Periprosthetic Joint Infection in Total Ankle Arthroplasty: An Exploratory Analysis of Outcomes and Challenges Persisting in Treatment

Abstract

Background:

Periprosthetic joint infection (PJI) remains an uncommon but devastating complication after total ankle arthroplasty (TAA). Literature investigating treatment of PJI in TAA is limited, demonstrating poor patient-reported outcomes and high rates of complications and reoperations. Therefore, continued investigation of PJI treatment following TAA is necessary. This exploratory study describes clinical, microbiological, and patient-reported outcomes for PJI treatment following TAA at minimum 2-year follow-up.

Methods:

Retrospective chart review was conducted for a single-institution registry of primary TAA patients between January 2015 and December 2021 with at least 1 follow-up appointment. Patients with PJI were identified using Musculoskeletal Infection Society (MSIS) criteria. Acute vs chronic PJI was defined as infectious symptom duration of <4 weeks and ≥4 weeks, respectively. Clinical, radiographic, microbiologic, and patient-reported outcomes were collected for PJI patients. The primary outcome was maintenance of a functioning TAA implant at the most recent follow-up; the secondary outcome was successful limb salvage.

Results:

Of the 955 patients included in this analysis, 12 (1.3%) underwent reoperation for PJI at median 5.7-year follow-up, with 5 acute and 7 chronic PJI patients. The PJI incidence rate was 5.4 per 1000 person-years at risk (95% CI: 2.8, 9.5). Implant retention rate was 50% across all PJI patients, including 4 of 5 acute and 2 of 7 chronic PJI patients. One acute PJI patient underwent explant with permanent cement spacer. Chronic PJI patients without functioning TAA implant at final follow-up had undergone permanent cement spacer with washouts (n = 1), tibiotalocalcaneal arthrodesis (n = 1), ankle arthrodesis (n = 1), and below-knee amputation (n = 2).

Conclusion:

Debridement, antibiotics, and implant retention (DAIR) appears to be a viable option for acute PJI treatment. However, DAIR and explant with staged revision may be insufficient for complete eradication of chronic PJI. Infection recurrence may result in permanent loss of function because of limited secondary treatment options after failed revision.