Mortality after an infected total knee arthroplasty : a meta-analysis

The aim of this study was to evaluate the overall mortality rate in patients with periprosthetic joint infection (PJI) after total knee arthroplasty (TKA), the overall mortality over time, and mortality after treatment.

Ovid MEDLINE, Embase, CINAHL, Cochrane Library, Scopus, and Web of Science, were searched for studies reporting the rate of mortality in patients with TKA PJI until December 2023. Full-length studies with extractable data dealing with mortality in these patients were included. Studies were excluded if they involved TKAs which were undertaken for oncological or traumatic indications or septic arthritis, or were partial or revision TKAs. Studies in which primarily high-risk patients, such those with an organ transplant or cancer, were also excluded, in order to allow the mortality rate in patients with PJI after TKA in routine clinical practice to be evaluated. Data were abstracted using a standardized form. Meta-analyses of the proportions with random-effects estimators were used to report the mortality rate after TKA PJI, over time, and after treatment. The study adhered to the 2020 PRISMA guidelines.

A total of 83,353 patients with a PJI after TKA from 39 studies were included. At a mean follow-up of 4.4 years (1 month to 17 years), the overall mortality rate after TKA PJI was 13.3% (95% CI 8.8 to 18.5). It was 4.8% (1.2 to 18.0), 7.0% (2.2 to 29.9), and 6.4% (3.0 to 46.0) at three, 12, and 24 months, respectively. The rate significantly differed between the different forms of surgical treatment for PJI (p < 0.001): debridement, antibiotics, and implant retention (DAIR) 12.3% (95% CI 3.9 to 24.0); one-stage exchange arthroplasty 0.47% (95% CI 0 to 1.5); and two-stage exchange arthroplasty 11.5% (95% CI 8.5 to 15.0). There were no significant differences in the mortality rate between patients treated with DAIR and those who underwent a two-stage exchange arthroplasty at three and 12 months.

Mortality after TKA PJI remains high, surpassing the five-year rates of mortality in patients with cancer of the breast and prostate. The burden associated with PJI necessitates a multidisciplinary approach and dedicated funding to improve patient care, address this critical issue generally, and reduce mortality.