What are the Factors Associated with Re-revision After One-stage Revision for Periprosthetic Joint Infection of the Hip? A Case-control Study
Authors: Abdelaziz Hussein , Grüber Hendrik , Gehrke Thorsten , Salber Jochen , Citak Mustafa 
Published: May 2019

Abstract

Background
Despite increased interest in one-stage revision arthroplasty for periprosthetic joint infection (PJI) of the hip, the reported infection-free proportions after the one-stage approach are still comparable to that of two-stage revision. However, we still lack studies that analyze factors associated with any re-revision after one-stage revision arthroplasty for PJI.

Questions/purposes
After one-stage revision arthroplasty for PJI of the hip, what factors were associated with an increased risk of re-revision, and what factors were associated with an increased risk of reinfection?

Methods
We performed a single-center retrospective case-control analysis. Patients who underwent one-stage revision arthroplasty for PJI of the hip in our hospital between 2009 and 2017, and who were subsequently re-revised due to any reason, including reinfection, were identified from our electronic medical records. A total of 121 patients who underwent repeat revision for any reason after one-stage exchange for PJI of the hip were identified. The re-revision procedures were performed after a mean of 407 days. The primary reasons for re-revision were repeated hip dislocation in 53 of 121 patients (44%), reinfection including both new and persistent infections in 40 of 121 patients (33%), and aseptic loosening in 16 patients (13%). Forty-three patients underwent another revision procedure after the re-revision procedure (43 of 121; 36%). More than 40 potential patient-, joint- and surgery-related risk factors were investigated and compared with a 1:1 matched control participants by age, sex and year of the one-stage revision. Similar to the re-revision patients, controls were treated for PJI with one-stage revision arthroplasty; however, they did not undergo subsequent revision for any reason by the latest followup examination. The mean followup of the control group was 66 months (range, 17-119 months). The mean length of hospital stay was 26 days in the re-revised group (SD, 11.6 days) compared with 22 days for the controls (SD, 6.6 days). All analyses were performed to identify factors associated with general re-revision and reinfection.

Results
The independent factors associated with repeat revision for any reason were persistent wound drainage for at least 1 week (odds ratio [OR], 7.4; 95% CI, 2.6–20.6; p < 0.001), isolation of enterococci (OR, 4.8; 95% CI, 1.4–15.7; p = 0.010), and prior surgery due to infection before the one-stage hip revision (OR, 3.6; 95% CI, 2.0–6.4; p < 0.001). The factors associated with reinfection including both new and persistent infections were prolonged wound drainage (OR, 6.9; 95% CI, 2.2–21.5; p = 0.001) and prior surgery due to infection (OR, 4.3; 95% CI, 1.9–9.5; p < 0.001).

Conclusions
Prolonged wound drainage after the one-stage revision arthroplasty for PJI of the hip must be treated rigorously. Patients with a history of a prior surgical procedure due to hip infection should be informed about the risk of further re-revision when deciding for the one-stage exchange. In case of enterococcal isolation, surgeons may consider another treatment approach rather than the one-stage exchange. Furthermore, we recommend the use of dual mobility cups when performing the one-stage revision hip arthroplasty to reduce the risk of dislocation.

Level of Evidence Level III, therapeutic study.