Periprosthetic Knee and Hip Infection — Is It Possible to Compare Treatment Outcomes?

Abstract

Background. It is known that the outcomes of patients treatment with periprosthetic joint infection (PJI) are significantly influenced by the state of the patient’s body, the nature of the pathogen, the state of tissues in the area of the infectious focus and the treatment tactics. However, topographic and anatomical features of the blood supply to the knee and hip joints, as well as the volume of soft tissues, can affect the spectrum of pathogens, manifestations of the infectious process and, as a consequence, the effectiveness of treatment.

The aim of the study was to conduct a comparative analysis of the somatic status of patients, the etiology of the infectious process and the effectiveness of treatment of PJI depending on its localization.

Methods. A single-center retrospective study was conducted. The cases of 337 patients were studied — 119 patients with knee and 218 patients with hip PJI who underwent treatment with a two-stage technique during the period from 2007 to 2017. A comparative analysis of the PJI pathogens structure and concomitant pathology between patients with hip and knee PJI was carried out. The frequency of infection relief in the groups following the first stage was counted.

Results. Recurrence was diagnosed four times more frequently in patients with hip PJI compared to knee PJI. Risk factors for recurrence were gram-negative pathogens, microbial associations, and fistulous forms of the infectious process. Localization of the infectious process in the hip area was associated with a statistically significant greater volume of blood loss during the prolonged debridement surgery.

Conclusion. Recurrences of PJI occur more frequently in the hip area compared to the knee joint. Further analysis of critical factors in recurrence development is necessary for potential intervention.

Keywords

periprosthetic joint infection / hip arthroplasty / knee arthroplasty / comorbidity / etiology

References

[1] Postler A., Lützner C., Beyer F., Tille E., Lützner J. Analysis of Total Knee Arthroplasty revision causes. BMC Musculoskelet Disord. 2018;19(1):55. doi: 10.1186/s12891-018-1977-y.

[2] Postler A, Lützner C, Beyer F, Tille E, Lützner J. Analysis of Total Knee Arthroplasty revision causes. BMC Musculoskelet Disord. 2018 Feb 14;19(1):55. doi: 10.1186/s12891-018-1977-y. PMID: 29444666; PMCID: PMC5813428.

[3] Boelch S.P., Jakuscheit A., Doerries S., Fraissler L., Hoberg M., Arnholdt J. et al. Periprosthetic infection is the major indication for TKA revision – experiences from a university referral arthroplasty center. BMC Musculoskelet Disord. 2018;19(1):395. doi: 10.1186/s12891-018-2314-1.

[4] Boelch SP, Jakuscheit A, Doerries S, Fraissler L, Hoberg M, Arnholdt J, Rudert M. Periprosthetic infection is the major indication for TKA revision - experiences from a university referral arthroplasty center. BMC Musculoskelet Disord. 2018 Nov 10;19(1):395. doi: 10.1186/s12891-018-2314-1. PMID: 30414610; PMCID: PMC6234791.

[5] Premkumar A., Kolin D.A., Farley K.X., Wilson J.M., McLawhorn A.S., Cross M.B. et al. Projected Economic Burden of Periprosthetic Joint Infection of the Hip and Knee in the United States. J Arthroplasty. 2021;36(5): 1484-1489.e3. doi: 10.1016/j.arth.2020.12.005.

[6] Premkumar A, Kolin DA, Farley KX, Wilson JM, McLawhorn AS, Cross MB, Sculco PK. Projected Economic Burden of Periprosthetic Joint In-fection of the Hip and Knee in the United States. J Arthroplasty. 2021 May;36(5):1484-1489.e3. doi: 10.1016/j.arth.2020.12.005. Epub 2020 Dec 9. PMID: 33422392.

[7] Kurtz S.M., Higgs G.B., Lau E., Iorio R.R., Courtney P.M., Parvizi J. Hospital Costs for Unsuccessful Two-Stage Revisions for Periprosthetic Joint Infection. J Arthroplasty. 2022;37(2):205-212. doi: 10.1016/j.arth.2021.10.018.

[8] Kurtz SM, Higgs GB, Lau E, Iorio RR, Courtney PM, Parvizi J. Hospital Costs for Unsuccessful Two-Stage Revisions for Periprosthetic Joint Infection. J Arthroplasty. 2022 Feb;37(2):205-212. doi: 10.1016/j.arth.2021.10.018. Epub 2021 Nov 8. PMID: 34763048.

[9] Rava A., Bruzzone M., Cottino U., Enrietti E., Rossi R. Hip Spacers in Two-Stage Revision for Periprosthetic Joint Infection: A Review of Literature. Joints. 2019;7(2):56-63. doi: 10.1055/s-0039-1697608.

[10] Rava A, Bruzzone M, Cottino U, Enrietti E, Rossi R. Hip Spacers in Two-Stage Revision for Periprosthetic Joint Infection: A Review of Literature. Joints. 2019 Oct 11;7(2):56-63. doi: 10.1055/s-0039-1697608. PMID: 31879732; PMCID: PMC6930843.

[11] Kini S.G., Gabr A., Das R., Sukeik M., Haddad F.S. Two-stage Revision for Periprosthetic Hip and Knee Joint Infections. Open Orthop J. 2016;10:579-588. doi: 10.2174/1874325001610010579.

[12] Мурылев В.Ю., Куковенко Г.А., Елизаров П.М., Иваненко Л.Р., Со-рокина Г.Л., Рукин Я.А., Алексеев С.С., Германов В.Г. (2018). Алгоритм первого этапа лечения поздней глубокой перипротезной инфекции тазо-бедренного сустава. Травматология и ортопедия России, 24 (4), 95-104. Murylev V.Yu., Kukovenko G.A., Elizarov P.M., Ivanenko L.R., Sorokina G.L., Rukin Ya.A., Alekseev S.S., Germanov V.G. [The First-Stage Treatment Аlgorithm for Deep Infected Total Hip Arthroplasty]. Travmatologiya i ortopediya Rossii [Traumatology and Orthopedics of Russia]. 2018;24(4):95-104. (In Russ.). DOI: 10.21823/2311-2905-2018-24-4-95-104.

[13] Ермаков А.М., Клюшин Н.М., Абабков Ю.В., Тряпичников А.С., Коюшков А.Н. Оценка эффективности двухэтапного хирургического лечения больных с перипротезной инфекцией коленного и тазобедренного суставов. Гений ортопедии. 2018;24(3):321-326. doi: 10.18019/1028-4427-2018-24-3-321-326. Ermakov A.M., Kliushin N.M., Ababkov Iu.V., Triapichnikov A.S., Koiushkov A.N. Efficiency of two-stage revision arthroplasty in management of periprosthetic knee and hip joint infection. Genij Ortopedii. 2018;24(3): 321-326. doi: 10.18019/1028-4427-2018-24-3-321-326. (In Russian).

[14] Ермаков А.М., Клюшин Н.М., Абабков Ю.В., Тряпичников А.С., Коюшков А.Н. Оценка эффективности двухэтапного хирургического лече-ния больных с перипротезной инфекцией коленного и тазобедренного су-ставов // Гений ортопедии. 2018. Т. 24. № 3. С. 321-326. DOI 10.18019/1028-4427-2018-24-3-321-326 Ermakov A.M., Kliushin N.M., Ab-abkov Iu.V., Triapichnikov A.S., Koiushkov A.N. [Efficiency of two-stage re-vision arthroplasty in management of periprosthetic knee and hip joint infec-tion]. Genij Ortopedii [Orthodaedic Genius]. 2018;24(3). pp. 321-326. DOI 10.18019/1028-4427-2018-24-3-321-326. (In Russian).

[15] Craig A., King S.W., van Duren B.H., Veysi V.T., Jain S., Palan J. Articular spacers in two-stage revision arthroplasty for prosthetic joint infection of the hip and the knee. EFORT Open Rev. 2022;7(2):137-152. doi: 10.1530/EOR-21-0037.

[16] Lazic I, Scheele C, Pohlig F, von Eisenhart-Rothe R, Suren C. Treatment options in PJI - is two-stage still gold standard? J Orthop. 2021 Jan 20;23:180-184. doi: 10.1016/j.jor.2020.12.021. PMID: 33551610; PMCID: PMC7848725.

[17] Ren X., Ling L., Qi L., Liu Z., Zhang W., Yang Z. et al. Patients’ risk factors for periprosthetic joint infection in primary total hip arthroplasty: a meta-analysis of 40 studies. BMC Musculoskelet Disord. 2021;22(1):776. doi: 10.1186/s12891-021-04647-1.

[18] Ren X, Ling L, Qi L, Liu Z, Zhang W, Yang Z, Wang W, Tu C, Li Z. Pa-tients' risk factors for periprosthetic joint infection in primary total hip arthro-plasty: a meta-analysis of 40 studies. BMC Musculoskelet Disord. 2021 Sep 12;22(1):776. doi: 10.1186/s12891-021-04647-1. PMID: 34511099; PMCID: PMC8436433.

[19] Kong L., Cao J., Zhang Y., Ding W., Shen Y. Risk factors for periprosthetic joint infection following primary total hip or knee arthroplasty: a meta-analysis. Int Wound J. 2017;14(3):529-536. doi: 10.1111/iwj.12640.

[20] Kong L, Cao J, Zhang Y, Ding W, Shen Y. Risk factors for periprosthetic joint infection following primary total hip or knee arthroplasty: a meta-analysis. Int Wound J. 2017 Jun;14(3):529-536. doi: 10.1111/iwj.12640. Epub 2016 Jul 10. PMID: 27397553; PMCID: PMC7949746.

[21] Kunutsor S.K., Whitehouse M.R., Blom A.W., Beswick A.D. INFORM Team. Patient-Related Risk Factors for Periprosthetic Joint Infection after Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. PLoS One. 2016;11(3):e0150866. doi: 10.1371/journal.pone.0150866.

[22] Тряпичников А.С., Ермаков А.М., Клюшин Н.М., Абабков Ю.В., Степанян А.Б., Коюшков А.Н. Результаты лечения перипротезной инфекции крупных суставов у ВИЧ-позитивных больных. Травматология и ортопедия России. 2019;25(4):117-125. doi: 10.21823/2311-2905-2019-25-4-117-125. Tryapichnikov A.S., Ermakov A.M., Klyushin N.V., Ababkov yu.V., Stepanyan A.B., Koyushkov A.N. [Treatment Outcomes of Periprosthetic Joint Infection in HIV-Positive Patients]. Travmatologiya i ortopediya Rossii [Traumatology and orthopedics of russia]. 2019;25(4):117-125. (In Russian). doi: 10.21823/2311-2905-2019-25-4-117-125.

[23] Parvizi J., Tan T.L., Goswami K., Higuera C., Della Valle C., Chen A.F. et al. The 2018 Definition of Periprosthetic Hip and Knee Infection: An Evidence-Based and Validated Criteria. J Arthroplasty. 2018;33(5):1309-1314.e2. doi: 10.1016/j.arth.2018.02.078.

[24] Parvizi J, Tan TL, Goswami K, Higuera C, Della Valle C, Chen AF, Shohat N. The 2018 Definition of Periprosthetic Hip and Knee Infection: An Evidence-Based and Validated Criteria. J Arthroplasty. 2018 May;33(5):1309-1314.e2. doi: 10.1016/j.arth.2018.02.078. Epub 2018 Feb 26. PMID: 29551303.

[25] Преображенский П.М., Божкова С.А., Каземирский А.В. Расчет индекса коморбидности как фактора риска рецидива перипротезной инфекции после установки спейсера коленного сустава. Травматология и ортопедия России. 2022;28(1):7-18. doi: 10.17816/2311-2905-1718. Preobrazhensky P.M., Bozhkova S.A., Kazemirsky A.V. Comorbidity Index as a Risk Factor of Knee PJI Recurrence After Spacer Implantation. Traumatology and Orthopedics of Russia. 2022;28(1):7-18. (In Russian). doi: 10.17816/2311-2905-1718.

[26] Преображенский П.М., Божкова С.А., Каземирский А.В. Расчет индекса коморбидности как фактора риска рецидива перипротезной ин-фекции после установки спейсера коленного сустава // Травматология и ортопедия России. - 2022. - Т. 28. - №1. - C. 7-18. doi: 10.17816/2311-2905-1718 Preobrazhensky P.M., Bozhkova S.A., Kazemirsky A.V. [Comorbidity Index as a Risk Factor of Knee PJI Recurrence After Spacer Implantation]. Travmatologiya i ortopediya Rossii [Traumatology and Orthopedics of Russia]. 2022;28(1): 7-18. (In Russian). https://doi.org/10.17816/2311-2905

[27] Zimmerli W., Trampuz A., Ochsner P.E. Prosthetic joint infections. N Engl J Med. 2004;351(16):1645-1654. doi: 10.1056/NEJMra040181.

[28] Zimmerli W., Trampuz A., Ochsner P.E. Prosthetic joint infections. N Engl J Med. 2004;351(16):1645-1654. doi: 10.1056/NEJMra040181.\

[29] Charette R.S., Melnic C.M. Two-Stage Revision Arthroplasty for the Treatment of Prosthetic Joint Infection. Curr Rev Musculoskelet Med. 2018;11(3):332-340. doi: 10.1007/s12178-018-9495-y.

[30] Charette RS, Melnic CM. Two-Stage Revision Arthroplasty for the Treatment of Prosthetic Joint Infection. Curr Rev Musculoskelet Med. 2018 Sep;11(3):332-340. doi: 10.1007/s12178-018-9495-y.

[31] Lazic I., Scheele C., Pohlig F., von Eisenhart-Rothe R., Suren C. Treatment options in PJI – is two-stage still gold standard? J Orthop. 2021;23:180-184. doi: 10.1016/j.jor.2020.12.021.

[32] Lazic I, Scheele C, Pohlig F, von Eisenhart-Rothe R, Suren C. Treatment options in PJI - is two-stage still gold standard? J Orthop. 2021 Jan 20;23:180-184. doi: 10.1016/j.jor.2020.12.021.

[33] Pangaud C., Ollivier M., Argenson J.N. Outcome of single-stage versus two-stage exchange for revision knee arthroplasty for chronic periprosthetic infection. EFORT Open Rev. 2019;4(8):495-502. doi: 10.1302/2058-5241.4.190003.

[34] Pangaud C, Ollivier M, Argenson JN. Outcome of single-stage ver-sus two-stage exchange for revision knee arthroplasty for chronic periprosthet-ic infection. EFORT Open Rev. 2019 Aug 2;4(8):495-502. doi: 10.1302/2058-5241.4.190003.

[35] Palazzo C., Nguyen C., Lefevre-Colau M.M., Rannou F., Poiraudeau S. Risk factors and burden of osteoarthritis. Ann Phys Rehabil Med. 2016;59(3):134-138. doi: 10.1016/j.rehab.2016.01.006.

[36] Palazzo C, Nguyen C, Lefevre-Colau MM, Rannou F, Poiraudeau S. Risk factors and burden of osteoarthritis. Ann Phys Rehabil Med. 2016 Jun;59(3):134-138. doi: 10.1016/j.rehab.2016.01.006.

[37] Vina E.R., Kwoh C.K. Epidemiology of osteoarthritis: literature update. Curr Opin Rheumatol. 2018;30(2): 160-167. doi: 10.1097/BOR.0000000000000479.

[38] Vina ER, Kwoh CK. Epidemiology of osteoarthritis: literature up-date. Curr Opin Rheumatol. 2018 Mar;30(2):160-167. doi: 10.1097/BOR.0000000000000479.

[39] Bae K.J., Chae Y.J., Jung S.J., Gong H.S. Incidence and risk factors for periprosthetic joint infection: A common data model analysis. Jt Dis Relat Surg. 2022;33(2):303-313. doi: 10.52312/jdrs.2022.671.

[40] Bae KJ, Chae YJ, Jung SJ, Gong HS. Incidence and risk factors for periprosthetic joint infection: A common data model analysis. Jt Dis Relat Surg. 2022;33(2):303-313. doi: 10.52312/jdrs.2022.671.

[41] Rodriguez-Merchan E.C., Delgado-Martinez A.D. Risk Factors for Periprosthetic Joint Infection after Primary Total Knee Arthroplasty. J Clin Med. 2022;11(20):6128. doi: 10.3390/jcm11206128.

[42] Rodriguez-Merchan EC, Delgado-Martinez AD. Risk Factors for Periprosthetic Joint Infection after Primary Total Knee Arthroplasty. J Clin Med. 2022 Oct 18;11(20):6128. doi: 10.3390/jcm11206128.

[43] Xu C., Wang Q., Kuo F.C., Goswami K., Tan T.L., Parvizi J. The Presence of Sinus Tract Adversely Affects the Outcome of Treatment of Periprosthetic Joint Infections. J Arthroplasty. 2019;34(6):1227-1232.e2. doi: 10.1016/j.arth.2019.02.040.

[44] Xu C, Wang Q, Kuo FC, Goswami K, Tan TL, Parvizi J. The Pres-ence of Sinus Tract Adversely Affects the Outcome of Treatment of Peripros-thetic Joint Infections. J Arthroplasty. 2019 Jun;34(6):1227-1232.e2. doi: 10.1016/j.arth.2019.02.040.

[45] Gabrielli A.S., Wilson A.E., Wawrose R.A., Dombrowski M., O’Malley M.J., Klatt B.A. The presence of a draining sinus is associated with failure of re-implantation during two-stage exchange arthroplasty. J Bone Jt Infect. 2022;7(2):55-60. doi: 10.5194/jbji-7-55-2022.

[46] Gabrielli AS, Wilson AE, Wawrose RA, Dombrowski M, O'Malley MJ, Klatt BA. The presence of a draining sinus is associated with failure of re-implantation during two-stage exchange arthroplasty. J Bone Jt Infect. 2022 Mar 22;7(2):55-60. doi: 10.5194/jbji-7-55-2022.

[47] Bredeche F., Gounot I., Belgaïd V., Macabeo C., Rouhana K., Aubrun F. et al. Anemia before reimplantation surgery - An overlooked modifiable risk factor of septic revision knee arthroplasty failure. SICOT J. 2020;6:47. doi: 10.1051/sicotj/2020046.

[48] Bredeche F, Gounot I, Belgaïd V, Macabeo C, Rouhana K, Aubrun F, Ferry T, Servien E, Lustig S, Dziadzko M. Anemia before reimplantation surgery - An overlooked modifiable risk factor of septic revision knee arthro-plasty failure. SICOT J. 2020;6:47. doi: 10.1051/sicotj/2020046.

[49] Артюх В.А., Божкова С.А., Бояров А.А., Муравьева Ю.В., Кочиш А.А. Эффективность одноэтапного ревизионного эндопротезирования при свищевой форме хронической перипротезной инфекции тазобедренного сустава. Травматология и ортопедия России. 2021;27(2):9-22. doi: 10.21823/2311-2905-2021-27-2-9-22. Artyukh V.A., Bozhkova S.A., Boyarov A.A., Muravyova J.V., Kochish A.A. Efficiency of the One-Stage Revision Hip Arthroplasty in Chronic Periprosthetic Joint Infection with Sinus Tract. Traumatology and Orthopedics of Russia. 2021;27(2):9-22. (In Russian). doi: 10.21823/2311-2905-2021-27-2-9-22.

[50] Артюх В.А., Божкова С.А., Бояров А.А., и др. Эффективность одноэтапного ревизионного эндопротезирования при свищевой форме хронической перипротезной инфекции тазобедренного сустава // Травма-тология и ортопедия России. - 2021. - Т. 27. - №2. - C. 9-22. doi: 10.21823/2311-2905-2021-27-2-9-22 Artyukh V.A., Bozhkova S.A., Boyarov A.A., Muravyova J.V., Kochish A.A. [Efficiency of the One-Stage Revision Hip Arthroplasty in Chronic Periprosthetic Joint Infection with Sinus Tract]. Travmatologiya i ortopediya Rossii [Traumatology and Orthopedics of Russia]. 2021;27(2):9-22. (In Russian). https://doi.org/10.21823/2311-2905-2021-27-2-9-22

[51] Preobrazhensky P., Bozhkova S., Kochish A., Tikhilov R., Kazemirsky A. Comparative analysis of pathogen structure in patients with PJI after primary total hip and knee arthroplasty. Arch Orthop Trauma Surg. 2021;141(11):1963-1969. doi: 10.1007/s00402-021-04139-w.

[52] Preobrazhensky P, Bozhkova S, Kochish A, Tikhilov R, Kazemirsky A. Comparative analysis of pathogen structure in patients with PJI after primary total hip and knee arthroplasty. Arch Orthop Trauma Surg. 2021 Nov;141(11):1963-1969. doi: 10.1007/s00402-021-04139-w.

[53] Li H., Fu J., Niu E., Chai W., Xu C., Hao L.B. et al. The risk factors of polymicrobial periprosthetic joint infection: a single-center retrospective cohort study. BMC Musculoskelet Disord. 2021;22(1):780. doi: 10.1186/s12891-021-04664-0.

[54] Li H, Fu J, Niu E, Chai W, Xu C, Hao LB, Chen J. The risk factors of polymicrobial periprosthetic joint infection: a single-center retrospective co-hort study. BMC Musculoskelet Disord. 2021 Sep 12;22(1):780. doi: 10.1186/s12891-021-04664-0.

[55] Efremov K., Benedetti Valentini M., De Maio F., Potenza V., Caterini R. et al. Periprosthetic hip and knee infections: comparison of etiology, perioperative management and costs. Eur Rev Med Pharmacol Sci. 2019;23 (2 Suppl):217-223. doi: 10.26355/eurrev_201904_17496.

[56] Efremov K, Benedetti Valentini M, De Maio F, Potenza V, Caterini R, Farsetti P. Periprosthetic hip and knee infections: comparison of etiology, perioperative management and costs. Eur Rev Med Pharmacol Sci. 2019 Apr;23(2 Suppl):217-223. doi: 10.26355/eurrev_201904_17496. PMID: 30977889.

[57] Paharik A.E., Horswill A.R. The Staphylococcal Biofilm: Adhesins, Regulation, and Host Response. Microbiol Spectr. 2016;4(2):10.1128/microbiolspec.VMBF-0022-2015. doi: 10.1128/microbiolspec.VMBF-0022-2015.

[58] Божкова С.А., Краснова М.В., Полякова Е.М., Рукина А.Н., Шабанова В.В. Cпособность к формированию биопленок у клинических штаммов S.aureus и S.epidermidis - ведущих возбудителей ортопедической имплант-ассоциированной инфекции. Клиническая микробиология и ан-тимикробная химиотерапия. 2014. Т. 16. № 2. С. 149-156. Bozhkova S.A., Krasnova M.V., Polyakova E.M., Rukina A.N., Shabanova V.V. [Biofilm formation ability of S.aureus and S.epidermidis strains - the leading pathogens for orthopaedic implant-assosiated infection]. Klinicheskaja mikrobiologija i antimikrobnaja himioterapija [Clinical microbiology and antimicrobial chemo-therapy]. 2014;16 (2). P. 149-156

[59] Zmistowski B., Fedorka C.J., Sheehan E., Deirmengian G., Austin M.S., Parvizi J. Prosthetic joint infection caused by gram-negative organisms. J Arthroplasty. 2011;26 (6 Suppl):104-108. doi: 10.1016/j.arth.2011.03.044.

[60] Zmistowski B, Fedorka CJ, Sheehan E, Deirmengian G, Austin MS, Parvizi J. Prosthetic joint infection caused by gram-negative organisms. J Arthroplasty. 2011 Sep;26(6 Suppl):104-8. doi: 10.1016/j.arth.2011.03.044

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