CORR Insights®: Patients with a History of Treated Septic Arthritis are at High Risk of Periprosthetic Joint Infection after Total Joint Arthroplasty

Where Are We Now?

Arthroplasty following septic arthritis is a challenging issue as it brings up concerns about the timing, staging, screening, and risk of recurrent infection [8]. Pre-existing osteomyelitis may be more important to discern than septic arthritis as it may confer a greater risk for development of periprosthetic joint infection [5].

Sultan and colleagues [10] performed a multicenter retrospective study of patients who had a history of native septic arthritis and who later underwent primary hip and knee arthroplasty in the same joint. The authors’ goal was to identify the risk of developing periprosthetic joint infection, and the risk factors associated with that complication. The authors only included patients who were believed to have cleared their prior infection by the following criteria: (1) Absence of clinical signs or symptoms of active infection or joint inflammation; (2) plain radiographs with advanced degenerative changes and no active osteolysis or bone infection; and (3) normal serologies and total leukocyte count

Five of 62 patients (8%) developed periprosthetic joint infection, all following knee arthroplasty. It would seem that the risk of periprosthetic joint infection is greater in knee arthroplasty.

Where Do We Need to Go?

While this study answered some of our questions, important ones remain. For example, this study raised the question about the appropriate interval (if there is one) between the prior infection and the arthroplasty, but perhaps because of small sample size, could not answer it. Future studies need to look at that; I believe it may be important. Similarly, we don’t have clear criteria for when a patient with a history of septic arthritis should undergo a two-stage revision, and when the primary arthroplasty can be performed straightaway. Related to this is the screening before arthroplasty [3, 4]; we have more questions than answers on this, and making things even more confusing, in the current study [10], no patients had positive cultures at the time of surgery. And, of course the treatment of native septic arthritis needs to be appropriate in the first place. Inadequately treated septic arthritis may undermine the hopes of success following future reconstructions.

Host factors need to be improved to every extent possible before any surgical intervention, including eradication of methicillin-resistant Staphylococcus aureus when it is present, attention to nutritional status, smoking cessation, thoughtful soft-tissue management, and glycemic control [11]. But even when this is performed, future studies will need to guide us on important surgical decisions like when to use a single-stage reconstruction, antibiotic-laden cement, or irrigation that contains antibiotics [2]. Antibiotic stewardship is important to prevent the development of antibiotic resistance [6]. The mortality of periprosthetic joint infection is daunting [7] and while the infection might not be the direct cause of death, there are associated factors that contribute to this substantial mortality.

How Do We Get There?

Available studies on arthroplasty following prior septic arthritis contains mostly case series without controls [1, 7, 9, 10], and no randomized trials. And the current treatment strategies are generally opinion based or similar to the treatments for periprosthetic joint infections. The management and treatment plan for patients with a history of treated septic arthritis will require consensus and a multidisciplinary team approach consisting of an infectious disease specialist, arthroplasty surgeon, internist, nursing, and wound care specialist if needed.

In order to fill the gaps in our knowledge, a research team would need to develop a multicenter trial with a standardized protocol that can determine the appropriate interval between the prior infection and the arthroplasty and develop clear criteria for when a patient with a history of septic arthritis should undergo a two-stage revision, and for when the primary arthroplasty can be performed straightaway. Additionally, the trial should determine the most-appropriate screening approach to use before arthroplasty and the best treatment for native septic arthritis. This is a daunting task. It will require consensus committee opinions through specialty societies. Specialized forums like the International Consensus Meeting on Musculoskeletal Infection may help to address these concerns.