Periprosthetic joint infection is the main reason for failure in patients following periprosthetic fracture treated with revision arthroplasty

Risk factors for metachronous periprosthetic joint infection in patients with multiple prosthetic joints: a systematic review and meta-analysis

OBJECT

Although periprosthetic joint infection (PJI) can affect multiple joints simultaneously, most individuals with multiple joint involvement exhibit PJI in only one joint. Data regarding the metachronous PJI management for these patients are limited. This study aimed to explore the risk factors for metachronous PJI in patients with multiple prosthetic joints, thereby guiding and optimizing clinical practice.

METHODS

The MEDLINE, Web of Science, Cochrane Library, and EMBASE were searched for all clinical studies of metachronous PJI from inception until May 2024. The clinical studies on risk factors for metachronous PJI in patients with multiple prosthetic joints after experiencing a periprosthetic infection were collected, with two authors independently screening the literatures. Newcastle Ottawa scale was used as a quality assessment tool for the included studies, and the meta-analysis was conducted to evaluate the potential risk factors of metachronous PJI.

RESULTS

A total of 1,544 patients with PJI after multiple joint arthroplasties were reported in 9 studies, including 189 with metachronous PJI. The meta-analysis showed that methicillin-resistant staphylococcus aureus (MRSA; OR, 3.43; 95%CI, 1.71-6.88; p = 0.0005), rheumatoid arthritis (RA; OR, 2.38; 95%CI, 1.06-5.38; p = 0.04), history of steroid use (OR, 2.93; 95%CI, 1.58-5.43; p = 0.0007), and previous or ongoing non-periprosthetic infection (OR, 4.47; 95%CI, 1.45-13.82; p = 0.009) were identified as significant risk factors for metachronous PJI in patients with multiple prosthetic joints. However, there was no significant difference between the metachronous PJI group and non-metachronous group in terms of revision, age, diabetes, and gender.

CONCLUSION

Patients with MRSA, RA, history of steroid use, previous or ongoing non-periprosthetic infection are at significantly higher risk for metachronous PJI. Further research is needed to optimize management strategies for preventing metachronous PJI in patients with multiple prostheses after a single joint PJI.

The impact of acetabular revision in revision total hip arthroplasty for a Vancouver B2 fracture requiring a change of femoral component

Aims

The aim of this study was to assess the necessity of revising the acetabular component in revision total hip arthroplasty (THA) in patients with a Vancouver type B2 periprosthetic femoral fracture (PFF) who require revision of the femoral component. The hypothesis was that revision of both the acetabular and femoral components and using a dual-mobility acetabular component would provide a lower postoperative risk of dislocation, without increasing perioperative morbidity and mortality.

Methods

Data were retrospectively analyzed from a continuously gathered database. We included 150 revisions, performed between January 2015 and December 2022, in 150 patients, with 81 revisions limited to only the femoral component and 69 involving revision of both components. This resulted, after surgery, in 60 patients having a simple-mobility acetabular component and 90 having a dual-mobility component. The mean age of the patients was 79.7 years (SD 10.1), and 98 were female (65.3%). The mean follow-up was 31 months (SD 2.3).

Results

There were no significant differences between those in whom only the femoral component was revised and those in whom both components were revised with the use of a dual-mobility acetabular component for the rate of intraoperative complications, postoperative mortality, blood loss, the requirement of a blood transfusion, medical complications, dislocation (11/81 in the femoral component-only group vs 6/69 in the femoral + acetabular component revision group) or the overall need for reoperation at the final follow-up. Patients were at a significantly higher risk for dislocation when a simple-mobility component was retained (18.3% (n = 11) vs 6.7% (n = 6) for dual-mobility implants; p = 0.036). The revision rate prompted by postoperative instability was significantly higher in patients in whom a simple-mobility acetabular component was retained at revision (10% (n = 6) vs 0%; p = 0.002).

Conclusion

Based on these results, concurrent revision of the acetabular component was not associated with a higher rate of mortality or increased morbidity and patients in whom a dual-mobility acetabular component was used were significantly less prone to dislocation. We thus recommend routine revision of the acetabular component in favour of a dual-mobility component for patients sustaining a Vancouver B2 PFF requiring revision of the femoral component if their initial THA included a simple-mobility acetabular component.

Surgeon Experience May Predict Failure After Revision Total Hip Arthroplasty for Periprosthetic Fracture

BACKGROUND

Periprosthetic fracture often requires revision hip arthroplasty. This study evaluated factors contributing to subsequent revisions and reoperations in patients who underwent revision hip arthroplasty for periprosthetic femur fracture. The authors hypothesized that surgeons who had higher revision volume would have decreased subsequent complications.

METHODS

A retrospective review of 84 revision hip arthroplasties for Vancouver B2 periprosthetic femur fractures performed at a single academic institution was conducted. Surgeons were categorized based on their reoperation volume: experienced (≥ 12 complicated hip reoperations annually) and less experienced (< 12 complicated hip reoperations annually). Univariable and multivariable analyses evaluated risk factors for all-cause revision. Survival analyses were performed using Cox proportional hazard modeling.

RESULTS

Of the 84 patients, there were eight (10%) revisions and 15 (18%) reoperations. Survivorship free of all-cause revision was greater for high-volume surgeons [hazard ratio [HR] 0.03 (0.00 to 0.43); P = 0.01]. Subanalysis demonstrated that experienced surgeons had increased 5-year survivorship free of septic revisions [HR 0.03 (0.00 to 0.54); P = 0.02]. The multivariable analysis also demonstrated that extended oral antimicrobial prophylaxis was associated with 5-year septic reoperation-free survival [HR 0.03 (0 to 0.45); P = 0.01]; this only trended toward significance in 5-year septic revision-free survival [HR 0.04 (0.00 to 1.97); P = 0.11]. There was no association between aseptic revision and surgeon experience in univariable or multivariable analysis.

CONCLUSIONS

Experienced arthroplasty surgeons, as well as extended oral antibiotic prophylaxis, may improve patient outcomes when treating patients who have periprosthetic fractures requiring revision arthroplasty. Consideration should be given to call schedules and management of this vulnerable population.

Vibratory insertion of press-fit acetabular components requires less force than a single blow technique

Aims

Periprosthetic fracture and implant loosening are two of the major reasons for revision surgery of cementless implants. Optimal implant fixation with minimal bone damage is challenging in this procedure. This pilot study investigates whether vibratory implant insertion is gentler compared to consecutive single blows for acetabular component implantation in a surrogate polyurethane (PU) model.

Methods

Acetabular components (cups) were implanted into 1 mm nominal under-sized cavities in PU foams (15 and 30 per cubic foot (PCF)) using a vibratory implant insertion device and an automated impaction device for single blows. The impaction force, remaining polar gap, and lever-out moment were measured and compared between the impaction methods.

Results

Impaction force was reduced by 89% and 53% for vibratory insertion in 15 and 30 PCF foams, respectively. Both methods positioned the component with polar gaps under 2 mm in 15 PCF foam. However, in 30 PCF foam, the vibratory insertion resulted in a clinically undesirable polar gap of over 2 mm. A higher lever-out moment was achieved with the consecutive single blow insertion by 42% in 15 PCF and 2.7 times higher in 30 PCF foam.

Conclusion

Vibratory implant insertion may lower periprosthetic fracture risk by reducing impaction forces, particularly in low-quality bone. Achieving implant seating using vibratory insertion requires adjustment of the nominal press-fit, especially in denser bone. Further preclinical testing on real bone tissue is necessary to assess whether its viscoelasticity in combination with an adjusted press-fit can compensate for the reduced primary stability after vibratory insertion observed in this study.

Disruption of Biofilm by Bacteriophages in Clinically Relevant Settings

INTRODUCTION

Antibiotic-resistant bacteria are a growing threat to civilian and military health today. Although infections were once easily treatable by antibiotics and wound cleaning, the frequent mutation of bacteria has created strains impermeable to antibiotics and physical attack. Bacteria further their pathogenicity because of their ability to form biofilms on wounds, medical devices, and implant surfaces. Methods for treating biofilms in clinical settings are limited, and when formed by antibiotic-resistant bacteria, can generate chronic infections that are recalcitrant to available therapies. Bacteriophages are natural viral predators of bacteria, and their ability to rapidly destroy their host has led to increased attention in potential phage therapy applications.

MATERIALS AND METHODS

The present article sought to address a knowledge gap in the available literature pertaining to the usage of bacteriophage in clinically relevant settings and the resolution of infections particular to military concerns. PRISMA guidelines were followed for a systematic review of available literature that met the criteria for analysis and inclusion. The research completed for this review article originated from the U.S. Military Academy's library "Scout" search engine, which complies results from 254 available databases (including PubMed, Google Scholar, and SciFinder). The search criteria included original studies that employed bacteriophage use against biofilms, as well as successful phage therapy strategies for combating chronic bacterial infections. We specifically explored the use of bacteriophage against antibiotic- and treatment-resistant bacteria.

RESULTS

A total of 80 studies were identified that met the inclusion criteria following PRISMA guidelines. The application of bacteriophage has been demonstrated to robustly disrupt biofilm growth in wounds and on implant surfaces. When traditional therapies have failed to disrupt biofilms and chronic infections, a combination of these treatments with phage has proven to be effective, often leading to complete wound healing without reinfection.

CONCLUSIONS

This review article examines the available literature where bacteriophages have been utilized to treat biofilms in clinically relevant settings. Specific attention is paid to biofilms on implant medical devices, biofilms formed on wounds, and clinical outcomes, where phage treatment has been efficacious. In addition to the clinical benefit of phage therapies, the military relevance and treatment of combat-related infections is also examined. Phages offer the ability to expand available treatment options in austere environments with relatively low cost and effort, allowing the impacted warfighter to return to duty quicker and healthier.

The Use of Artificial Intelligence for the Prediction of Periprosthetic Joint Infection Following Aseptic Revision Total Knee Arthroplasty

Periprosthetic joint infection (PJI) following revision total knee arthroplasty (TKA) for aseptic failure is associated with poor outcomes, patient morbidity, and high health care expenditures. The aim of this study was to develop novel machine learning algorithms for the prediction of PJI following revision TKA for patients with aseptic indications for revision surgery. A single-institution database consisting of 1,432 consecutive revision TKA patients with aseptic etiologies was retrospectively identified. The patient cohort included 208 patients (14.5%) who underwent re-revision surgery for PJI. Three machine learning algorithms (artificial neural networks, support vector machines, k-nearest neighbors) were developed to predict this outcome and these models were assessed by discrimination, calibration, and decision curve analysis. This is a retrospective study. Among the three machine learning models, the neural network model achieved the best performance across discrimination (area under the receiver operating characteristic curve = 0.78), calibration, and decision curve analysis. The strongest predictors for PJI following revision TKA for aseptic reasons were prior open procedure prior to revision surgery, drug abuse, obesity, and diabetes. This study utilized machine learning as a tool for the prediction of PJI following revision TKA for aseptic failure with excellent performance. The validated machine learning models can aid surgeons in patient-specific risk stratifying to assist in preoperative counseling and clinical decision making for patients undergoing aseptic revision TKA.

A mapping review on preoperative prognostic factors and outcome measures of revision total knee arthroplasty

To map literature on prognostic factors related to outcomes of revision total knee arthroplasty (rTKA), to identify extensively studied factors and to guide future research into what domains need further exploration. We performed a systematic literature search in MEDLINE, Embase, and Web of Science. The search string included multiple synonyms of the following keywords: "revision TKA", "outcome" and "prognostic factor". We searched for studies assessing the association between at least one prognostic factor and at least one outcome measure after rTKA surgery. Data on sample size, study design, prognostic factors, outcomes, and the direction of the association was extracted and included in an evidence map. After screening of 5,660 articles, we included 166 studies reporting prognostic factors for outcomes after rTKA, with a median sample size of 319 patients (30 to 303,867). Overall, 50% of the studies reported prospectively collected data, and 61% of the studies were performed in a single centre. In some studies, multiple associations were reported; 180 different prognostic factors were reported in these studies. The three most frequently studied prognostic factors were reason for revision (213 times), sex (125 times), and BMI (117 times). Studies focusing on functional scores and patient-reported outcome measures as prognostic factor for the outcome after surgery were limited (n = 42). The studies reported 154 different outcomes. The most commonly reported outcomes after rTKA were: re-revision (155 times), readmission (88 times), and reinfection (85 times). Only five studies included costs as outcome. Outcomes and prognostic factors that are routinely registered as part of clinical practice (e.g. BMI, sex, complications) or in (inter)national registries are studied frequently. Studies on prognostic factors, such as functional and sociodemographic status, and outcomes as healthcare costs, cognitive and mental function, and psychosocial impact are scarce, while they have been shown to be important for patients with osteoarthritis.

Do cobalt and chromium blood metal ion levels normalize after revision of failed metal-on-metal total hip replacements?

INTRODUCTION

Increased cobalt (Co) and chromium (Cr) serum levels are one reason for revision surgery in metal on metal (MoM) total hip arthroplasty (THA) patients. Dual mobility liners are a simple revision option; however, they preserve the metal shell and stem and it is therefore not clear if metal ion levels will fully normalize after revision surgery.

MATERIAL AND METHODS

Between April 2013 and December 2017 25 hips (24 patients) underwent revision from a MoM THA to an off-label dual mobility liner. Five patients were lost to follow-up and one patient refused leaving 18 patients (11 men, 7 female, average age 63.9 years) for pre- and postoperative metal ion level blood tests at a minimum follow-up of 2 years.

RESULTS

Fourteen patients were revised for osteolysis, two for elevated metal ion levels and two for fluid or cysts around the femoral or acetabular component. The average preoperative Co and Cr levels were 8.3 µg/l and 5.0 µg/l, respectively. At a minimum follow-up of 2 years (30-95 months), metal ions dropped to 0.8 µg/l. Harris Hip Score (HHS), Hip Osteoarthritis Outcome Score (HOOS), Visual Analog Scale (VAS) and the UCLA activity score improved non-significantly from pre- to postoperative. There was one postoperative complication in the study cohort. One patient with persisting pain required revision surgery to a standard acetabular component during the follow-up period.

CONCLUSION

The off-label use of a dual-mobility liner in the current study resulted in normalization of the metal ion levels suggesting that preserving the cobalt-chromium acetabular component has little impact on ion levels. In addition, dual mobility liners have a low complication and revision rate.

Reinfection rates after one- and two-stage revision surgery for hip and knee arthroplasty: a systematic review and meta-analysis

PURPOSE

Revisions for periprosthetic joint infection of knee and hip arthroplasty can be performed following one- or two-stage treatment protocols. Current literature is inconclusive whether one protocol is superior to the other, as prior literature reported similar reinfection rates for both treatment options. We aimed to provide a systematic review and meta-analysis of current literature on septic arthroplasty revisions.

METHODS

Between April 2015 and December 2020, Medline, Embase, and The Cochrane Library were searched for studies reporting reinfection outcomes in patients treated with one-stage and two-stage knee or hip revision arthroplasty. Two reviewers independently extracted data and disagreements were resolved by a third investigator. We utilized a double arcsine transformation, prior to pooling using a random-effects model.

RESULTS

For hip revision arthroplasty, we identified 14 one-stage studies (n = 1237) with a pooled reinfection rate of 5.7% (95% CI 3.7-8.1%), and 46 two-stage studies (n = 5009) with a reinfection rate of 8.4% (95% CI 6.9-9.9%). For knee revision arthroplasty, 6 one-stage studies (n = 527) and 48 two-stage studies (n = 4344) were identified with reinfection rates of 12.7% (7.0-19.7%) and 16.2% (13.7-19.0%), respectively. Overall, reinfection rates did not vary substantially after subgroup analysis. Limitations of our study are the limited amount of one-stage studies that introduce a potential bias.

CONCLUSION

The reinfection rates following one- and two-stage hip and knee arthroplasty revisions were similar. Knee reinfection rates have increased compared to the previous analysis. Individual patient characteristics and adequate treatment algorithms are needed for a more individual selection approach, until a randomized trial is performed.

Plasma fibrinogen: a sensitive biomarker for the screening of periprosthetic joint infection in patients undergoing re-revision arthroplasty

BACKGROUND

Although serum C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), plasma fibrinogen and neutrophil-lymphocyte ratio (NLR) are promising biomarkers for screening PJI in patients undergoing revision arthroplasty, their efficacy with respect to re-revision arthroplasty remains unclear.

METHODS

We included patients who underwent re-revision arthroplasty at our hospital during 2008-2020, and stratified them into two groups whether they had been diagnosed with PJI (infected) or aseptic failure (non-infected) according to the 2013 International Consensus Meeting criteria. We evaluated the diagnostic performance of CRP, ESR, fibrinogen and NLR, both individually and in combinations, based on sensitivity, specificity, and area under the receiver operating characteristic curve.

RESULTS

Of the 63 included patients, 32 were diagnosed with PJI. The area under the ROC curve was 0.821 for CRP, 0.794 for ESR, 0.885 for fibrinogen and 0.702 for NLR. CRP gave a sensitivity of 87.5% and specificity of 74.2% with an optimal predictive cut-off of 8.50 mg/mL. ESR gave a sensitivity of 81.3% and specificity of 71.0% with an optimal predictive cut-off of 33 mm/h. Plasma fibrinogen gave a comparatively higher sensitivity of 93.8% and specificity of 77.4% with an optimal predictive cut-off of 3.55 g/L, while NLR gave a moderate sensitivity of 84.4% but low specificity of 54.8% with an optimal predictive cut-off of 2.30. The combination of fibrinogen and CRP gave a high AUC of 0.897, an acceptable sensitivity of 75% and a high specificity 93.5%.

CONCLUSIONS

Plasma fibrinogen is a cost-effective, convenient biomarker that can be used to rule out PJI in patients scheduled for re-revision arthroplasty. In combination with CRP, it may be effective in diagnosing PJI in such patients.

Can machine learning models predict failure of revision total hip arthroplasty?

INTRODUCTION

Revision total hip arthroplasty (THA) represents a technically demanding surgical procedure which is associated with significant morbidity and mortality. Understanding risk factors for failure of revision THA is of clinical importance to identify at-risk patients. This study aimed to develop and validate novel machine learning algorithms for the prediction of re-revision surgery for patients following revision total hip arthroplasty.

METHODS

A total of 2588 consecutive patients that underwent revision THA was evaluated, including 408 patients (15.7%) with confirmed re-revision THA. Electronic patient records were manually reviewed to identify patient demographics, implant characteristics and surgical variables that may be associated with re-revision THA. Machine learning algorithms were developed to predict re-revision THA and these models were assessed by discrimination, calibration and decision curve analysis.

RESULTS

The strongest predictors for re-revision THA as predicted by the four validated machine learning models were the American Society of Anaesthesiology score, obesity (> 35 kg/m²) and indication for revision THA. The four machine learning models all achieved excellent performance across discrimination (AUC > 0.80), calibration and decision curve analysis. Higher net benefits for all machine learning models were demonstrated, when compared to the default strategies of changing management for all patients or no patients.

CONCLUSION

This study developed four machine learning models for the prediction of re-revision surgery for patients following revision total hip arthroplasty. The study findings show excellent model performance, highlighting the potential of these computational models to assist in preoperative patient optimization and counselling to improve revision THA patient outcomes.

LEVEL OF EVIDENCE

Level III, case-control retrospective analysis.

What is the rate of reinfection with different and difficult-to-treat bacteria after failed one-stage septic knee exchange?

PURPOSE

Re-operation after septic failure of a one-stage exchange for prosthetic joint infection (PJI) of the knee is a highly challenging procedure with concerns over residual bone stock, soft tissues, and stability. The associated changes in microbiology in cases of reinfection are still largely unknown.

METHODS

A comprehensive analysis was performed of all patients treated at our tertiary institution between 2001 and 2017 who developed reinfection after a one-stage exchange for PJI of the knee. Prerequisites for inclusion were a certain diagnosis of PJI according to the ICM criteria and a minimum follow-up of three years. Data on comorbidities, previous surgical interventions, microbiological findings at the time of the initial one-stage exchange and at the time of reinfection, detection methods, and antibiotic resistance patterns were retrospectively studied.

RESULTS

Sixty-six patients were identified that met the inclusion criteria. Reinfection occurred after a mean time interval of 27.7 months (SD ± 33.9, range 1-165). Ten types of bacteria were found that were not present before the one-stage exchange. The causative pathogen remained identical in 22 patients (33%) and additional microorganisms were detected in ten patients (15%). Half of the reinfections were however due to (a) completely different microorganism(s). A significant increase in the number of PJIs on the basis of high-virulent (23 vs 30, p = 0.017) and difficult-to-treat bacteria (13 vs 24, p = 0.035) was found.

CONCLUSION

The present study provides a novel insight into the microbiological changes following septic failure after one-stage exchange for PJI of the knee. A higher prevalence of more difficult-to-treat bacteria might increase the complexity of subsequent procedures. Also, a longer follow-up of these patients than previously suggested seems in order.

Plasma levels of D-dimer and fibrin degradation product are unreliable for diagnosing periprosthetic joint infection in patients undergoing re-revision arthroplasty

BACKGROUND

The preoperative diagnosis of periprosthetic joint infection (PJI) in patients undergoing re-revision arthroplasty is crucial, so we evaluated whether plasma levels of D-dimer and fibrin degradation product (FDP) could aid such diagnosis.

METHODS

We retrospectively analyzed data on patients who underwent re-revision hip or knee arthroplasty at our institute during 2008-2020. Patients were stratified into those who experienced PJI or not, based on 2013 International Consensus Meeting Criteria. Plasma levels of D-dimer and FDP as well as levels of the traditional inflammatory biomarkers C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and interleukin-6 were compared between the groups. The ability of these biomarkers to diagnose PJI was assessed based on the area under the receiver operating characteristic (AUC) curve, for which predictive cut-offs were optimized based on the Youden index.

RESULTS

Based on a cut-off of 0.80 mg/L, D-dimer gave an AUC of 0.595, high sensitivity of 85.7% but poor specificity of 47.8%. Based on a cut-off of 2.80 mg/L, FDP gave an AUC of 0.550, poor sensitivity of 56.5% and poor specificity of 52.9%. CRP, ESR and interleukin-6 showed much better diagnostic ability, with AUCs > 0.82. The combination of CRP and interleukin-6 gave an AUC of 0.877, high sensitivity of 91.7% and acceptable specificity of 78.3%.

CONCLUSIONS

Plasma levels of D-dimer and FDP may be inappropriate for diagnosing PJI in patients undergoing re-revision arthroplasty, whereas the combination of serum CRP and interleukin-6 may be effective.