Editorial: Periprosthetic Joint Infection Is a Disease Unto Itself

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The incidence of periprosthetic joint infection (PJI) has remained at about 1% for nearly 50 years, despite implementation of preventive measures such as preoperative antibiotics. In North America, the mainstay of treating chronic PJI is two-stage exchange, but select centers in Europe have decades of experience with one-stage exchange.

In Clinical Orthopaedics and Related Research (CORR), an editorial by Hany Bedair, MD, orthopaedic surgeon at the Center for Hip & Knee Replacement at Massachusetts General Hospital, comments on a retrospective case–control study in Germany, also published in CORR, that analyzed factors associated with re-revision after one-stage revision arthroplasty for PJI of the hip.

The German Study

In the case–control study, which was conducted at Ruhr University Hospital, Bochum, Germany, the researchers examined all potential causes of re-revision after one-stage exchange. They found:

• The most common reason for re-revision was not a recurrent infection but rather hip instability/dislocation (53 of 121 patients, 44%)
• Of the 40 patients who underwent re-revision because of infection, 58% did so because of a new infecting pathogen rather than the persistence of the original organism
• 43 patients required repeat revision after the re-revision, and 19 of them (44%) had repeat infections

PJI does not seem to be entirely avoidable, Dr. Bedair infers. He states that treatment may require as much or more attention than PJI prevention.

A meticulous surgical technique is clearly needed not just for infection control but also for implant positioning and maintenance of soft-tissue integrity, Dr. Bedair adds. He suggests that surgeons consider advanced technologies such as dual articulation bearing constructs.

Three Areas of Future Interest

Etiology of PJI

According to Dr. Bedair, the high rate of new infecting organisms in the German study is probably attributable to some degree of immune dysfunction. The problem could be as straightforward as nutritional deficiencies or as complex as altered immune system interaction with the microbiome. Another area for future research will be to build on a recent study in The Journal of Bone and Joint Surgery that demonstrated a genetic link between relatives who develop PJI.

Implant-related Solutions to PJI

Dr. Bedair predicts the next wave of prosthetics will feature improvements such as antifouling surfaces or local drug elution. Studies have shown that prolonged antimicrobial therapy into the joint space, both during the index procedure and the time of infection treatment, is associated with less infection risk.

Multidisciplinary Care

Individual efforts to treat PJI is the historical paradigm but can't compare to a multidisciplinary approach, Dr. Bedair emphasizes. He foresees regional specialty centers, similar to cancer centers, where orthopedic surgeons, infectious disease specialists and other clinicians will collaborate on PJI treatment.

In fact, he says PJI should not be considered singularly as a surgical complication but as a disease unto itself. Patients, clinicians and medical centers should not be penalized for PJI by withholding reimbursement. Centers with the expertise to treat PJI should be transparent in their reporting of PJI incidence, so professional societies will have accurate data when lobbying payors and policy makers.

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Learn more about the Center for Hip and Knee Replacement at Mass General

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