Preoperative Risk Factors for Periprosthetic Joint Infection: A Narrative Review of the Literature

The application of antibiotic-loaded bone cement in preventing periprosthetic joint infection: an umbrella review

OBJECTIVES

The purpose of this study was to provide thorough, understandable and precise evidence for the clinical use of antibiotic-loaded bone cement (ALBC) in preventing periprosthetic joint infection (PJI).

METHODS

We evaluated the effectiveness of ALBC in preventing PJI by conducting an umbrella review of existing meta-analysis. Four databases, PubMed/MEDLINE, Cochrane Library, Embase and Web of Science, were searched until May 2024. Two reviewers were reviewers for literature screening, and data were extracted independently. AMSTAR 2 guideline and GRADE were also used for quality evaluation. The clinical outcomes were evaluated for effectiveness by several indicators, including surface infection rate (SIR), deep infection rate (DIR), total infection rate (TIR), unadjusted/adjusted all-cause revision rate, and revision rate for PJI.

RESULTS

We synthesized the results of ten meta-analyses. Two meta-analyses had high AMSTAR 2 scores, two had moderate AMSTAR 2 ratings, three had critically low AMSTAR 2 scores, and the remaining meta-analyses had low AMSTAR 2 ratings. In terms of postoperative surgical site infection and revision rate, SIR (OR 1.50, 95% CI 1.14, 1.99, P = 0.004, I2 = 0%), unadjusted all-cause revision rate (RR 1.44, 95% CI 1.08, 1.90, P = 0.011, I2 = 91.8%) and adjusted all-cause revision rate (HR 1.21, 95% CI 1.12, 1.31, P < 0.001, I2 = 0%) in ALBC group were significantly higher than those in non-antibiotic-loaded bone cement (NALBC) group. ALBC group was significantly lower than NALBC group in DIR (OR 0.53, 95% CI 0.39, 0.70, P < 0.0001, I2 = 57%), (RR 0.506, 95% CI 0.341, 0.751, P = 0.001, I2 = 0%) and revision for PJI (RR 0.721, 95% CI 0.628, 0.828, P = 0, I2 = 53%). There was no statistical difference in total infection rate (TIR) between the ALBC group and the NALBC group (OR 0.81, 95% CI 0.51, 1.28, P = 0.37, I2 = 73%).

CONCLUSIONS

On the basis of the results of our analysis, we do not believe that ALBC is more effective than NALBC in preventing PJI after primary total joint arthroplasty (PTJA). No statistically significant difference was found on TIR between the two groups, although it was lower in the ALBC group. In addition, the DIR and revision for PJI are significantly lower in the ALBC group, but the results are of low quality, which calls for high-quality and large-sample studies in the future.

Effectiveness of Local Antibiotics for Infection Prevention in Primary Joint Arthroplasty: A Systematic Review and Meta-Analysis

Background/Objectives: To evaluate the effectiveness of local antibiotic prophylaxis (e.g., powder, bone cement, intraosseous injection) in reducing periprosthetic joint infections (PJI) and deep wound infections in adults undergoing primary joint replacement surgery. Methods: A comprehensive search of PubMed, EMBASE, and the Cochrane Library was conducted from inception to 7 September 2024, including randomized controlled trials (RCTs) and cohort studies without language restrictions. Quality assessment was performed using the Cochrane Risk of Bias (RoB) 2.0 for RCTs and the Newcastle-Ottawa Scale (NOS) for cohort studies. Infection rates were extracted and analyzed using risk ratios (RR) or odds ratios (OR) in a random-effects model with Review Manager (RevMan) 5.4. Sensitivity analysis and meta-regression were also performed to validate the study results and possible risk factors. Results: Twelve RCTs and 21 cohort studies were included in the review. Vancomycin powder in the cohort studies demonstrated statistical significance (OR = 0.47, 95% confidence interval (CI): 0.36-0.61, I2 = 0%), in contrast to the results in the RCTs (RR = 0.37, 95% CI: 0.06-2.47, I2 = 49%). Sensitivity analyses confirmed the robustness and statistical significance of these findings. Both the control and treatment groups primarily cultured Gram-positive pathogens, including in the overall data and specifically for vancomycin powder. The evidence for the use of intraosseous injection (RR of RCTs not estimable, I2 not applicable; OR of cohorts = 0.12, 95% CI: 0.02-0.63, I2 = 0%) and bone cement (RR of RCTs = 0.40, 95% CI: 0.14-1.17, I2 = 56%; OR of cohorts = 1.88, 95% CI: 1.25-2.82, I2 not applicable) was inconclusive. Smoking was identified as an important risk factor for post-operative infection. Further research, including more robust trials and cohort studies, is needed to confirm these findings. Conclusions: Local administration of vancomycin powder appears effective in preventing deep wound infection after arthroplasty.

The Management of Wound Healing in Infections after Hip Arthoplasty Using Stimulan and Negative Pressure Wound Therapy

BACKGROUND

medical teams continue to face challenges with infections following hip replacement surgery, whether they occur shortly after the procedure or months or years later. Certain medical conditions like diabetes, rheumatoid arthritis, and obesity are risk factors that make patients more susceptible to infections. Traditional intervention methods such as DAIR, one-step, or two-step procedures are being enhanced and refined to ensure quicker and more effective treatment. Some cases present particularly difficult challenges, featuring persistent fistulas and unpredictable responses to treatment.

METHODS

in our article, we share two unique cases, detailing their histories, progressions, and treatment decisions. We explore the use of antibiotic-impregnated calcium biocomposite as a local adjuvant therapy and the application of negative pressure therapy to expedite healing. The system of NWPT has seen widespread uptake and is now implemented routinely for open wounds, such as open fractures, fasciotomies, ulcers, and infected wounds.

RESULTS

our findings demonstrate that surgical debridement and calcium sulfate bead insertion successfully treat bone and joint infections without causing any side effects or complications. As a particularity, in the first case, we encountered the exteriorization of Stimulan pearls after surgery, without other complications related to the biocomposite.

CONCLUSIONS

we have found that NPWT is a beneficial tool in managing complex wounds in both acute and chronic stages, after the infection is cured, reducing the need for frequent dressing changes, shortening hospital stays, and enhancing patient comfort.

Tranexamic Acid as a Preventive Strategy Against Periprosthetic Joint Infection in Aseptic Revision Arthroplasty: A Comprehensive Review

Periprosthetic joint infection (PJI) is a severe complication following joint replacement surgeries, particularly in aseptic revision arthroplasty, where infection rates are higher compared to primary procedures. The extended surgical time, increased blood loss, and the presence of scar tissue contribute to the higher susceptibility to PJI in revision surgeries. Tranexamic acid (TXA), a synthetic antifibrinolytic agent, is widely used in orthopaedic surgery to reduce intraoperative and postoperative bleeding. By stabilising blood clots and reducing the need for blood transfusions, TXA improves patient outcomes and reduces complications related to excessive bleeding. Emerging evidence suggests that TXA may also play a role in reducing PJI, as minimising bleeding and haematoma formation can reduce bacterial colonisation and blood transfusions are associated with increased infection risks due to immunomodulation. This review explores the potential of TXA as a preventive strategy against PJI in aseptic revision arthroplasty, evaluating its mechanisms, clinical applications, and current evidence. While TXA's efficacy in reducing blood loss is well-established, its role in infection prevention, particularly through indirect mechanisms such as limiting haematoma formation, warrants further investigation. By incorporating TXA into multimodal strategies aimed at reducing PJI, surgeons can potentially improve patient outcomes and reduce the financial burden on healthcare systems. This review provides a comprehensive examination of the available data on TXA's role in preventing PJI in revision arthroplasty, with an emphasis on understanding its mechanisms and identifying gaps in current knowledge that require further research.

Advances and Challenges in Orthopedic Implant-Associated Infections

The number for orthopedic implants and reconstructive joint replacements, including knee and hip implants, underwent a considerable increase, driven by the aging population and increasing prevalence of musculoskeletal disorders [...].

Genetic and Modifiable Risk Factors for Postoperative Complications of Total Joint Arthroplasty: A Genome-Wide Association and Mendelian Randomization Study

Background: Total joint arthroplasty (TJA) is an orthopedic procedure commonly used to treat damaged joints. Despite the efficacy of TJA, postoperative complications, including aseptic prosthesis loosening and infections, are common. Moreover, the effects of individual genetic susceptibility and modifiable risk factors on these complications are unclear. This study analyzed these effects to enhance patient prognosis and postoperative management. Methods: We conducted an extensive genome-wide association study (GWAS) and Mendelian randomization (MR) study using UK Biobank data. The cohort included 2964 patients with mechanical complications post-TJA, 957 with periprosthetic joint infection (PJI), and a control group of 398,708 individuals. Genetic loci associated with postoperative complications were identified by a GWAS analysis, and the causal relationships of 11 modifiable risk factors with complications were assessed using MR. Results: The GWAS analysis identified nine loci associated with post-TJA complications. Two loci near the PPP1R3B and RBM26 genes were significantly linked to mechanical complications and PJI, respectively. The MR analysis demonstrated that body mass index was positively associated with the risk of mechanical complications (odds ratio [OR]: 1.42; p < 0.001). Higher educational attainment was associated with a decreased risk of mechanical complications (OR: 0.55; p < 0.001) and PJI (OR: 0.43; p = 0.001). Type 2 diabetes was suggestively associated with mechanical complications (OR, 1.18, p = 0.02), and hypertension was suggestively associated with PJI (OR, 1.41, p = 0.008). Other lifestyle factors, including smoking and alcohol consumption, were not causally related to postoperative complications. Conclusions: The genetic loci near PPP1R3B and RBM26 influenced the risk of post-TJA mechanical complications and infections, respectively. The effects of genetic and modifiable risk factors, including body mass index and educational attainment, underscore the need to perform personalized preoperative assessments and the postoperative management of surgical patients. These results indicate that integrating genetic screening and lifestyle interventions into patient care can improve the outcomes of TJA and patient quality of life.