Is Treatment of Periprosthetic Joint Infection Improving Over Time?

BackgroundIt is unknown whether the outcomes of treatment for periprosthetic joint infection (PJI) are improving with time. This study evaluated trends in PJI treatment outcomes in the hip and knee following 2-stage exchange arthroplasty and irrigation and debridement (I&D) over the last 17 years.MethodsWe reviewed 550 two-stage exchange arthroplasties and 194 I&Ds between 2000 and 2016 at our institution. Treatment success was defined according to the Delphi consensus criteria and Kaplan-Meier survivorship curves were generated. A multivariate Cox proportional hazards regression model was generated to determine time trends in the outcome of PJI treatment with the year of surgery included as both a continuous covariate (per 1-year increase) and a categorical covariate (2000-2010 or 2011-2016).ResultsThe survivorship of I&D, 2-stage revision, and the total combined cohort were comparable between 2000-2010 and 2011-2016 groups. Multivariate Cox regression analysis showed that the year of surgery was not associated with treatment failure following an I&D or 2-stage exchange arthroplasty, and neither did it increase the risk of non-reimplantation. When year of surgery was considered as a categorical variable, there remained no significant difference in treatment failure following an I&D or 2-stage exchange arthroplasty between the 2000-2010 cohort and 2011-2016 cohort.ConclusionDespite the increasing clinical focus, research advances, and growing literature relating to PJI, we were unable to detect any substantial improvement in the treatment success rates of PJI at our institution over the 17 years examined in this study. Novel treatments and techniques are certainly needed as current and prior strategies remain far from optimal.     

Is There Still a Role for Irrigation and Debridement With Liner Exchange in Acute Periprosthetic Total Knee Infection?

Background

Periprosthetic joint infection (PJI) is an important cause of failure in total knee arthroplasty. Irrigation and debridement including liner exchange (I&D/L) success rates have varied for acute PJI. The purpose of this study is to present results of a specific protocol for I&D/L with retention of total knee arthroplasty components.

Do Culture Negative Periprosthetic Joint Infections Remain Culture Negative?

BackgroundDiagnosis and treatment of culture negative total knee arthroplasty (TKA) periprosthetic joint infection (PJI) is challenging. There is debate over whether culture negative PJI confers increased risk of failure and which organisms are responsible. It is also unclear as to what factors predict conversion from culture negative to culture positivity. To address these issues, we performed an observational study to detect factors associated with transition from culture negative to culture positive TKA PJI in those patients that failed irrigation and debridement (I&D), determine the incidence of this transition, and identify those organisms that were associated with treatment failure.MethodsA multicenter observational cohort study was performed on patients with TKA PJI as defined by Musculoskeletal Infection Society criteria without cultured organisms and treated with I&D. Primary outcome was failure defined as any subsequent surgical procedure. Secondary outcome included cultured organism within 2 years of initial I&D.ResultsTwo hundred sixteen TKA I&D procedures were performed for PJI, and 36 met inclusion criteria. The observed treatment failure rate for culture negative PJI treated with I&D was 41.67%. Of those culture negative I&Ds that failed, 53.33% became culture positive after failure. Of those that converted to culture positive, 62.5% were Staphylococcus species. The odds ratio associated with becoming culture positive following culture negative treatment failure in the setting of antibiotic administration prior to the initial I&D procedure was 0.69 (95% confidence interval 0.14-3.47, P = .65).ConclusionMany cases of culture negative TKA PJI treated with I&D eventually fail and become culture positive. Staphylococci are common organisms identified after culture negative PJI.     

Outcome after total ankle arthroplasty with a minimum of five years follow-up: A systematic review and meta-analysis

BackgroundTotal ankle arthroplasty (TAA) is increasingly gaining recognition as an alternative to ankle arthrodesis in the treatment of end-stage ankle arthritis. Despite high rates of adverse events during early inception, newer generations of uncemented prosthesis and design modifications have improved outcomes. Questions remain regarding the long-term outcomes and implant survivorship of TAA.AimThis analysis aims to establish an updated review of intermediate and long-term clinical outcome and complication profile of TAA.Patients and methodsA multi database search was performed on 14th October 2018 according to PRISMA guidelines. All articles that involved patients undergoing uncemented TAA with 5 years minimum follow-up, reported clinical outcome or complication profile of TAA were included. Seventeen observational studies were included in the review, with 1127 and 262 ankles in the 5 and 10 years minimum follow-up groups respectively.ResultsMean difference between pre- and post-operative AOFAS score was 43.60 (95%CI: 37.51–49.69, p < 0.001) at 5 years minimum follow-up. At 5 years minimum follow-up, pooled proportion (PP) of prostheses revision for any reason other than polyethylene exchange was 0.122 (95%CI: 0.084–0.173), all cause revision was 0.185 (95%CI: 0.131–0.256), unplanned reoperation was 0.288 (95%CI: 0.204–0.390) and all infection was 0.033 (95%CI: 0.021–0.051). At 10 years minimum follow-up, PP of prostheses revision for any reason other than polyethylene exchange was 0.202 (95%CI: 0.118–0.325), all cause revision was 0.305 (95%CI: 0.191–0.448), unplanned reoperation was 0.422 (95%CI: 0.260–0.603) and all infection was 0.029 (95%CI: 0.013–0.066).ConclusionDespite good intermediate and long-term functional outcome measures, TAA has relatively higher revision surgery prevalence with longer follow-up periods. Further research should be directed towards identifying patient populations that would best benefit from TAA and those at greatest risk of requiring revision surgery.     

Irrigation and Debridement for Early Periprosthetic Knee Infection: Is It Effective?

Background

Irrigation and debridement (I&D) is performed for early management of periprosthetic joint infection (PJI) following total knee arthroplasty (TKA). Symptom reporting is a subjective measure and may miss direct management of PJI. Utilizing an objective time interval from index procedure to I&D may better inform treatment decisions.

Diagnostic Accuracy of the Alpha-Defensin Test for Periprosthetic Joint Infection in Patients With Inflammatory Diseases

BackgroundThe alpha-defensin test has been reported to have high accuracy to diagnose periprosthetic joint infection (PJI). There are remaining concerns about the utility of the test in patients with inflammatory diseases. The purpose of this study is to determine sensitivity and specificity of laboratory-based alpha-defensin in diagnosing PJI in patients with systemic inflammatory disease in revision total hip/knee arthroplasty.MethodsA retrospective review was conducted of 1374 cases who underwent revision total hip/knee arthroplasty at a single healthcare system from 2014 to 2017. Cases with inflammatory diseases who received a 1-stage revision arthroplasty, the first stage of 2-stage revision arthroplasty, or irrigation and debridement with available preoperative alpha-defensin results were included. Patients who received a second-stage procedure, spacer exchange, who had insufficient Musculoskeletal Infection Society criteria, or with early postoperative PJI were excluded from this study. Cases were classified as infected or not according to Musculoskeletal Infection Society criteria. A total of 41 cases met the inclusion criteria. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of alpha-defensin to diagnose PJI were calculated.ResultsThe alpha-defensin test demonstrated a sensitivity of 93%, a specificity of 100%, a positive predictive value of 100%, a negative predictive value of 96%, and an accuracy of 97% for diagnosing PJI. There was 1 patient with polymyositis who had a false-negative result.ConclusionAlpha-defensin had high accuracy for diagnosing PJI even in inflammatory diseases. The alpha-defensin test provides useful information with high accuracy in diagnosing PJI in patients with inflammatory diseases.     

A Multicenter Study of Irrigation and Debridement in Total Knee Arthroplasty Periprosthetic Joint Infection: Treatment Failure Is High

Background

In total knee arthroplasty (TKA) periprosthetic joint infection (PJI), irrigation and debridement (I&D) with component retention is a treatment option with a wide variation in reported failure rates. The purpose of this study was to determine failure rates, outcomes, and factors that predict failure in I&D for TKA PJI.

Outcome of Direct Anterior Total Hip Arthroplasty Complicated by Superficial Wound Dehiscence Requiring Irrigation and Debridement

BackgroundSuperficial wound dehiscence after total hip arthroplasty (THA) performed through the direct anterior approach (DAA) can be treated with superficial irrigation and debridement (I&D). The incidence and treatment of this complication has been described, but there are little data on the outcomes after a superficial I&D have not been described. The purpose of this paper was to examine the clinical outcomes of DAA THAs requiring postoperative superficial I&D.MethodsA retrospective review of 1573 THAs performed using the DAA were identified utilizing a prospectively collected, single-institution joint registry. Of these 1573 cases, 18 THAs in 18 patients (1.1%) underwent a superficial I&D for superficial wound dehiscence. Outcomes studied included prosthetic joint infection (PJI) after superficial I&D, revisions, re-reoperations, complications, and clinical outcome scores.ResultsSurvivorship from superficial I&D at 1, 2, and 5 years postoperatively was 98.6% at all time points. In the 18 patients who underwent superficial I&D, this was performed an average of 37 (range 12-83) days after their THA. Female gender (hazard ratio 5.5, 95% confidence interval 1.20-32.34, P = .0271) was associated with a higher risk of undergoing superficial I&D as was body mass index >30 kg/m² (P = .0028), >35 kg/m² (P < .0001), and >40 kg/m² (P = .0037). At average follow-up of 2.2 (range 0.2-5.5) years, 0 patients developed PJI. Complications included femoral revision for a painful fibrously ingrown femoral component (1), pulmonary embolus (1), and death from respiratory failure (1). Postoperative Harris Hip Scores averaged score was 86.8 (range 57-99).ConclusionsSuperficial wound dehiscence requiring superficial I&D after DAA THA occurs in about 1%-2% of patients with low risk of subsequent PJI.     

Wound dehiscence after total knee arthroplasty

IntroductionWound dehiscence is one of the most common complications of surgical ulcer, involving the breaking open of the surgical incision along the stitch. This condition is a severe complication of total knee arthroplasty.Presentation of caseWe report a case of a 59-year-old female patient with diabetes who underwent a total knee arthroplasty in which all layers of wounds were dehiscence and prosthetic was exposed.DiscussionWound dehiscence is a complication after total knee arthroplasty especially in diabetic patient. So, patients with diabetes more susceptible to development of wound dehiscence following total knee arthroplasty and should be followed particularly postoperatively care.ConclusionPostoperative care after knee replacement should be more considered in diabetic patients. Finally the patient was successfully treated with irrigation and debridement (I&D) and polyethylene insert exchange.     

The Fate of Periprosthetic Joint Infection With Corynebacterium striatum: A Rare but Catastrophic Causative Organism

BackgroundThe virulence and antibiotic resistance profile of an infecting organism have been shown to impact the outcomes of periprosthetic joint infection (PJI). However, there are no existing data on the outcomes of PJI caused by Corynebacterium striatum, a rare organism. Thus, our objective is to ascertain: (1) the treatment success of PJI caused by this rare organism and (2) patient characteristics in the setting of C striatum PJI.MethodsA retrospective review was conducted on 741 consecutive PJIs managed at 2 hospital facilities by 8 surgeons (February 4, 2015 to October 30, 2019). The inclusion criteria represented the presence of minimum 1 positive culture of C. striatum. After excluding 1 patient with no follow-up, 15 patients were finally analyzed (9 hips/6 knees). Out of 15 patients, 9 underwent explantation with spacer insertion, 5 underwent irrigation and debridement with polyexchange (I&D), and 1 underwent Girdlestone. Out of 9 explanted patients, only 6 cleared infection and were reimplanted. The clinical staging system for PJI was determined using McPherson classification. The mean follow-ups for I&D and explantation were 35 and 23.5 months, respectively. Success of reimplantation was determined using Delphi criteria.ResultsOut of 5 I&D patients, 40% had to be reoperated because of persistent infection. Out of 6 explanted patients who were reimplanted, 67% failed. According to McPherson, 40% of I&D and 22.2% of explanted patients were significantly compromised hosts.ConclusionC. striatum PJI has a high-treatment failure rate in patient undergoing I&D or 2-stage revision surgery. Surgeons should be aware of the difficulty controlling this PJI and advise patients accordingly.     

Reporting Outcomes of Treatment for Periprosthetic Joint Infection of the Knee and Hip Together With a Minimum 1-Year Follow-Up is Reliable

BackgroundAlthough there is an increasing trend toward reporting the outcome of hip and knee arthroplasty separately, it remains unknown whether joint-specific reporting is necessary for periprosthetic joint infection (PJI) as sample sizes are already low, given its relatively rare occurrence. The aim of this study is to compare treatment outcomes of PJI occurring after knee and hip arthroplasty. Furthermore, we aim to establish the necessary follow-up time for an accurate reporting of PJI treatment outcomes.MethodsA retrospective study of 792 cases of hip and knee PJI treated with irrigation and debridement or two-stage exchange arthroplasty from 2000 to 2017 was performed. Treatment failure was defined based on the Delphi method–based criteria. The Kaplan-Meier survivorship curves were generated, and a log-rank test was used to evaluate differences in survivorship. A multivariate Cox proportional hazards regression and a sensitivity analysis using propensity matching were performed. A two-piecewise linear regression model was used to examine the threshold effect of time after treatment on survival rates.ResultsThere were no significant differences between hip and knee PJIs in overall survivorship (P = .71), or when stratified by irrigation and debridement (P = .39), or two-stage exchange arthroplasty (P = .59). There was also no difference by joint in the multivariate or sensitivity analysis. Survival rates had the most dramatic rates of decrease in the initial months after treatment of PJI but began to plateau after 1.09 years.ConclusionThis study reveals no difference in treatment outcomes between knee and hip PJIs. In addition, given the difficulty with obtaining follow-up, we suggest that one-year follow-up is sufficient for an accurate reporting of treatment failure.     

Hospital Costs for Unsuccessful Two-Stage Revisions for Periprosthetic Joint Infection

BackgroundAlthough 2-stage exchange arthroplasty is the preferred surgical treatment for periprosthetic joint infection (PJI) in the United States, little is known about the risk of complications between stages, mortality, and the economic burden of unsuccessful 2-stage procedures.MethodsThe 2015-2019 Medicare 100% inpatient sample was used to identify 2-stage PJI revisions in total hip and knee arthroplasty patients using procedural codes. We used the Fine and Gray sub-distribution adaptation of the conventional Kaplan-Meier method to estimate the probability of completing the second stage of the 2-stage PJI infection treatment, accounting for death as a competing risk. Hospital costs were estimated from the hospital charges using “cost-to-charge” ratios from Centers for Medicare and Medicaid Services.ResultsA total of 5094 total hip arthroplasty and 13,062 total knee arthroplasty patients had an index revision for PJI during the study period. In the first 12 months following the first-stage explantation, the likelihood of completing a second-stage PJI revision was 43.1% (95% confidence interval [CI] 41.7-44.5) for hips and 47.9% (95% CI 47.0-48.8) for knees. Following explantation, 1-year patient survival rates for hip and knee patients were 87.4% (95% CI 85.8-88.9) and 91.4% (95% CI 90.6-92.2), respectively. The median additional cost for hospitalizations between stages was $23,582 and $20,965 per patient for hips and knees, respectively. Hospital volume, Northeast or Midwest region, and younger age were associated with reduced PJI costs (P < .05).ConclusionAlthough viewed as the most preferred, the 2-stage revision strategy for PJI had less than a 50% chance of successful completion within the first year, and was associated with high mortality rates and substantial costs for treatment failure.     

Is There Harm in Debridement,Antibiotics, and Implant Retention Versus Two-Stage Revision in the Treatment of Periprosthetic Knee Infection? Experiences Within a Large US Health Care System

BackgroundWhen faced with a periprosthetic joint infection (PJI) following total knee arthroplasty, the treating surgeon must determine whether 2-stage revision or “liner exchange,” aka debridement, antibiotics, exchange of the modular polyethylene liner, and retention of fixed implants (DAIR), offers the best balance of infection eradication versus treatment morbidity. We sought to determine septic re-revision risk following DAIR compared to initial 2-stage revision.MethodsWe conducted a cohort study using data from Kaiser Permanente's total joint replacement registry. Primary total knee arthroplasty patients who went on to have a PJI treated by DAIR or 2-stage revision were included (2005-2018). Propensity score–weighted Cox regression was used to evaluate risk for septic re-revision.ResultsIn total, 1,410 PJIs were included, 1,000 (70.9%) treated with DAIR. Applying propensity score weights, patients undergoing DAIR had a higher risk for septic re-revision compared to initial 2-stage procedures (hazard ratio 3.09, 95% CI 2.22-4.42). Of DAIR procedures, 150 failed (15%) and went on to subsequent 2-stage revision (DAIR-F). When compared to patients undergoing an initial 2-stage revision, we failed to observe a difference in septic re-revision risk following DAIR-F (hazard ratio 1.11, 95% CI 0.58-2.12).ConclusionAlthough DAIR had a higher risk of septic re-revision, we failed to observe a difference in risk following DAIR-F when compared to those who initially underwent 2-stage revision. Functional outcome, patient, and organism factors are important to consider when discussing PJI management options.Level of EvidenceLevel III.     

Is 2-Stage Septic Revision Worth the Money? A Cost-Utility Analysis of a 1-Stage Versus 2-Stage Septic Revision of Total Knee Arthroplasty

BackgroundTwo-stage exchange arthroplasty remains the gold standard for the management of prosthetic joint infection (PJI) of the knee, but several studies have demonstrated that 1-stage exchange is as effective as 2-stage exchange. This study aimed to support decision-making via an economic evaluation of 1-stage compared to 2-stage exchange for total knee arthroplasty septic revision in patients who did not have compelling indication PJI (ie, Methicillin-resistant Staphylococcus aureus, multiorganism, systemic sepsis, comorbidities, culture negative, resistant organism, and immunocompromised) to undergo a 2-stage exchange.MethodsA cost-utility analysis was performed using a Markov cohort model from the health care provider perspective using Australia data. One-stage septic knee revisions were compared with 2-stage exchange procedures for chronic PJI using a patient-lifetime horizon. Health outcomes were expressed as quality-adjusted life-years (QALY), whereas costs were presented in 2020 Australian dollars. Sensitivity analyses, population expected values of perfect information, and the perfect information for parameters (EVPPI) were assessed to estimate the opportunity costs surrounding the decision made at a willingness-to-pay threshold of $50,000 per QALY.ResultsThe incremental cost-effectiveness ratio of 2-stage exchange compared with 1-stage exchange was $231,000 per QALY, with 98.5% of the probabilistic sensitivity simulations above the willingness-to-pay threshold. The population expected value of perfect information was $882,000, whereas the expected value of perfect information for parameters for the “cost parameters” was $207,000.ConclusionThe adoption of 1-stage septic knee revision is the optimal choice for patients who have a PJI and who do not have a compelling need for a 2-stage exchange arthroplasty. One-stage exchange for PJI should be advocated in patients who meet the eligibility criteria.     

Outcomes of Superficial and Deep Irrigation and Debridement in Total Hip and Knee Arthroplasty

BackgroundFollowing total knee arthroplasty and total hip arthroplasty, wound-related problems and deep periprosthetic joint infection may present in a similar fashion. Irrigation and debridement (I&D) has a great role in management of patients with early infection. The question that often arises is how to tell the difference between superficial and deep infection. This study evaluated the role and outcomes of both superficial and deep I&D in patients with wound-related issues and/or suspected periprosthetic joint infection.MethodsA retrospective study was conducted evaluating patients who underwent I&D within 28 days of total joint arthroplasty. A total of 176 cases with a minimum of 1-year follow-up were identified, and clinical records were reviewed in detail. Reoperations included superficial (fascia not opened) or deep (fascia opened) I&D. Failure was defined as the need for further surgical intervention within 1 year of initial I&D.ResultsThe overall success for superficial I&D was 84.28% vs 68.86% for deep I&D. The success of both deep and superficial I&D was higher if the I&D was performed closer to the index surgery. Superficial I&D in patients with a positive joint aspiration or evidence of intraoperative purulence or those in whom had no subcutaneous fluid had higher failure rates.ConclusionSuperficial I&D is a viable option in patients with wound-related issues as long as joint aspiration is performed to rule out infection involving the prosthesis. If there are findings of no fluid or purulence, fascia may need to be opened and the deeper tissues explored.     

Incidence and predictors of early complications following primary and revision total ankle arthroplasty

BackgroundTotal ankle arthroplasty (TAA) offers an effective option for end-stage osteoarthritis. The incidence and preoperative risk factors for early adverse events (AEs) following primary and revision TAA may be useful information for providers.MethodsA large database was queried from 2010 to 2016 to identify 905 patients of whom 818 underwent primary TAA (90.4%) and 87 underwent revision TAA (9.6%). Data on patient demographics, comorbidities, and hospital length of stay were analyzed as risk factors for reported 30-day AEs.ResultsThe overall AE rate was 5.5% (50/905) for the entire cohort. AEs occurred more frequently for revision TAA (9/87) than primary TAA (41/818) cases (OR 2.43, p = 0.022). Age (OR 1.03, p = 0.045), BMI (OR 1.04, p = 0.046), and revision TAA (OR 2.56, p = 0.002) were independent risk factors for 30-day AEs in multivariate analysis.ConclusionsOlder age, higher BMI, and revision cases are associated with a higher risk of AEs.     

Patient-Related Risk Factors for Periprosthetic Ankle Joint Infection: An Analysis of 6977 Total Ankle Arthroplasties

Periprosthetic joint infection (PJI) after total ankle arthroplasty (TAA) is a devastating complication that often results in explantation to resolve the infection. The purpose of the present investigation was to determine the patient-related risk factors for PJI after TAA. A national insurance database was queried for patients undergoing TAA using the Current Procedural Terminology and International Classification of Diseases, ninth revision, procedure codes from 2005 to 2012. Patients undergoing TAA with concomitant fusion procedures or more complex forefoot procedures were excluded. PJI within 6 months was then assessed using the International Classification of Diseases, ninth revision, codes for diagnosis or treatment of postoperative PJI. Multivariate binomial logistic regression analysis was performed to evaluate the patient-related risk factors for PJI. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for each risk factor, with p?<?.05 considered statistically significant. A total of 6977 patients were included in the present study. Of these 6977 patients, 294 (4%) had a diagnosis of, or had undergone a procedure for, PJI. The independent risk factors for PJI included age <65 years (OR 1.44; p?=?.036), body mass index <19?kg/m² (OR 3.35; p?=?.013), body mass index >30?kg/m² (OR 1.49; p?=?.034), tobacco use (OR 1.59; p?=?.002), diabetes mellitus (OR 1.36; p?=?.017), inflammatory arthritis (OR 2.38; p?<?.0001), peripheral vascular disease (OR 1.64; p?<?.0001), chronic lung disease (OR 1.37; p?=?.022), and hypothyroidism (OR 1.32; p?=?.022). The independent patient-related risk factors identified in the present study should help guide physicians and patients considering elective TAA and develop risk stratification algorithms that could decrease the risk of deep, postoperative infection.     

2-stage revision recommended for treatment of fungal hip and knee prosthetic joint infections

Background and purpose Fungal prosthetic joint infections are rare and difficult to treat. This systematic review was conducted to determine outcome and to give treatment recommendations.

Patients and methods After an extensive search of the literature, 164 patients treated for fungal hip or knee prosthetic joint infection (PJI) were reviewed. This included 8 patients from our own institutions.

Results Most patients presented with pain (78%) and swelling (65%). In 68% of the patients, 1 or more risk factors for fungal PJI were found. In 51% of the patients, radiographs showed signs of loosening of the arthroplasty. Candida species were cultured from most patients (88%). In 21% of all patients, fungal culture results were first considered to be contamination. There was co-infection with bacteria in 33% of the patients. For outcome analysis, 119 patients had an adequate follow-up of at least 2 years. Staged revision was the treatment performed most often, with the highest success rate (85%).

Interpretation Fungal PJI resembles chronic bacterial PJI. For diagnosis, multiple samples and prolonged culturing are essential. Fungal species should be considered to be pathogens. Co-infection with bacteria should be treated with additional antibacterial agents.

We found no evidence that 1-stage revision, debridement, antibiotics, irrigation, and retention (DAIR) or antifungal therapy without surgical treatment adequately controls fungal PJI. Thus, staged revision should be the standard treatment for fungal PJI. After resection of the prosthesis, we recommend systemic antifungal treatment for at least 6 weeks—and until there are no clinical signs of infection and blood infection markers have normalized. Then reimplantation can be performed.     

Risk factors for periprosthetic joint infection following total ankle replacement

BackgroundIdentifying preoperative patient characteristics that correlate with an increased risk of periprosthetic joint infection (PJI) following total ankle replacement (TAR) is of great interest to orthopaedic surgeons, as this may assist with appropriate patient selection. The purpose of this study is to systematically review the literature to identify risk factors that are associated with PJI following TAR.MethodsUtilizing the terms “(risk factor OR risk OR risks) AND (infection OR infected) AND (ankle replacement OR ankle arthroplasty)” we searched the PubMed/MEDLINE electronic databases. The quality of the included studies was then assessed using the AAOS Clinical Practice Guideline and Systematic Review Methodology. Recommendations were made using the overall strength of evidence.ResultsEight studies met the inclusion criteria. A limited strength of recommendation can be made that the following preoperative patient characteristics correlate with an increased risk of PJI following TAR: inflammatory arthritis, prior ankle surgery, age less than 65 years, body mass index less than 19, peripheral vascular disease, chronic lung disease, hypothyroidism, and low preoperative AOFAS hindfoot scores. There is conflicting evidence in the literature regarding the effect of obesity, tobacco use, diabetes, and duration of surgery.ConclusionsSeveral risk factors were identified as having an association with PJI following TAR. These factors may alert surgeons that a higher rate of PJI is possible. However, because of the low level of evidence of reported studies, only a limited strength of recommendation can be ascribed to regard these as risk factors for PJI at this time.     

Time to Revision After Periprosthetic Joint Infection in Total Ankle Arthroplasty: A Systematic Review

While not a common complication after total ankle arthroplasty (TAA), periprosthetic joint infection (PJI) presents a significant risk of implant failure. The primary aim of this systematic review was to evaluate time to revision after PJI in patients who had undergone TAA. An extensive search strategy via electronic databases initially captured 11,608 citations that were evaluated for relevance. Ultimately, 12 unique articles studying 3040 implants met inclusion criteria. The time to revision surgery due to PJI was recorded for each study and a weighted average obtained. The prevalence of PJI was 1.12% (n = 34). We found that the average time to revision due to PJI was 30.7 months, or approximately 2.6 years after the index TAA procedure. By literature definitions, the majority of cases (91.2%, n = 31) were beyond the “acute” PJI phase. The population was divided into 2 groups for further analysis of chronic infections. PJIs before the median were classified as “early” and those after as “late” chronic. The majority of cases (61.8%) were late chronic with an average time to revision of 44.3 months. A smaller number were early chronic (29.4%) with revision within 10.8 months. After summarizing the rates of infection and times to revision reported in the literature, we suggest modifying the current PJI classification to include early chronic and late chronic subgroups so that the total ankle surgeon is better prepared to prudently diagnose and treat PJIs.