systematic Reviews, ACP Journal Club (via Ovid):

1) knee replacement?.mp

2) knee arthroplast$.mp

3) knee prosthes$.mp

4) arthroplasty, replacement, knee.mp

5) reoperat$.mp

6) revis$.mp

7) reimplant$.mp

8) exchang$.mp

9) infect$.mp

10) prosthesis-related infection?.mp

11) (1 or 2 or 3 or 4) and (5 or 6 or 7 or 8) and (9 or 10)

Search strategy for Science Citation Index:

1) TS=arthroplasty

2) TS=infection

3) TS=knee

4) TS=(revision OR reoperation OR reimplantation OR exchange)

5) #1 AND #2 AND #3 AND #4

Search strategy for Health Technology Assessment, NHS Economic Evaluation Database:

1) prosthesis-related infections (subject headings)

2) arthroplasty-replacement-knee (subject headings) OR knee-prosthesis (subject headings) AND infect (all fields)

3) knee replacem OR knee arthroplas AND infect

Appendix 2. The form used for assessment of study quality

STUDY QUALITY Question: Yes; No; Unclear

Was the patient population described in sufficient detail so that you could compare it to the patient population you treat or to the materials of other studies on the same subject?

– Average age

– Male-to-female ratio

– Indications for primary knee replacement

– ASA classification

– Pathogens idenepsied

– Preoperative Knee Society (KSS) or Hospital for Special Surgery (HSS) knee score

– Preoperative range of motion

Was the intervention described in sufficient detail so that you could provide the same treatment for your own patiens?

– Use of antibiotics peroperatively

– The type of spacer used in two-stage revisions

– The length of interim period between the stages in two-stage revisions

Was the associated treatment/rehabilitation described in sufficient detail so that you could provide the same for your own patients?

– Use of antibiotics postoperatively

– Rehabilitation

Were the primary outcome variables reported?

– Number of all post-treatment infections

– Number of reinfections

– Postoperative KSS or HSS

– Postoperative range of motion

Were both advantages and disadvantages of the treatment presented?

Was the proportion of patients excluded less than 20% of the number of patients included?

Was the species of infecting pathogen used as exclusion criterion?

Was loss to follow-up less than 20%?