title: Patients With Failed Prior Two-Stage Exchange Have Poor Outcomes After Further Surgical Intervention.
abstract: Failure of 2-stage exchange arthroplasty for the management of periprosthetic joint infection (PJI) poses a major clinical challenge. There is a paucity of information regarding the outcomes of further surgical intervention in these patients. Thus, we aim to report the clinical outcomes of subsequent surgery for a failed prior 2-stage exchange arthroplasty.
  
  
  
  Our institutional database was used to identify 60 patients (42 knees and 18 hips), with a failed prior 2-stage exchange, who underwent further surgical intervention between 1998 and 2012, and had a minimum 2-year follow-up. A retrospective review was performed to extract relevant clinical information, including mortality, microbiology, and subsequent surgeries. Musculoskeletal Infection Society criteria were used to define PJI, and treatment success was defined using Delphi criteria.
  
  
  
  Irrigation and debridement (I&D) was performed after a failed 2-stage exchange in 61.7% of patients; 56.8% subsequently failed. Forty patients underwent an intended second 2-stage exchange; 6 cases required a spacer exchange. Reimplantation occurred only in 65% of cases, and 61.6% had infection controlled. The 14 cases that were not reimplanted resulted in 6 retained spacers, 5 amputations, 2 PJI-related mortalities, and 1 arthrodesis.
  
  
  
  Further surgical intervention after a failed prior 2-stage exchange arthroplasty has poor outcomes. Although I&D has a high failure rate, many patients who are deemed candidates for a second 2-stage exchange either do not undergo reimplantation or fail after reimplantation. The management of PJI clearly remains imperfect, and there is a dire need for further innovations that may improve the care of these patients.
authors.affiliation: The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.
authors.forename: Michael M
authors.initials: MM
authors.lastname: Kheir
authors.affiliation: The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.
authors.forename: Timothy L
authors.initials: TL
authors.lastname: Tan
authors.affiliation: The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.
authors.forename: Miguel M
authors.initials: MM
authors.lastname: Gomez
authors.affiliation: The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.
authors.forename: Antonia F
authors.initials: AF
authors.lastname: Chen
authors.affiliation: The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.
authors.forename: Javad
authors.initials: J
authors.lastname: Parvizi
mesh_terms: D000368:Aged; D001174:Arthrodesis; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects* / Q000706:statistics & numerical data; D019645:Arthroplasty, Replacement, Knee / Q000009:adverse effects* / Q000706:statistics & numerical data; D016208:Databases, Factual; D003646:Debridement; D005260:Female; D006622:Hip Prosthesis / Q000009:adverse effects; D006801:Humans; D007720:Knee Prosthesis / Q000009:adverse effects; D008297:Male; D008875:Middle Aged; D016459:Prosthesis-Related Infections / Q000382:microbiology / Q000601:surgery*; D012086:Reoperation / Q000009:adverse effects* / Q000706:statistics & numerical data; D012092:Replantation; D012189:Retrospective Studies; D013997:Time Factors; D017211:Treatment Failure; D016896:Treatment Outcome
keywords: 2-stage exchange; arthroplasty; outcomes; periprosthetic joint infection; revision hip arthroplasty; revision knee arthroplasty