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Novel Diagnostics in Revision Arthroplasty: Implant Sonication and Multiplex Polymerase Chain Reaction
Published on: December 3, 2017
Risk Factors, Diagnoses, and Clinical Characteristics of Synchronous and Metachronous Periprosthetic Joint Infections
Christian J Hecht1, Christian B Ong2, Keith E Arnold2
1Department of Orthopaedics, University of Nebraska Medical Center, Omaha, Nebraska.
Background:
Although multiple PJIs (periprosthetic joint infections), either synchronous or metachronous, occur in up to 20% of patients who have an index PJI after total joint arthroplasty (TJA), there remains a lack of understanding regarding multiple PJI risk factors, diagnosis, and management. Therefore, we asked: (1) What risk factors have been identified for synchronous and metachronous PJI after TJA compared to single-PJI patients? (2) What is the clinical relation of additional PJIs to the index PJI (time and location)? (3) Are the infectious organisms in multiple PJIs the same? and (4) Are clinical suspicion and blood cultures reliable in working up a possible multiple PJI?
Methods:
PubMed, Medline, Embase, Google Scholar, and EBSCOhost were queried to identify studies assessing prevalence, risk factors, and clinical features of synchronous and metachronous PJI following TJA through December 2024. A total of 372 distinct articles were retrieved. After screening, 18 studies were included, comprising 3,292 patients.
Results:
Primary risk factors for developing multiple PJIs included having 3+ prosthetic joints, methicillin-resistant Staphylococcus aureus (MRSA) in the joint space, and positive blood cultures. Metachronous PJI comprised roughly two-thirds of multiple PJIs, with 80% presenting within one year of the index PJI. Additionally, 72 to 90% of synchronous and metachronous PJI involved the contralateral knee prosthetic joint. Identical organism cultures were found in 72.7% of synchronous PJI cases and up to 88.9% of metachronous PJI cases. Blood cultures were inconsistent in differentiating single from multiple PJIs, but clinical suspicion of multiple PJIs was found to be highly specific.
Conclusions:
Our findings suggest that sepsis and MRSA from local tissue are major risk factors for multiple PJIs, necessitating frequent monitoring of patients who have primary PJI. Surgeons should maintain a high suspicion for Staphylococcus and polymicrobial infections, standardize blood culture reporting, and closely monitor preimplanted prostheses, as multiple PJIs can remain elusive.
Level Of Evidence:
Level III, Therapeutic study.
Insights
Multiple periprosthetic joint infections (PJIs) are linked to having multiple prosthetic joints and MRSA. Early suspicion and monitoring are key for timely diagnosis and management of these complex infections.
Area of Science:
- Orthopedic Surgery
- Infectious Diseases
- Biomedical Engineering
Background:
- Multiple periprosthetic joint infections (PJIs) occur in up to 20% of patients post-total joint arthroplasty (TJA).
- Limited understanding exists regarding risk factors, diagnosis, and management of multiple PJIs.
- This study addresses knowledge gaps concerning synchronous and metachronous PJIs.
Purpose of the Study:
- Identify risk factors for multiple PJIs compared to single PJI.
- Clarify the clinical relationship (timing, location) of additional PJIs to the index PJI.
- Determine if infectious organisms are consistent across multiple PJIs.
- Assess the reliability of clinical suspicion and blood cultures in diagnosing multiple PJIs.
Main Methods:
- Systematic literature review of PubMed, Medline, Embase, Google Scholar, and EBSCOhost.
- Included 18 studies comprising 3,292 patients with periprosthetic joint infections.
- Data analyzed for prevalence, risk factors, and clinical features of multiple PJIs.
Main Results:
- Key risk factors identified: 3+ prosthetic joints, methicillin-resistant Staphylococcus aureus (MRSA), and positive blood cultures.
- Metachronous PJIs constitute two-thirds of multiple infections, often presenting within one year.
- Contralateral knee involvement is common (72-90%); identical organisms found in 72.7% (synchronous) to 88.9% (metachronous) cases.
- Blood cultures showed inconsistency; clinical suspicion demonstrated high specificity for multiple PJIs.
Conclusions:
- Sepsis and local MRSA are significant risk factors for multiple PJIs.
- Frequent monitoring of patients with index PJI is crucial.
- High suspicion for Staphylococcus and polymicrobial infections is warranted.
- Standardized blood culture reporting and close monitoring of prostheses are recommended.
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