The Dark Side of Arthroplasty: Competing Risk Analysis of Failed Hip and Knee Arthroplasty With Periprosthetic Joint Infection

Increasing total hip (THA) and knee (TKA) arthroplasties inevitably lead to accumulating failed arthroplasty (FA) with periprosthetic joint infections (PJI) and definite treatment recommendations are scarce. Our aims were to evaluate patient and infection site specific risk factors, and to identify case-dependent salvage procedure recommendations.

Retrospective analysis was conducted of salvage procedures for FA after PJI (amputation, Girdlestone resection arthroplasty [GRA], arthrodesis, or chronic fistulation [CF]) from 2008 to 2018. Univariable and multivariable modeling of revision and mortality rates, using cumulative incidence competing risk analysis, and Cox proportional hazards models were calculated.

In total, 135 patients (THA 62%; TKA 38%) were diagnosed for FA after PJI, having undergone an average of 3 [1-4] revisions at a mean follow-up of 12.8 [7.8-20.9] years. Forty-four percent of THAs and 55% of TKAs had to be revised following FA, 44% deceased during follow-up, and 16% could be reconverted to an infection-free arthroplasty. GRA revealed significantly higher revision rates than CF (P = .015) for THA. Lower age (P = .003), higher number of revisions before FA (P = .007), more than one microorganism at infection site (P = .034), and GRA (P = .037, only THA) prevailed independent risk factors for revision. Patients’ age remained an independent mortality risk factor (P = .001).

High-risk patients suffering from FA after THA with poor constitution profit from controlled constitution of CF, reducing the risk for revision surgeries and hospitalization. In case of FA after TKA, data did not allow definite treatment recommendations. We believe that education concerning amputation should be considered early after multiple TKA revisions.