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AAOS Now / Issue: Jun 2024 / clinical03

AAOS Now

Published 6/20/2024
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Jeremy Wodarek, MD; Ajay Srivastava, MD, FAAOS
Clinical Total Joint Hip Knee

Surgeons Continue to Battle the Burden of PJI in Total Joint Arthroplasty

Total joint arthroplasty has been widely successful in treating hip and knee osteoarthritis, and utilization of hip and knee arthroplasty continues to increase. Despite the success of this procedure, total joint arthroplasty is plagued by periprosthetic joint infections (PJIs).

PJI is a troubling complication causing significant morbidity. This article will review the burden of PJI on patients, society, and surgeons.

Diagnosis
PJI rates have been relatively consistent, ranging from 0.3 to 1.5 percent between 1990 and 2015. The definition of PJI has evolved throughout the history of joint surgery.

The current definition includes major criteria considered diagnostic if either is present: sinus tract communicating with implants or two positive cultures from the joint space. The minor criteria comprise a cumulative score based on preoperative assessment: 6 points or greater is considered positive for infection, 2 to 5 is inconclusive, and 0 to 1 is considered not infected.

When including intraoperative findings, the scoring system is similar, but 4 to 5 is determined to be inconclusive and 3 or less is considered not infected. The scoring system includes several tests; if positive, related scores (listed next to each test in brackets or parentheses) are added to determine whether a PJI is present.

Preoperative assessment for suspicion of infection includes serum analysis (elevated C-reactive protein [CRP] or D-dimer [2] and elevated erythrocyte sedimentation rate [1]) and synovial analysis (elevated white blood cell count or leukocyte esterase [3], positive alpha defensin [3], elevated polymorphonuclear cells percentage [2], and elevated synovial CRP [1]). Intraoperative assessment, also cumulative, includes preoperative score, positive histology (3), positive purulence (3), and positive culture (2). The sensitivity and specificity for these criteria are 97.7 percent and 99.5 percent, respectively.

Treatment options
After diagnosis of a PJI, multiple treatment methods are available. Traditionally, two-stage revision has been the gold standard.

Today, treatment options include chronic suppressive antibiotics; debridement, antibiotics, and implant retention (DAIR); one-stage revision; two-stage revisions; and amputation. There are varying perspectives on this subject and continued debate regarding which procedure is best for a specific patient.

In the hopes of having one procedure that can eradicate infection for patients, DAIR and one-stage revisions have been evaluated. DAIR is considered for early postoperative infections or acute hematogenous PJI. DAIR success rates range from 70 to 85 percent. DAIR is more successful when modular components are exchanged at the time of the procedure. The one-stage approach may include varying
protocols but generally involves implant removal, debridement, and placement of final implants. This approach is used for chronic infections to reduce the need for a second procedure. One-stage revision has been successful in eradicating infection in 77 to 100 percent of cases.

The two-stage protocol includes one procedure for implant removal and implantation of an antibiotic spacer and a second procedure for removal of spacer and placement of final components. The two-stage approach has been successful in eradicating infection in 78 to 96 percent of cases.

Amputation may be pursued for those with recurrent infections despite multiple debridements for definitive eradication of the infectious process. Chronic suppressive antibiotics can be an option for patients when the risk of surgical intervention is too high. Chronic suppression can be successful in 50 to 67 percent of cases. Each treatment modality can be effectively used in the appropriate situation.

Financial impact
Medical expenses are one of the top reasons for individual bankruptcy in the United States. The financial implications of PJI must be addressed when evaluating the disease’s burden. In 2017, the average cost of a total hip arthroplasty (THA) PJI was $31,100, with a cumulative cost in the United States of $384.7 million. In the same year, the average cost of a total knee arthroplasty (TKA) PJI was $28,161, with a cumulative national cost of $518.2 million.

Costs are estimated to rise to a combined projected annual national cost of $1.8 billion for THA PJIs ($753.4 million) and TKA PJIs ($1.1 billion) in 2030. These data highlight the projected increase in the financial impact of THA and TKA PJIs.

A recent study suggested that 1.26 million primary TKAs and 935,000 primary THAs will be performed annually by 2030. As the volume of total joint procedures increases, PJI will likely increase, causing a significant financial burden on society.

Psychological impact
Beyond the financial impact of PJI, patients experience psychological distress and functional impairment up to 5 years after a revision procedure. Studies report more depression in patients undergoing revision due to PJI versus those undergoing revision for noninfectious causes.

Furthermore, patients who underwent two-stage revision experienced increased psychological stress and mobility impairment when compared to those who had a one-stage revision. PJI causes significant and long-lasting negative psychological effects.

Mortality
Patients undergoing revision for PJI experience higher mortality rates. Mortality after revision surgery ranges from 0.8 to 4 percent at 1 year and 12.9 to 25.9 percent at 5 years.

Zmistowski et al compared mortality rates between patients undergoing revision total joint surgery for aseptic causes versus PJI. They found that there was a five-fold increase in mortality for those undergoing revision for PJI compared to those undergoing aseptic revision when the groups were matched.

Few studies have been done evaluating suppressive antibiotic therapy. Current data suggest that mortality with long-term suppressive antibiotic therapy for PJI is between 7 and 24 percent. Mortality related to PJI treatment is an important topic to discuss with patients before total joint surgery.

Physician impact
Physicians, like their patients, experience negative psychological consequences when faced with PJI. In a 2020 study out of Sweden, 18 surgeons were found to have feelings of guilt and stress, a sense of failure, and an overall negative emotional impact after one of their patients experienced PJI. The authors found peer support to be the most important coping strategy for physicians. Similarly, surgeons experience a negative impact on their well-being when treating PJI.

PJI continues to be a devastating complication of total joint procedures. The consequences of PJI are broadly experienced throughout the medical system and affect patients, physicians, hospitals, and insurance providers. The authors recommend continued research into the prevention and treatment of PJI to improve the health of patients, surgeons, and society.

This article was submitted on behalf of the AAOS Committee on Healthcare Safety.

Jeremy Wodarek, MD, is an orthopaedic surgery resident at the Michigan State University–McLaren Health Care program in Flint, Michigan.

Ajay Srivastava, MD, FAAOS, is an adult reconstruction surgeon and director of the McLaren Flint orthopaedic surgery residency program at McLaren Flint Medical Center and Hurley Medical Center in Flint, Michigan.

References [online only]

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