Abstract
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.
Introduction
Many patients have more than one joint arthroplasty, and studies have estimated that one in 30 people living in Australia and the United States have at least one shoulder, hip, or knee implant in situ [14, 15, 18]. Furthermore, the number of people living with more than one joint replacement is increasing at a faster pace than the number of those living with only one joint replacement [15]. We have made little headway in preventing periprosthetic joint infection (PJI), the incidence of which has remained somewhat similar over the past 15 years [14, 16, 17]. PJI affects 1% of patients with a joint implant [21]. As a result, the absolute number of patients with PJI is rising. When treating a patient with PJI, there is a 33% to 45% chance the patient will have at least one additional joint implant in situ [1, 11, 12]. The chance of experiencing a PJI in a second joint is 8% to 20% [1, 12]. We do not have a good way to assess the risk of a metachronous PJI (periprosthetic infection in patients who have previously had PJI in another joint, after a lag period) in a joint in a patient who has a PJI in the other joint. The risk appears to be higher in patients in whom the initial PJI is accompanied by systemic inflammatory response syndrome or bacteremia, in whom the PJI is caused by methicillin-resistant Staphylococcus aureus, patients who must undergo three or more stages of resection arthroplasty, female patients, and those who have rheumatoid arthritis, all of which are nonmodifiable risk factors [1, 11, 12]. An orthopaedic surgeon might have a positive or negative impact on the chance that a subsequent PJI will develop in patients with an uninfected implant in the same bone as the infected implant.
Although we know that most metachronous PJIs are caused by the same microorganisms that led to the initial PJI, the exact route of infection is not fully understood. Many may be hematogenic, but in a patient with an uninfected implant in the same bone as the infected implant, there is also a chance of continuous infection or infection by inoculation because of surgical procedures. Given the lack of data, there are no recommendations on this matter.
We therefore asked, (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?
Patients and Methods
Study Design and Setting
This retrospective study used data from a longitudinally maintained institutional database of patients with PJI. The study was performed at a high-volume tertiary referral arthroplasty center, where approximately 7000 total joint arthroplasties are performed every year, with 400 to 500 PJIs treated each year. Our institution’s practice is to perform a preoperative joint aspiration on all patients undergoing revision arthroplasty. Revisions for PJI were based on the International Consensus Meeting criteria [20, 23].
Participants
We 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). In this group, 161 patients received an ipsilateral hip or knee implant in situ at the time of undergoing surgical treatment for PJI of the hip or knee (Fig. 1). Sixty-three patients were excluded because they met the following criteria: incomplete documentation (seven patients), unavailability of full-leg radiographs (48), and synchronous infection (eight). Regarding the latter, per internal protocol, all artificial joints were aspirated before revision arthroplasty, allowing us to differentiate between synchronous and metachronous infection. Patients were followed for a minimum of 24 months for any complications. The remaining 98 patients were followed for a mean follow-up period of 85 ± 33 months (Table 1). Twenty percent (20 of 98) of patients experienced ipsilateral metachronous PJI during the study period. The mean time between the initial PJI and ipsilateral metachronous PJI was 8 ± 14 months. The ipsilateral metachronous PJI group was followed for 71 months (range 37 to 102 months), and the other group was followed for 79 months (range 34 to 135 months).
Fig. 1.
This flow diagram shows the study’s flow.
Table 1.
Descriptive data and procedure-related data (n = 98)
| Parameter | Value |
| Age in years, mean ± SD | 77 ± 9.6 |
| BMI in kg/m2, mean ± SD | 30 ± 6.2 |
| Height in meters, mean ± SD | 1.68 ± 0.1 |
| Weight in kg, mean ± SD | 85 ± 21.4 |
| Follow-up in months, mean ± SD | 85 ± 33.2 |
| Femur length in cm, mean ± SD | 44 ± 7.0 |
| Empty bone distance in cm, median (range) | 8 (0-36) |
| Stem-to-stem distance in cm, median (range) | 12 (1-43) |
| Female, % (n) | 65 (64) |
| Right side, % (n) | 56 (55) |
| Draining sinus (fistula) at first PJI, % (n) | 20 (20) |
| First PJI, % (n) | |
| Hip | 52 (51) |
| Knee | 48 (47) |
| Difficult-to-treat infections, % (n)a | 26 (26) |
| High-virulence infections, % (n)a | 33 (32) |
| Polymicrobial infections, % (n) | 11 (11) |
| Fungal infections, % (n) | 1 (1) |
| Gram-positive pathogens, % (n) | 17(17) |
| Culture-negative infection, % (n) | 4 (4) |
| Proximal or distal femur resection, % (n) | 14 (14) |
| Cement restrictor failure, % (n) | 18 (18) |
| One-stage or two-stage protocol, % (n) | |
| One-stage | 76 (77) |
| Two-stage | 23 (23) |
Difficult-to-treat infections are defined as those caused by rifampicin-resistant staphylococci, fluoroquinolone-resistant streptococci, enterococci, and fungi. High-virulence infections are defined as those cause by S. aureus, Enterobacteriaceae, Streptococcus spp., and Candida spp.
Descriptive Data and Variables
We divided the study population into two groups, one in whom a metachronous infection developed (n = 20) and the other in whom infection did not develop (n = 78). There was no difference in age, sex, BMI, and the initial PJI-affected joint between the two groups. In addition, the groups did not differ in terms of bacterial virulence (high and low virulence were defined by Morgenstern et al. [19]), polymicrobial infection, and difficult-to-treat germs (defined as those caused by rifampicin-resistant staphylococci, fluoroquinolone-resistant streptococci, enterococci, and fungi [2, 7]). Of the patients, 65% (64 of 98) were female; the mean patient age was 77 ± 9.6 years, and the mean BMI was 30 ± 6.2 kg/m2. The implants were located on the right side in 56% (55 of 98) of the patients. The prosthesis with the primary infection was the hip in 52% (51 of 98) of the patients. The mean follow-up period was 85 ± 33 months (Table 1).
Primary and Secondary Outcome Measures
The primary study goal was to determine whether there were factors associated with the development of subsequent PJI of the other implant in patients with both a hip and knee arthroplasty on the same side who experienced a PJI of one implant. To achieve this, we studied the following patient-related risk factors: sex, age, BMI, rheumatoid arthritis, renal insufficiency (Grade > 3 as defined by Kidney Disease Outcomes Quality Initiative and modified and endorsed by Kidney Disease: Improving Global Outcomes [6]), coronary heart disease, and chronic obstructive pulmonary disease or asthma.
The secondary study goal was to determine how often the same organism was responsible for both PJIs. To achieve this, we studied the following PJI-related risk factors: the presence of a draining sinus, a one-stage or two-stage procedure for the initial PJI treatment, type of microorganisms (gram-positive, gram-negative, fungi, and polymicrobial) and microbiological characteristics (high-virulence bacteria, defined as S. aureus, Enterobacteriaceae, Streptococcus spp., and Candida spp.; and difficult-to-treat organisms, defined as rifampicin-resistant staphylococci, fluoroquinolone-resistant streptococci, enterococci, and fungi) [2].
The third study goal was to determine whether a shorter distance from an infected prosthetic joint to the ipsilateral prosthetic joint was associated with greater odds of subsequent infection of the second joint. To achieve this, we analyzed calibrated full-leg radiographs containing three radiographic parameters that may lead to an increased risk of ipsilateral metachronous infection. These were (1) stem-to-stem distance, defined as the distance between the tips of the femoral components of the hip and knee implants (Fig. 2A) (for primary TKA, the pegs of the femoral component on a lateral radiograph were used [Fig. 3]); (2) femoral empty native bone distance (Fig. 2B), defined as the distance between the ends of the cement of both femoral components; and (3) cement restrictor failure, defined as radiographic evidence of cement that unintentionally went beyond the cement stop (Fig. 4).
Fig. 2.
Radiographic measurement of the (A) stem-to-stem distance and (B) the empty native bone distance is shown in a revision TKA.
Fig. 3.
Radiographic measurement of the stem-to-stem distance (yellow) and the empty native bone distance (red) is shown in a patient undergoing a primary TKA.
Fig. 4.
This figure shows radiographic evidence of cement restrictor failure with cement protruding distally to the cement stop used for the revision THA.
Ethical Approval
The study was approved by the ethics committee of our institution (approval number 2022-300156-WF).
Statistical Analysis
We used the Shapiro-Wilk test to assess the normality of the distribution of continuous variables. Then, we used descriptive statistics (mean, median, and standard deviation) to describe the patients’ variables and radiologic data. Categorical variables were assessed using the chi-square test or Fisher exact test for statistical significance. We compared continuous variables using paired and unpaired t-tests, as appropriate. Receiver operating characteristic (ROC) curves were created and then studied to analyze the cutoff for stem-to-stem distance and empty native bone distance. A post hoc power analysis was performed for stem-to-stem distance, empty bone distance, and cement restrictor failure. All p values < 0.05 were considered statistically significant. All data were analyzed using SAS® version 9.3 (SAS Institute).
Results
Factors Associated With the Development of Ipsilateral Metachronous PJI
Patients in whom ipsilateral metachronous PJI developed were shorter and weighed less than those in whom an infection did not develop (1.6 ± 0.1 m and 76 ± 16 kg for height and weight, respectively) (Table 2). We found no differences in age, sex, the initial prosthetic joint involved, or BMI between groups (Table 3). We found no differences in the incidence of PJI-induced fever (15% [3 of 20] versus 4% [3 of 78]; p > 0.01), rheumatoid arthritis (20% [4 of 20] versus 9% [7 of 78]; p > 0.01), or renal insufficiency (40% [8 of 20] versus 21% [16 of 78]; p > 0.01) between groups (Table 3). We also found no differences in femur length between groups (42 ± 4.1 cm versus 44 ± 7.6 cm; p > 0.01).
Table 2.
Demographic data of patients with ipsilateral and metachronous PJI and those with contralateral PJI
| Parameter | Contralateral metachronous PJI at the final follow-up (n = 78) | Ipsilateral metachronous PJI at the final follow-up (n = 20) | Mean difference (95% CI) | p value |
| Age in years, mean ± SD | 76 ± 10 | 80 ± 7 | -4 (-8 to 1) | 0.14 |
| BMI in kg/m2, mean ± SD | 30 ± 6 | 29 ± 6.5 | 1 (-2 to 4) | 0.47 |
| Height in m, mean ± SD | 1.7 ± 0.1 | 1.6 ± 0.1 | 0.1 (0 to 0.1) | 0.003 |
| Weight in kg, mean ± SD | 87 ± 22 | 76 ± 16 | 10 (0 to 21) | 0.04 |
| Femur length in cm, mean ± SD | 44 ± 8 | 42 ± 4 | 2 (-1 to 6) | 0.21 |
Table 3.
Surgical characteristics of patients with ipsilateral and contralateral metachronous PJI
| Parameter | Contralateral metachronous PJI at the most-recent follow-up (n = 78) | Ipsilateral metachronous PJI at the most-recent follow-up (n = 20) | Odds ratio (95% CI) | p value |
| Female | 62 (48) | 80 (16) | 0.19 | |
| Initial PJI | ||||
| Hip | 54 (42) | %45 (9) | 0.62 | |
| Knee | 46 (3 6) | 55 (11) | ||
| Difficult-to-treat infectionsa | 28 (22) | 20 (4) | 0.57 | |
| High-virulence infectiona | 34 (27) | 25 (5) | 0.59 | |
| Polymicrobial infections | 12 (9) | 10 (2) | 0.33 | |
| Fungal infection | 0 (0) | 5 (1) | 0.45 | |
| Gram-positive pathogens | 15 (12) | 25 (5) | 0.33 | |
| Culture-negative infections | 4 (3) | 5 (1) | 0.23 | |
| Proximal or distal femur resection | 5 (4) | 50 (10) | 0.2 (0.1 to 0.3) | 0.001 |
| Cement restrictor failure | 5 (4) | 70 (14) | 0.1 (0.0 to 0.2) | 0.001 |
| Same bacteria causing the ipsilateral metachronous PJI | 0 (0) | 70 (14) | ||
| Fever at presentation | 4 (3) | 15 (3) | 0.09 | |
| Rheumatoid arthritis | 9 (7) | 20 (4) | 0.23 | |
| Renal insufficiency | 21 (16) | 40 (8) | 0.09 | |
| Coronary heart disease | 15 (12) | 10 (2) | 0.73 | |
Data are presented as % (n).
Difficult-to-treat infections are defined as those caused by rifampicin-resistant staphylococci, fluoroquinolone-resistant streptococci, enterococci, and fungi. High-virulence infections are defined as those cause by S. aureus, Enterobacteriaceae, Streptococcus spp., and Candida spp.
Microbiology of Metachronous PJI
Patients in whom ipsilateral PJI developed were no more likely to present with difficult-to-treat organisms (20% [4 of 20] versus 28% [22 of 78]; p > 0.1), high-virulence organisms (25% [5 of 20] versus 34% [27 of 78]; p > 0.1), or polymicrobial infections (10% [2 of 20] versus 12% [9 of 78]; p > 0.1) than those who did not (Table 3). Patients who underwent bone resections as part of the treatment of PJI had higher odds of having metachronous PJI than those who underwent single-stage exchange arthroplasty (50% [10 of 20] versus 5% [four of 78]; p < 0.01).
Minimum Safe Distance Between Implants
Patients in whom ipsilateral metachronous PJI developed had a shorter stem-to-stem (8 ± 5 cm versus 14 ± 7 cm; p < 0.01) and empty native bone distance (5 ± 4 cm versus 11 ± 7 cm; p < 0.01) (Table 4) and higher risk of extrusion of cement past their restrictor (70% [14 of 20] versus 5% [four of 78]; p < 0.01) than patients in whom such an infection did not develop (Table 3).
Table 4.
Empty bone and stem-to-stem distance of patients
| Parameter | Contralateral metachronous PJI at final follow-up (n = 78) | Ipsilateral metachronous PJI at final follow-up (n = 20) | Mean difference (95% CI) | p value |
| Empty native bone distance in cm, mean ± SD | 11 ± 7 | 5 ± 4 | 6 (4 to 9) | 0.001 |
| Stem-to-stem distance in cm, mean ± SD | 14 ± 7 | 8 ± 5 | 6 (3 to 9) | 0.001 |
Analysis of the ROC curve (Table 5) showed a cutoff of 7 cm for the empty native bone distance (p < 0.01), with a sensitivity of 72% and specificity of 75% (Fig. 5). A cutoff of 9 cm for the stem-to-stem distance was found (p < 0.01), with a sensitivity of 74% and specificity of 70%. In absolute numbers, this means that 7% (four of 61) of patients with an empty native bone distance of more than 7 cm experienced ipsilateral metachronous PJI, whereas 43% (16 of 37) of patients with an empty native bone distance of less than 7 cm experienced ipsilateral metachronous PJI (p < 0.01).
Table 5.
An ROC analysis of the empty bone and stem-to-stem distance of patients
| Test result variable | Cutoff value, cm | Sensitivity, % | Specificity, % | AUC | 95% CI AUC | p value |
| Empty native bone distance | 7.0 | 72 | 75 | 0.78 | 0.67 to 0.89 | 0.001 |
| Stem-to-stem distance | 9.0 | 74 | 70 | 0.75 | 0.64 to 0.87 | 0.001 |
ROC = receiver operating characteristic; AUC = area under the curve.
Fig. 5.
A receiver operating characteristic curve analysis was used in this study to determine the optimal cutoff for the stem-to-stem and empty native bone distance. A color image accompanies the online version of this article.
Discussion
PJI, the most common cause of failure and reason for revision after TKA and THA, is a devastating complication with a challenging diagnosis and treatment process [5, 8, 28]. Moreover, the incidence of a much more severe condition such as multiple PJIs (including synchronous and metachronous) has been rising because of the expanding number of patients with more than one prosthetic joint, and it has become necessary for orthopaedic surgeons to have a deeper understanding of multiple PJIs [12, 22]. Identifying the risk factors, micro-organism patterns, and safe distance between implants for metachronous PJIs as well as patients who may benefit from additional investigation is essential in these patient groups. This clinical study emphasized that patients with a shorter stature and narrow stem-to-stem distance between two implants should be more careful regarding the risk of ipsilateral metachronous PJI.
Limitations
First, the sample was relatively small, even though more than 2000 exchange arthroplasties for PJI were performed in almost a decade at our tertiary referral center using a consistent philosophy that has been in place since the 1980s. This could have led to a Type II statistical error; that is, failure to identify statistically significant findings that would have been found if the sample was larger. Nevertheless, important and new findings were already detectable, regardless of the small number of patients available for analysis.
Second, the study was at risk of assessment bias and transfer bias because metachronous PJIs could have been missed if patients remained relatively asymptomatic or went to other hospitals for treatment. However, it seems very unlikely that this would change the main finding of this study; that is, that a minimum distance should be kept between the infected implant that is being revised and the uninfected implant in the same femur.
Third, 30% (six of 20) of patients with ipsilateral metachronous PJI had different bacteria in the metachronous PJI than in the initial PJI. This weakens our hypothesis that these metachronous infections are caused by either contiguous spread or direct inoculation, to some extent. However, it is a well-known phenomenon that recurrent infection (in the same or in another artificial joint) is often caused by different or additional micro-organisms [3, 4], which is probably related to the overall health status of the host. Additionally, the chance a metachronous infection of an implant will develop in the same femur is higher than when the implant is in the contralateral femur, indicating that infections by either contiguous spread or direct inoculation plays a role [24].
Factors Associated With the Development of Ipsilateral Metachronous PJI
Patients in whom ipsilateral metachronous PJI developed were shorter and weighed less than those who did not experience ipsilateral metachronous PJI, but we otherwise found no differences between groups in age, sex, the initial prosthetic joint involved, and BMI. Ninety-eight patients had an uninfected THA or TKA implant in situ at the time of receiving surgical treatment for ipsilateral PJI of the hip or knee. During a mean follow-up duration of more than 7 years, one of five patients experienced ipsilateral metachronous PJI. Although this is in line with earlier studies [9, 13], previously identified factors did not apply to our study population. Considering demographic data that may have an impact on the risk of ipsilateral metachronous PJI, age, BMI, and sex did not differ between those with PJI and those without in this study. Similarly, Lee et al. [12] compared patients with a single PJI and multiple PJIs, and found that the same demographic data (age, sex, and BMI) did not change the risk of PJI [17]. On the other hand, a respective evaluation of weight and height showed that patients with ipsilateral metachronous PJI were shorter and thinner, and there was a difference between groups with and without PJI in terms of these two parameters. In addition, in a study by Komnos et al. [11], the presence of coexisting rheumatoid arthritis led to an increased incidence of multiple PJIs. In the present study, however, rheumatoid arthritis, renal failure, and coronary artery disease were not associated with a difference between patients with same-side PJI and those without.
Microbiology of Metachronous PJI
Patients with ipsilateral PJI were no more likely than those without to present with difficult-to-treat organisms, high-virulence organisms, or polymicrobial infections. The rate of difficult-to-treat organisms was reported to be up to 38% in patients undergoing one-stage exchange arthroplasty after PJI [27]. In addition, research comparing one- and two-stage exchange arthroplasties performed after PJI found that the rate of reinfection was higher in patients infected with difficult-to-treat organisms [26]. The rate of difficult-to-treat organisms was found to be 20% to 30% in both groups of the present study, in which the risk of reinfection was still high although lower than that reported previously. Infection with highly virulent organisms was associated with a poor outcome and a high risk of revision [6, 25]. In the present study, 25% to 35% of the patients in both groups were infected with highly virulent organisms and therefore were at risk of reinfection. Similarly, polymicrobial infection was also reported to be a major risk factor for reinfection [10]. In this study, the rate of polymicrobial infection was 10% to 15% in both groups, which led to an increased risk of reinfection. These risk factors, which were present in both groups at similar rates, did not create a difference in reinfection.
Minimum Safe Distance Between Implants
Interestingly, we found differences when examining basic biometrics of the patients and their femurs, particularly the remaining femoral distance between implants. Patients with ipsilateral metachronous PJI were shorter, weighed less, and tended to have shorter femurs. They also had shorter stem-to-stem distances, shorter empty native bone distances, and a higher risk of extrusion of cement past the restrictor. We found that patients with an empty native bone distance of at least 7 cm and stem-to-stem distance of 9 cm were less likely to have an ipsilateral metachronous PJI, with sensitivity and specificity values for these cutoffs ranging between 70 and 80%. These findings provide indirect evidence that at least a proportion of metachronous PJIs are caused by contiguous spread or direct inoculation instead of via the hematogenic route. This implies that an uninfected implant in the same bone as the infected implant is associated with a higher risk of metachronous PJI. The ROC analysis showed that maintaining a gap of 7 cm of empty native bone between the femoral implants could reduce the risk of ipsilateral metachronous PJI from 43% to 7%. Based on our results, we recommend a stem-to-stem distance of at least 7 cm. In these situations, extrusion of cement of more than 2 cm beyond the restrictor can compromise a distant joint. Extrusion compromises the empty native bone distance and therefore the biological buffer zone for the bone to protect the uninfected implant.
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. We recommend maintaining a minimum of 7 cm of native bone between the uninfected implant and the revised implant for PJI of the hip or knee to reduce the risk of ipsilateral metachronous PJI.
Footnotes
One or more of the authors (TG, MC) certifies receipt of personal payments or benefits, during the study period, in an amount of less than USD 10,000 from W. Link & Co KG, outside the submitted manuscript. One of the authors (TG) certifies receipt of personal payments or benefits, during the study period, in an amount of less than USD 10,000 from Zimmer Biomet Inc and in an amount of less than USD 10,000 from CeramTec Co, all outside the submitted manuscript.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.
Ethical approval for this study was obtained from the Ethik-Komission der Arztekammer Hamburg, Hamburg, Germany (2022-300156-WF).
This work was performed at the HELIOS ENDO-Klinik, Hamburg, Germany.
Contributor Information
Mustafa Akkaya, Email: makkaya@outlook.com.
Georges Vles, Email: georges.vles@uzleuven.be.
Rudy Sangaletti, Email: rudy.sangaletti@gmail.com.
Luigi Zanna, Email: luigizanna90@gmail.com.
Thorsten Gehrke, Email: thorsten.Gehrke@helios-gesundheit.de.
References
- 1.Abblitt WP, Chan EW, Shinar AA. Risk of periprosthetic joint infection in patients with multiple arthroplasties. J Arthroplasty. 2018;33:840-843. [DOI] [PubMed] [Google Scholar]
- 2.Akgun D, Perka C, Trampuz A, Renz N. Outcome of hip and knee periprosthetic joint infections caused by pathogens resistant to biofilm-active antibiotics: results from a prospective cohort study. Arch Orthop Trauma Surg. 2018;138:635-642. [DOI] [PubMed] [Google Scholar]
- 3.Akkaya M, Vles G, Bakhtiari IG, et al. What is the rate of reinfection with different and difficult-to-treat bacteria after failed one-stage septic knee exchange? Int Orthop. 2022;46:687-695. [DOI] [PubMed] [Google Scholar]
- 4.Bakhtiari IG, Vles G, Busch SM, et al. Septic failure after one-stage exchange for prosthetic joint infection of the hip: microbiological implications. J Arthroplasty. 2022;37:373-378. [DOI] [PubMed] [Google Scholar]
- 5.Boddapati V, Fu MC, Mayman DJ, Su EP, Sculco PK, McLawhorn AS. Revision total knee arthroplasty for periprosthetic joint infection is associated with increased postoperative morbidity and mortality relative to noninfectious revisions. J Arthroplasty. 2018;33:521-526. [DOI] [PubMed] [Google Scholar]
- 6.Cordero-Ampuero J, Esteban J, Garcia-Rey E. Results after late polymicrobial, gram-negative, and methicillin-resistant infections in knee arthroplasty. Clin Orthop Relat Res. 2010;468:1229-1236. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Faschingbauer M, Bieger R, Kappe T, Weiner C, Freitag T, Reichel H. Difficult to treat: are there organism-dependent differences and overall risk factors in success rates for two-stage knee revision? Arch Orthop Trauma Surg. 2020;140:1595-1602. [DOI] [PubMed] [Google Scholar]
- 8.Gomez-Barrena E, Warren T, Walker I, et al. Prevention of periprosthetic joint infection in total hip and knee replacement: one European consensus. J Clin Med. 2022;11:381. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Haverstock JP, Somerville LE, Naudie DD, Howard JL. Multiple periprosthetic joint infections: evidence for decreasing prevalence. J Arthroplasty. 2016;31:2862-2866. [DOI] [PubMed] [Google Scholar]
- 10.Kildow BJ, Springer BD, Brown TS, Lyden E, Fehring TK, Garvin KL. Long term results of two-stage revision for chronic periprosthetic hip infection: a multicenter study. J Clin Med. 2022;11:1657. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Komnos GA, Manrique J, Goswami K, et al. Periprosthetic joint infection in patients who have multiple prostheses in place: what should be done with the silent prosthetic joints. J Bone Joint Surg Am. 2020;102:1160-1168. [DOI] [PubMed] [Google Scholar]
- 12.Lee SH, Chang CH, Hu CC, Chang Y, Hsieh PH, Lin YC. The risk factor and outcome of metachronous periprosthetic joint infections: a retrospective analysis with a minimum ten-year follow-up. J Arthroplasty. 2021;36:3734-3740. [DOI] [PubMed] [Google Scholar]
- 13.Luessenhop CP, Higgins LD, Brause BD, Ranawat CS. Multiple prosthetic infections after total joint arthroplasty. Risk factor analysis. J Arthroplasty. 1996;11:862-868. [DOI] [PubMed] [Google Scholar]
- 14.Manning L, Davis JS, Robinson O, et al. High prevalence of older Australians with one or more joint replacements: estimating the population at risk for late complications of arthroplasty. ANZ J Surg. 2020;90:846-850. [DOI] [PubMed] [Google Scholar]
- 15.Maradit Kremers H, Larson DR, Crowson CS, et al. Prevalence of total hip and knee replacement in the United States. TJ Bone Joint Surg Am. 2015;97:1386-1397. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.The McMaster Arthroplasty Collaborative (MAC). Risk factors for periprosthetic joint infection following primary total hip arthroplasty: a 15-year, population-based cohort study. J Bone Joint Surg Am. 2020;102:503-509. [DOI] [PubMed] [Google Scholar]
- 17.McMaster Arthroplasty Collaborative (MAC). Incidence and predictors of prosthetic joint infection following primary total knee arthroplasty: a 15-year population-based cohort study. J Arthroplasty. 2022;37:367-372.e361. [DOI] [PubMed] [Google Scholar]
- 18.Mishra N, Mohanty S, Patil P, Desale A. Functional evaluation of patients undergoing multiple joint replacements: a retrospective study of 50 patients with a minimum of six months of follow-up. Cureus. 2016;8:e830. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Morgenstern C, Cabric S, Perka C, Trampuz A, Renz N. Synovial fluid multiplex PCR is superior to culture for detection of low-virulent pathogens causing periprosthetic joint infection. Diagn Microbiol Infect Dis. 2018;90:115-119. [DOI] [PubMed] [Google Scholar]
- 20.Parvizi J, Gehrke T; International Consensus Group on Periprosthetic Joint Infection. Definition of periprosthetic joint infection. J Arthroplasty. 2014;29:1331. [DOI] [PubMed] [Google Scholar]
- 21.Pulido L, Ghanem E, Joshi A, Purtill JJ, Parvizi J. Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res. 2008;466:1710-1715. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Sambri A, Caldari E, Fiore M, et al. Synchronous periprosthetic joint Infections: a scoping review of the literature. Diagnostics (Basel). 2022;12:1841. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Shohat N, Bauer T, Buttaro M, et al. Hip and knee section, what is the definition of a periprosthetic joint infection (PJI) of the knee and the hip? Can the same criteria be used for both joints? Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty. 2019;34:S325-S327. [DOI] [PubMed] [Google Scholar]
- 24.Thiesen DM, Mumin-Gunduz S, Gehrke T, et al. Synchronous periprosthetic joint infections: the need for all artificial joints to be aspirated routinely. J Bone Joint Surg Am. 2020;102:283-291. [DOI] [PubMed] [Google Scholar]
- 25.Tigani D, Trisolino G, Fosco M, Ben Ayad R, Costigliola P. Two-stage reimplantation for periprosthetic knee infection: Influence of host health status and infecting microorganism. Knee. 2013;20:9-18. [DOI] [PubMed] [Google Scholar]
- 26.Tuecking LR, Silligmann J, Savov P, Omar M, Windhagen H, Ettinger M. Detailed revision risk analysis after single- vs. two-stage revision total knee arthroplasty in periprosthetic joint infection: a retrospective tertiary center analysis. Antibiotics (Basel). 2021;10:1177. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Zeller V, Lhotellier L, Marmor S, et al. One-stage exchange arthroplasty for chronic periprosthetic hip infection: results of a large prospective cohort study. J Bone Joint Surg Am. 2014;96:e1. [DOI] [PubMed] [Google Scholar]
- 28.Zmistowski B, Karam JA, Durinka JB, Casper DS, Parvizi J. Periprosthetic joint infection increases the risk of one-year mortality. J Bone Joint Surg Am. 2013;95:2177-2184. [DOI] [PubMed] [Google Scholar]