Paper of the Week: Inflammatory Bowel Diseases Increase the Risk of Periprosthetic Join Infection

Emanuele Chisari, MD, Darren D’Mello, BA, Matthew B. Sherman, BS, and Javad Parvizi, MD, FRCS

J Bone Joint Surg Am. 2021;00:1-6
DOI: 10.2106/JBJS.20.01585

Summary by Colin M. Baker, BS

Periprosthetic joint infection (PJI) is a rare but devastating complication following total hip and knee arthroplasties [1]. Historically, three primary etiological processes have been deemed responsible for PJI: operative site inoculation, hematogenous spread, and extension of local infection. Newer hypotheses suggest that increased intestinal permeability and dysbiosis, both of which are present in the setting of inflammatory bowel diseases (IBD) [2], may facilitate the translocation of bacteria from the gastrointestinal (GI) tract. Importance has been placed on identifying patients at higher risk of developing PJI. However, few studies have examined the role of IBD in this setting.  

Chisari et al. [3] evaluated the impact IBD have on the incidence of PJI for patients who underwent total hip or knee arthroplasty. In this retrospective study, 152 primary arthroplasties (130 hip, 22 knee) with a diagnosis of IBD were matched 3 to 1 with a control cohort of patients with no history of IBD. At 2 years post-operatively the PJI rate was 4.61% in the IBD group compared to 0.88% in the control group, with a hazard ratio of 5.4 (95% CI, 1.59 to 18.60). Additionally, IBD patients had a higher rate of aseptic revisions than the control group (5.92% to 1.54%, p=0.0028).  

IBD was associated with a higher incidence of both septic and aseptic failure. Inherently, patients who are immunocompromised or receiving immunosuppressive therapy are at a greater risk of infection. Despite the increase in PJI for IBD patients, none of the patients in this study were taking immunosuppressive medications at the time of arthroplasty, indicating the influence of a IBD on PJI development. A proposed mechanism called “The Trojan Horse Theory” suggests that bacteria that has crossed the gut membrane is engulfed by white blood cells and transported to distant sites in the body, leading to infection [4,5]. This theory may partly explain the results observed in this study.       

The relatively small sample size and reliance on accurate documentation are potential limitations for this study. Despite these limitations, this study demonstrates that patients with IBD are at increased risk of PJI and aseptic failure following total joint arthroplasty. Although the exact mechanism of failure could not be identified, the authors are of the opinion that dysbiosis within the gastrointestinal tract played a significant role in both PJI development and aseptic failure in these patients.

References

1. Kapadia BH, Berg RA, Daley JA, Fritz J, Bhave A, Mont MA. Periprosthetic joint infection. The Lancet 2016;387:386–94. https://doi.org/10.1016/S0140-6736(14)61798-0.
2. Halfvarson J, Brislawn CJ, Lamendella R, Vázquez-Baeza Y, Walters WA, Bramer LM, et al. Dynamics of the human gut microbiome in inflammatory bowel disease. Nat Microbiol 2017;2:17004. https://doi.org/10.1038/nmicrobiol.2017.4.
3. Chisari E, D’Mello D, Sherman MB, Parvizi J. Inflammatory Bowel Diseases Increase the Risk of Periprosthetic Joint Infection. Journal of Bone and Joint Surgery 2021;Publish Ahead of Print. https://doi.org/10.2106/JBJS.20.01585.
4. Thwaites GE, Gant V. Are bloodstream leukocytes Trojan Horses for the metastasis of Staphylococcus aureus? Nat Rev Microbiol 2011;9:215–22. https://doi.org/10.1038/nrmicro2508.
5. Zhu H, Jin H, Zhang C, Yuan T. Intestinal methicillin-resistant Staphylococcus aureus causes prosthetic infection via ‘Trojan Horse’ mechanism: Evidence from a rat model. Bone & Joint Research 2020;9:152–61. https://doi.org/10.1302/2046-3758.94.BJR-2019-0205.R1.