Bettencourt, J. W., Wyles, C. C., Fruth, K. M., Osmon, D. R., Hanssen, A. D., Berry, D. J., & Abdel, M. P.

JBJS, 103(18), 1685-1693, 2021
doi: 10.2106/JBJS.20.01678

Summary by Nareena Imam, BA

Rates of same-joint periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) in patients with a history of septic arthritis of the native knee have been reported to be higher than the overall rate of PJI after TKA.^1,2 A majority of the literature examining this high-risk population has focused on treatment modalities to improve post-operative outcomes,³ with few studies exploring risk factors for infection or quantifying the incidence of post-operative outcomes and complications for patient with a history of septic arthritis.^1,2,4,5 Furthermore, these studies were limited by small sample sizes, a lack of inclusion of survivorship measures compared to a control cohort, or were systematic reviews.

Bettencourt et al. investigated the risk of PJI in patients with a history of native knee septic arthritis undergoing TKA compared to matched controls undergoing TKA for osteoarthritis (OA). They conducted a retrospective case-control study examining 215 knees treated with TKA with a history of native knee septic arthritis at a single institution from 1971 to 2016. These knees were matched 1:1 based on age, sex, BMI, and surgical year to controls undergoing TKA for primary osteoarthritis at the same institution for a total of 430 knees. Primary outcomes were survivorship free of infection, PJI, aseptic revision, any revision, and any reoperation. Secondary outcomes were clinical outcomes and complications.

The study found that patients with a history of native knee septic arthritis had statistically significant increased risk of developing PJI within ten years of TKA compared to matched controls (hazard ratio, HR=6.1, p=0.004). Cox regression and Kaplan-Meier survival analysis showed increased risk of any revision (HR=2.7, p<0.001), aseptic revision (HR=2.5, p=0.007), and any reoperation (HR=2.9, p<0.001). Mean Knee Society Scores (KSS) were similar between the two groups, both preoperative (p=0.16) and 2 years postoperatively (p=0.19). Subgroup analysis of patients with a history of septic arthritis demonstrated higher relative risk of developing any infection if TKA occurred within 5-7 years of diagnosis of septic arthritis as opposed to after 7 years.

The authors concluded that patients with a history of native knee septic arthritis have increased risk of any infection, PJI, any revision, aseptic revision, and any reoperation as compared to matched controls undergoing TKA for primary OA. Furthermore, longer intervals between diagnosis of native knee septic arthritis and TKA are associated with lower risk of any infection. However, this retrospective study had limited generalizability due to the data being sourced from a single institution. Lack of standardized diagnostic criteria and treatment protocols for PJI were further limitations of this study.

References

1. Sultan AA, Mahmood B, Samuel LT, et al. Patients with a History of Treated Septic Arthritis are at High Risk of Periprosthetic Joint Infection after Total Joint Arthroplasty. Clin Orthop Relat Res 2019;477(7):1605-1612. DOI: 10.1097/CORR.0000000000000688.
2. Ohlmeier M, Delgado G, Calderon CA, Hartwig CH, Gehrke T, Citak M. Are Patients With a History of Septic Arthritis Undergoing Total Knee Arthroplasty at Higher Risk for Revision Surgery? A Single-Center Study. J Arthroplasty 2020;35(7):1857-1861. DOI: 10.1016/j.arth.2020.02.065.
3. Xu C, Kuo FC, Kheir M, Li X, Chai W, Chen JY. Outcomes and predictors of treatment failure following two-stage total joint arthroplasty with articulating spacers for evolutive septic arthritis. BMC Musculoskelet Disord 2019;20(1):272. DOI: 10.1186/s12891-019-2652-7.
4. Tan T, Xu C, Kuo FC, Ghanem E, Higuera C, Parvizi J. Risk Factors for Failure and Optimal Treatment of Total Joint Arthroplasty for Septic Arthritis. J Arthroplasty 2021;36(3):892-896. DOI: 10.1016/j.arth.2020.09.020.
5. Bezwada HP. CORR Insights(R): Patients with a History of Treated Septic Arthritis are at High Risk of Periprosthetic Joint Infection after Total Joint Arthroplasty. Clin Orthop Relat Res 2019;477(7):1613-1614. DOI: 10.1097/CORR.0000000000000734