| Background:Periprosthetic joint infection(PJI)is the most serious complication after arthroplasty,and two-stage revision surgery using antibiotic bone cement spacers is considered the gold standard for the treatment of chronic PJI.Recent findings suggest that the success rate of two-stage revision surgery may need to be re-recognized,because most studies report only considering patients who received complete two-stage revision surgery when calculating the success rate and ignoring patients who did not undergo replantation,therefore,the true success rate of two-stage revision surgery may be overestimated.Reasons for not undergoing reimplantation vary,with recurrent infection following prosthesis removal and antibiotic bone cement spacer implantation being probably the main cause,and these patients often require additional surgical procedures to control the infection to complete the second stage of reimplantation.Prosthesis removal and antibiotic bone cement spacer implantation is the most important link of the two-stage revision surgery and is the key to whether two-stage revision surgery can be carried out smoothly.Exploring the risk factors of recurrent infection after treatment and actively improving the preoperative preparation of high-risk patients is of significance for the treatment of PJI after arthroplasty,because it may help to improve the success rate of two-stage revision surgery of PJI patients.Previous studies have mostly focused on the risk factors for treatment failure of PJI after debridement,antibiotics,irrigation and retention(DAIR)or two-stage revision surgery,and there was no relevant report on the risk factors of failure of prosthesis removal and antibiotic bone cement spacer implantation.Objective:To investigate the risk factors of reinfection after prosthesis removal and antibiotic bone cement spacer implantation for the treatment of PJI,and to provide help for the smooth progress of two-stage revision surgery,in order to improve the success rate of infection control and the replantation rate of two-stage revision surgery.Methods:Clinical data of 161 patients with PJI who met the inclusion criteria from January 2011 to January2021 in our hospital were retrospectively analyzed.Among them,34 patients had recurrent infection after prosthesis removal and antibiotic bone cement spacer implantation,and the success rate of infection control was 78.88%.Ninety-one of 127 patients without recurrent infection underwent complete two-stage revision,with a replantation rate of 71.65%.There were 80 males and 81 females with an average age of 65.00(60.00,71.00)years;There were 83 patients after total knee arthroplasty(TKA)and 78 patients after total hip arthroplasty(THA).Variables that may affect the treatment outcome of PJI were then collected according to previous literature studies and combined with the completeness of institutional data,including patient characteristics,medical diseases,microbiological examination after admission,and other possible risk factors,then univariate analysis was performed for the risk factors of recurrent infection after treatment of PJI had been confirmed.Patients were followed up by outpatient and telephone for infection control and divided into success and failure groups according to whether reinfection occurred after prosthesis removal and antibiotic bone cement spacer implantation.The success group was defined as having been followed-up for at least 2 years without any evidence of reinfection found by the patients;The failure group was defined as cases in which an initial infection that was not effectively controlled,or mixed infection formed by new pathogens occurred,all of which eventually developed symptoms of reinfection and require additional antibiotic therapy or reoperation,in this group of patients,the presence of reinfection was the end point of our observation.Associations of clinically meaningful variables with reinfection were assessed by univariate and multivariate analyses,and survival period was defined as the time from the start of prosthesis removal and antibiotic bone cement spacer implantation until the patient developed reinfection requiring additional treatment or the end of follow-up.Univariate analysis was performed using the log-rank test for categorical variables,and survival rates were calculated and survival curves were drew using the Kaplan-Meier method;univariate analysis was performed using univariate Cox regression analysis for grade variables and continuous variables.Variables with differences in univariate analysis were included in the Cox model for multivariate analysis to screen out the independent risk factors of failure after prosthesis removal and antibiotic bone cement spacer implantation for the treatment of PJI.Results:All patients received complete follow-up,with an average follow-up time of 37.13(24.59,82.94)-up period,no fracture of bone cement spacer was found in the included patients.Of the 161 patients,34 developed reinfection after prosthesis removal and antibiotic bone cement spacer implantation,with an average reinfection time of 2.55(1.30,4.72)months follow-up.There were 127 patients in the success group and 34 patients in the failure group,and the infection control rate of prosthesis removal and antibiotic bone cement spacer implantation was 78.88%.Of the patients in the success group,91 patients underwent second-stage revision surgery,and 36 patients did not undergo revision surgery due to perceived good function of the bone cement spacer.Univariate analysis was statistically significant for fungi infection(x~2 = 4.095,P = 0.043),history of prior revision surgery(x~2= 14.110,P < 0.001),and presence of sinus tract(x~2 = 15.437,P < 0.001).Multivariate analysis showed that fungi infection(HR = 6.198,95% CI: 2.022 ～ 18.998;P = 0.001),history of prior revision surgery(HR= 5.314,95% CI: 2.309 ～ 12.230;P < 0.001)and presence of sinus tract(HR = 4.606,95% CI: 2.225 ～9.537;P < 0.001)were independent risk factors of failure after prosthesis removal and antibiotic bone cement spacer implantation for the treatment of PJI.The survival rates of patients without recurrent infection at 3,6,and 12 months after prosthesis removal and antibiotic bone cement spacer implantation were 87.58%,81.99%,and 78.88%,respectively,and the survival rates calculated using the Kaplan-Meier method and plotted using log-rank test showed that patients with PJI who had the following risk factors,fungal infection(55.56%,55.56%,55.56%;P = 0.043),history of prior revision surgery(78.57%,42.86%,42.86%;P < 0.001),and the presence of sinus tract(81.13%,69.81%,60.38%;P < 0.001),at 3,6,and 12 months after prosthesis removal and antibiotic bone cement spacer implantation,had significantly reduced survival rates for no recurrent infection.Conclusions:1.Fungal infection,history of prior revision surgery,and presence of sinus tract were independent risk factors of failure after prosthesis removal and antibiotic bone cement spacer implantation for the treatment of PJI.2.Individualized treatment strategies for patients with high risk of reinfection after prosthesis removal and antibiotic bone cement spacer implantation may help to reduce the incidence of reinfection as well as improve the rate of replantation in two-stage revision surgery. |
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