Changing Surgical Approach During Periprosthetic Joint Infection Treatment Does Not Increase Risk of Eradication Failure: A Multicenter Retrospective Cohort Study.

Abstract

Hip approach discordance in aseptic revision total hip arthroplasty is not associated with increased dislocation or rerevision risk. Whether the same holds true for the treatment of periprosthetic joint infection (PJI) is unknown. This study reported the rate of hip approach discordance during PJI treatment, identified associated factors, and tested possible associations with outcomes (septic and aseptic failures). This is an ethics-approved, multicenter, consecutive case series of 517 primary total hip arthroplasties (mean age 65 years [range, 20 to 94], mean body mass index 31 [range, 16.7 to 58.7]), and 52.6% women treated for PJI. Of these, 431 had minimum 1-year follow-up (mean five years [range, one to 17.2]) and were included in the outcome analyses. Most index approaches were posterior (posterior approach: 302, 58.4%), followed by lateral (lateral approach: 111, 21.5%) and anterior (anterior approach: 104, 20.1%). Acute PJI accounted for 37% of cases, with the remaining cases representing chronic infections. Initial treatment across the entire cohort included debridement, antibiotics, and implant retention (61.9%), first-stage revision (30.4%), and single-stage revision (5.4%), reflecting management of both acute and chronic PJI. Outcomes of interest included PJI treatment success (Musculoskeletal Infection Society tiers 1 to 2) and aseptic complications (dislocation, fracture, and aseptic loosening). Change of approach occurred in 23.8% of cases, mostly occurring at the first surgical intervention (19.9%). Approach discordance was more common with anterior approach (62.1%), followed by lateral approach (51%) and posterior approach (0.7%) (P < 0.001), and with first-stage revisions (36.3%) compared to debridement, antibiotics, and implant retention (17.2%) and single-stage (10.7%) revisions (P < 0.001). There were no patient factors that were associated with approach discordance. Success of PJI treatment by the latest follow-up was 87.2% (376 of 431) and not associated with approach change (P = 0.73). Aseptic complications were seen in 4.4% of cases, with dislocation being most common (2.6%). There was no difference in overall complication or dislocation rates when the approach was changed (P = 0.33 to 0.73). Comparable outcomes are seen in PJI treatment with concordant and discordant approaches between primary and PJI treatment. These data provide reassurance to surgeons that the change of approach is safe and efficacious in PJI treatment without increased septic or aseptic risks.