Abstract
Aim
What is the fate of revision total joint arthroplasty, when conventional tissue sample culture (TSC) is negative and sonication fluid culture (SFC) is positive, in terms of re-revision?
Method
We prospectively analyzed explanted prosthetic materials from 211 consecutive cases of total hip and knee arthroplasty revision surgery performed on any indication during a one year period. We used a sonication apparatus and protocol that was previously described [Borens et al, 2013. J Orthop Res]. Sampling of five periprosthetic tissue biopsies was performed according to the local protocol and incubated for 5 days. In our non-interventional study design, clinicians were blinded to the results from sonication-culture, which were not used for the subsequent treatment strategy.
In cases with suspected deep infection, thorough debridement was performed during revision surgery, and routine antibiotic treatment was dicloxacillin for 6–8 weeks. Patients were routinely seen in the outpatient clinic after 3 and 12 months, where clinical examination and any antibiotic treatment were documented. Minimum follow-up was 1 year. This cohort study is reported according to the STROBE guidelines.
Results
Microbial findings in TSC and SFC were similar in 41/211 cases. Additional 11/211 cases were identified with positive SFC, despite negative in conventional culture. Of these, 8/11 cases with suspected prosthetic joint infection (PJI) a strategy of revision and empirical antibiotic therapy was completed. Another 3/11 cases with suspected aseptic failure, partial 1-stage revisions were performed with no subsequent antibiotic therapy.
Re-revisions were necessary in 5/11 cases of expected PJI, and 2/11 of these ended up with permanent Girdlestone status. A strategy of antibiotic suppression was implemented in 1/11 case. Another 1/11 patient diseased in circulatory failure 4 days after 2nd stage operation. In 3/11 cases the painful joint prosthesis is still unsolved after 1 year, and only 1/11 case had an asymptomatic prosthesis at follow-up after 1 year. Culture results of the subsequent revisions in this small cohort shows several links to the microbiological findings in SFC.
Conclusions
We identified 11/211 revisions of total joint arthroplasty, where conventional TSC was negative and SFC was positive. The fate of these cases included re-revision in 5/11. From a clinical perspective, patients with additional microbial findings by SFC had a discouraging prognosis and may represent true positive findings that have to be taken into consideration in the infection treatment.
