The Risk Factor and Outcome of Metachronous Periprosthetic Joint Infections: A Retrospective Analysis With a Minimum Ten-Year Follow-Up

The co-occurrence of spondylodiscitis and periprosthetic joint infections: clinical and microbiological perspectives

PURPOSE

To assess the potential relationship between synchronous and metachronous occurrences of spondylodiscitis and subsequent periprosthetic joint infection (PJI), shedding light on the interplay between these two distinct yet interconnected conditions. The secondary aim was to investigate the time interval between the occurrences of spondylodiscitis and PJI in metachronous infections, and to identify potential similarities or differences in the causative pathogens between synchronous and metachronous infections.

METHODS

A retrospective single-center study was performed. Patients diagnosed with either spondylodiscitis or PJI (based on the 2018 International Consensus Meeting criteria) were included. Demographic, clinical, laboratory and microbiology patient data were retrieved.

RESULTS

The incidence of metachronous infection and synchronous infection were 86.7% and 13.3% respectively. In metachronous infections, time between spondylodiscitis and PJI was 29.1 months (SD 31.1). The most common relation between spondylodiscitis and PJI were between hip PJI and lumbar spondylodiscitis. There was a statistically significant difference in the time between spondylodiscitis and PJI in the patient who had or had not arthroplasty prior to the spondylodiscitis (p = 0.02). The spondylodiscitis and PJI concomitant infection were predominant a monobacterial infection. Staphylococcus aureus was the most frequent species isolated (47.6%). The same organism was isolated in the cultures in metachronous and in the synchronous infections between spondylodiscitis and PJI in 100% of cases.

CONCLUSION

The findings of this study suggest a potential link between spondylodiscitis and PJI; however, further research is required to understand the mechanisms underlying the potential relationship between these events, as well as to develop effective strategies for prevention, diagnosis, and treatment of these infections.

LEVEL OF EVIDENCE

Level IV, Retrospective case series.

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.

Prevalence of unexpected intraoperative cultures (UPIC) in revision total knee arthroplasty (TKA) and risk of periprosthetic joint infection (PJI)

INTRODUCTION

Prevalence of unexpected positive intraoperative cultures (UPIC) in revision total knee arthroplasty (TKA) is reported to be 8.32% with largely varying findings in individual studies (5.92-62.07%) due to a heterogeneity in preoperative diagnostic work-up and diagnostic criteria for periprosthetic joint infection (PJI). When diagnosed as unsuspected PJI, re-revision rate is reported to be as high as 18.45% compared to 2.94% in patients with UPIC classified as contamination (p = 0.0237). We performed a monocentric retrospective analysis of revision TKA surgery to determine prevalence of UPIC, risk of developing a subsequent PJI and re-revision rate after 24 months compared to those without UPIC.

MATERIALS AND METHODS

All presumed aseptic total knee revision procedures from 2008 until 2017 were retrospectively reviewed. Single stage femorotibial revisions of TKA with at least 3 intraoperative cultures and a minimum follow-up of 24 months were included, whereas partial revisions or revisions from unicompartimental knee prosthesis to TKA were excluded. Demographic data were collected as well as initial reason for revision, preoperative aspiration results, micro-organism identified and postoperative antibiotics' administration. Primary outcome was survival rate after 24 months with differentiation based on UPIC interpretation: sterile, contamination, unsuspected PJI.

RESULTS

Of 256 included cases, 75 (29.3%) were found to have at least 1 UPIC during revision surgery, 72% of whom a single UPIC was found. Thirty-four cases (13.28%) were interpreted as unsuspected PJI and therefore treated with antibiotics. In total, 13 of the 256 patients (5.08%) had to be re-revised during follow-up with 7 PJI (2.73%), none of them developing reinfection defined as PJI with the same microorganism. A statistically significant trend towards earlier failure in the unsuspected PJI group compared to the contaminant group was not observed. However, a higher incidence of re-revisions attributed to septic reasons was noted in the former group.

CONCLUSIONS

Presence of UPIC in presumed aseptic revision TKA does not correlate with a lower survival rate, but a higher incidence of subsequent PJI was observed in cases interpreted as unsuspected PJI.

Periprosthetic Infection in Patients With Multiple Joint Arthroplasties

The number of total joint arthroplasties performed in the United States is increasing every year. Owing to the aging population and excellent long-term prosthesis survival, 45% of patients who undergo joint arthroplasty will receive two or more joint arthroplasties during their lifetimes. Periprosthetic joint infection (PJI) is among the most common complications after arthroplasty. Evaluation and treatment of PJI in patients with multiple joint arthroplasties is challenging, and no consensus exists for the optimal management. Multiple PJI can occur simultaneously, synchronous, or separated by extended time, metachronous. Patient risk factors for both scenarios have been reported and may guide evaluation and long-term management. Whether to perform joint aspiration for asymptomatic prosthesis in the presence of suspected PJI in patients with multiple joint arthroplasties is controversial. Furthermore, no consensus exists regarding whether patients who have multiple joint arthroplasties and develop PJI in a single joint should be considered for prolonged antibiotic prophylaxis to reduce the risk of future infections. Finally, the optimal treatment of synchronous joint infections whether by débridement, antibiotics and implant retention, and one-stage or two-stage revision has not been defined. This review will summarize the best information available and provide pragmatic management strategies.

Single, Recurrent, Synchronous, and Metachronous Periprosthetic Joint Infections in Patients With Multiple Hip and Knee Arthroplasties

BACKGROUND

The rate for periprosthetic joint infection (PJI) exceeds 1% for primary arthroplasties. Over 30% of patients who have a primary arthroplasty require an additional arthroplasty, and the impact of PJI on this population is understudied. Our objective was to assess the prevalence of recurrent, synchronous, and metachronous PJI in patients who had multiple arthroplasties and to identify risk factors for a subsequent PJI.

METHODS

We identified 337 patients who had multiple arthroplasties and at least 1 PJI that presented between 2003 and 2021. The mean follow-up after revision arthroplasty was 3 years (range, 0 to 17.2). Patients who had multiple infected prostheses were categorized as synchronous (ie, presenting at the same time as the initial infection) or metachronous (ie, presenting at a different time as the initial infection). The PJI diagnosis was made using the MusculoSkeletal Infection Society (MSIS) criteria.

RESULTS

There were 39 (12%) patients who experienced recurrent PJI in the same joint, while 31 (9%) patients developed PJI in another joint. Positive blood cultures were more likely in the second joint PJI (48%) compared to recurrent PJI (23%) or a single PJI (15%, P < .001). Synchronous PJI represented 42% of the second joint PJI cases (n = 13), while metachronous PJI represented 58% (n = 18). Tobacco users had 75% higher odds of metachronous PJI (odds ratio 1.75, 95% confidence interval: 1.1-2.9, P = .041).

CONCLUSION

Over 20% of the patients with multiple arthroplasties and a single PJI will develop a subsequent PJI in another arthroplasty with 12% recurring in the initial arthroplasty and nearly 10% ocurring in another arthroplasty. Particular caution should be taken in patients who use tobacco, have bacteremia, or have Staphylococcus aureus isolation at time of their initial PJI. Optimizing the management of this high-risk patient population is necessary to reduce the additional burden of subsequent PJI.

LEVEL OF EVIDENCE

Prognostic Level IV.

What is the Safe Distance Between Hip and Knee Implants to Reduce the Risk of Ipsilateral Metachronous Periprosthetic Joint Infection?

BACKGROUND

Periprosthetic joint infection (PJI), the most common cause of revision after TKA and THA, is a devastating complication for patients that is difficult to diagnose and treat. An increase in the number of patients with multiple joint arthroplasties in the same extremity will result in an increased risk of ipsilateral PJI. However, there is no definition of risk factors, micro-organism patterns, and safe distance between knee and hip implants for this patient group.

QUESTIONS/PURPOSES

(1) In patients with hip and knee arthroplasties on the same side who experience a PJI of one implant, are there factors associated with the development of subsequent PJI of the other implant? (2) In this patient group, how often is the same organism responsible for both PJIs? (3) Is a shorter distance from an infected prosthetic joint to an ipsilateral prosthetic joint associated with greater odds of subsequent infection of the second joint?

METHODS

We designed a retrospective study of a longitudinally maintained institutional database that identified all one-stage and two-stage procedures performed for chronic PJI of the hip and knee at our tertiary referral arthroplasty center between January 2010 and December 2018 (n = 2352). Of these patients, 6.8% (161 of 2352) had an ipsilateral hip or knee implant in situ at the time of receiving surgical treatment for a PJI of the hip or knee. The following criteria led to the exclusion of 39% (63 of 161) of these patients: 4.3% (seven of 161) for incomplete documentation, 30% (48 of 161) for unavailability of full-leg radiographs, and 5% (eight of 161) for synchronous infection. With regard to the latter, per internal protocol, all artificial joints were aspirated before septic surgery, allowing us to differentiate between synchronous and metachronous infection. The remaining 98 patients were included in the final analysis. Twenty patients experienced ipsilateral metachronous PJI during the study period (Group 1) and 78 patients did not experience a same-side PJI (Group 2). We analyzed the microbiological characteristics of bacteria during the first PJI and ipsilateral metachronous PJI. Calibrated, full-length plain radiographs were evaluated. Receiver operating characteristic curves were analyzed to determine the optimal cutoff for the stem-to-stem and empty native bone distance. The mean time between the initial PJI and ipsilateral metachronous PJI was 8 ± 14 months. Patients were followed for a minimum of 24 months for any complications.

RESULTS

The risk of ipsilateral metachronous PJI in the other joint secondary to a joint implant in which PJI develops can increase up to 20% in the first 2 years after the procedure. There was no difference between the two groups in age, sex, initial joint replacement (knee or hip), and BMI. However, patients in the ipsilateral metachronous PJI group were shorter and had a lower weight (1.6 ± 0.1 m and 76 ± 16 kg). An analysis of the microbiological characteristics of bacteria at the time of the initial PJI showed no differences in the proportions of difficult-to-treat, high virulence, and polymicrobial infections between the two groups (20% [20 of 98] versus 80% [78 of 98]). Our findings showed that the ipsilateral metachronous PJI group had a shorter stem-to-stem distance, shorter empty native bone distance, and a higher risk of cement restrictor failure (p < 0.01) than the 78 patients who did not experience ipsilateral metachronous PJI during the study period. An analysis of the receiver operating characteristic curve showed a cutoff of 7 cm for the empty native bone distance (p < 0.01), with a sensitivity of 72% and a specificity of 75%.

CONCLUSION

The risk of ipsilateral metachronous PJI in patients with multiple joint arthroplasties is associated with shorter stature and stem-to-stem distance. Appropriate position of the cement restrictor and native bone distance are important in reducing the risk of ipsilateral metachronous PJI in these patients. Future studies might evaluate the risk of ipsilateral metachronous PJI owing to bone adjacency.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Periprosthetic joint infection in patients with multiple arthroplasties

Despite numerous studies focusing on periprosthetic joint infections (PJIs), there are no robust data on the risk factors and timing of metachronous infections. Metachronous PJIs are PJIs that can arise in the same or other artificial joints after a period of time, in patients who have previously had PJI. Between January 2010 and December 2018, 661 patients with multiple joint prostheses in situ were treated for PJI at our institution. Of these, 73 patients (11%) developed a metachronous PJI (periprosthetic infection in patients who have previously had PJI in another joint, after a lag period) after a mean time interval of 49.5 months (SD 30.24; 7 to 82.9). To identify patient-related risk factors for a metachronous PJI, the following parameters were analyzed: sex; age; BMI; and pre-existing comorbidity. Metachronous infections were divided into three groups: Group 1, metachronous infections in ipsilateral joints; Group 2, metachronous infections of the contralateral lower limb; and Group 3, metachronous infections of the lower and upper limb. We identified a total of 73 metachronous PJIs: 32 PJIs in Group 1, 38 in Group 2, and one in Group 3. The rate of metachronous infection was 11% (73 out 661 cases) at a mean of four years following first infection. Diabetes mellitus incidence was found significantly more frequently in the metachronous infection group than in non-metachronous infection group. The rate of infection in Group 1 (21.1%) was significantly higher (p = 0.049) compared to Groups 2 (6.2%) and 3 (3%). The time interval of metachronous infection development was shorter in adjacent joint infections. Concordance between the bacterium of the first PJI and that of the metachronous PJI in Group 1 (21/34) was significantly higher than Group 2 (13/38; p = 0.001). The findings of this study suggest that metachronous PJI occurs in more than one in ten patients with an index PJI. Female patients, diabetic patients, and patients with a polymicrobial index PJI are at significantly higher risk for developing a metachronous PJI. Furthermore, metachronous PJIs are significantly more likely to occur in an adjacent joint (e.g. ipsilateral hip and knee) as opposed to a more remote site (i.e. contralateral or upper vs lower limb). Additionally, adjacent joint PJIs occur significantly earlier and are more likely to be caused by the same bacteria as the index PJI.

Trends in gastrointestinal disease hospitalizations and outcomes during the first year of the coronavirus pandemic

BACKGROUND

The impact of the coronavirus on hospitalizations for gastrointestinal (GI) disease, particularly at a population level is understudied.

AIM

To investigate trends in hospitalizations, inpatient endoscopy resource utilization, and outcomes during the first year of the coronavirus pandemic and subsequent lockdowns.

METHODS

Using the California State Inpatient Database for 2018-2020, we explored year-to-year and 2020 month-to-month trends in hospitalizations, length of stay, and inpatient mortality (all-cause & viral pneumonia-specific) for common inpatient GI diagnoses including acute pancreatitis, diverticulitis, cholelithiasis, non-infectious gastroenteritis, upper and lower GI bleeding (LGIB), Clostridium difficile, viral gastroenteritis, inflammatory bowel disease, and acute cholangitis.

RESULTS

Disease-specific hospitalizations decreased for all included conditions except nonvariceal upper GI bleeding (NVUGIB), LGIB, and ulcerative colitis (UC) (ptrend < 0.0001). All-cause inpatient mortality was higher in 2020 vs 2019, for acute pancreatitis (P = 0.029), diverticulitis (P = 0.04), NVUGIB (P = 0.003), and Crohn’s disease (P = 0.004). In 2020, hospitalization rates were lowest in April, November, and December. There was no significant corresponding increase in inpatient mortality except in UC (ptrend = 0.048). Viral pneumonia and viral pneumonia complicated by respiratory failure increased (P < 0.001) among GI hospitalizations. Endoscopy utilization within 24 h of admission was unchanged for GI emergencies except NVUGIB (P < 0.001).

CONCLUSION

Our findings suggest that hospitalization rates for common GI conditions significantly declined in California during the COVID pandemic, particularly in April, November and December 2020. All-cause mortality was significantly higher among acute pancreatitis, diverticulitis, NVUGIB, and Crohn’s disease hospitalizations. Emergency endoscopy rates were mostly comparable between 2020 and 2019.

Lockdown Social Isolation and Lockdown Stress During the COVID-19 Pandemic in China: The Impact of Mindfulness

This study is aimed to examine the impact of mindfulness in the relationship between social isolation, job and financial insecurity, and stress during the lockdown period of the COVID-19 pandemic. Drawing on Conservation of Resources theory, Psychological Contract theory, Mindfulness theory, and Awareness notion, we propose that lockdown job insecurity partially mediates the link from lockdown social isolation to lockdown financial insecurity, and that the relationship between lockdown social isolation and lockdown stress is mediated as follows: first, simple partial mediation through both lockdown job and financial insecurity and second, sequential mediation through lockdown job and financial insecurity, respectively. Moreover, we assume that mindfulness moderates the relationship between lockdown financial insecurity and lockdown stress. The results from our SEM analyses, using a sample of 1,356 respondents in China, support all the research hypotheses. Based on this empirical work, this study concludes that mindfulness, which is considered by many people to play a role in reducing stress during the COVID-19 lockdown period, is de facto endangering their mental health (that is, they experience more stress) instead. Theoretical and practical implications, as well as limitations and proposals for future research are discussed.