Prosthetic Joint Infection in Mega-Arthroplasty Following Shoulder, Hip and Knee Malignancy—A Prospective Follow-Up Study

Abstract

Introduction: The risk of prosthetic joint infection (PJI) in mega-prosthesis for malignancy is increased compared with non-tumor cases. While several studies describe PJI in tumor-related arthroplasty, prospective studies comparing infection characteristics among different joints are limited. The present study analyzes mega-arthroplasty for hip, knee, and shoulder malignancy and compares the epidemiology, diagnosis, microbe spectrum, treatments, and outcomes between the different entities. Methods: The retrospective inclusion criteria were as follows: (1) mega-arthroplasty (2) in the hip, knee, or shoulder joint and a total femur arthroplasty (3) following a malignant bone tumor or metastasis (4) between 1996 and 2019. All included patients were prospectively followed and invited for a renewed hospital examination, and their PJI characteristics (if identified) were analyzed using both retrospective as well as newly gained prospective data. A PJI was defined according to the Infectious Disease Society of America (IDSA) and re-infection was defined according to the modified Delphi Consensus criteria. Results: In total, 83 cases of tumor mega-arthroplasty at a mean follow-up of 3.9 years could be included (32 knee, 30 hip, and 19 shoulder cases and 2 cases of total femur arthroplasty). In total, 14 PJIs were identified, with chondrosarcoma in 6 and osteosarcoma in 3 being the leading tumor entities. Knee arthroplasty demonstrated a significantly higher rate of PJI (p = 0.027) compared with hips (28.1% vs. 6.7%), while no significant difference could be found between the knee and shoulder (10.5%) (p = 0.134) or among shoulder and hip cases (p = 0.631). The average time of PJI following primary implantation was 141.4 months in knee patients, 64.6 in hip patients, and 8.2 months in shoulder patients. Age at the time of the primary PJI, as well as the time of the first PJI, did not show significant differences among the groups. Thirteen of the fourteen patients with PJI had a primary bone tumor. Statistical analysis showed a significant difference in the disadvantage of primary bone tumors (p = 0.11). While the overall cancer-related mortality in the knee PJI group (10%) was low, it was 50% in the hip and 100% in the shoulder group. Conclusion: The risk of PJI in knee tumor arthroplasty is significantly increased compared with hips, while cancer-related mortality is significantly higher in hip PJI cases. At the same time, mega-prostheses appear to be associated with a higher risk of infection due to a primary bone tumor compared with metastases. The study confirms existing knowledge concerning PJI in tumor arthroplasty, while, being one of the few studies to compare three different joints concerning PJI characteristics.

Risk factors for peri-megaprosthetic joint infections in tumor surgery: A systematic review

“…Age has not been associated with increased risk for PJI in any of the included studies [2,10,12,22]. Although, most of the studies that investigated gender as a potential risk factor for PJI found no correlation [2,17,22], one study reported that male sex was a significant risk factor [12].…”

“…Additionally, one study conducted a retrospective and prospective analysis focused on a specific time point [2]. Importantly, only one study maintained a prospective followup of their study group [10]. A total of 4.445 patients were included in all studies with a mean age of 35.78 years (range, 4-95 years).…”

“…The mean follow-up of the patients ranged from 17 months [16] to 10.3 years [15]. Five studies included megaprosthetic reconstruction for tumors of the femur, tibia, and humerus [10,14,17,20,23], while three studies included megaprosthetic reconstruction for tumors of the lower extremity. Two studies focused on the outcomes of proximal femoral replacement [13,21], one study on the outcomes of the proximal tibia [16], and another study on the outcomes of the total femur resection and reconstruction [15].…”

“…After exclusions, a total of 15 studies were left for review [2,[10][11][12][13][14][15][16][17][18][19][20][21][22][23]. All the studies included in the analysis underwent thorough evaluation, and relevant data pertaining to areas of interest were extracted and summarized (Table 1…”

Topical Application of Vancomycin Powder to Prevent Infections after Massive Bone Resection and the implantation of Megaprostheses in Orthopaedic Oncology Surgery

“…Massive bone resections, especially in case of soft tissue involvement for oncological cases, and the following reconstructive phase with the construction and the implant of the prosthetic body require longer surgical times compared to common primary arthroplasty. Furthermore, cases who suffer from malignant bone tumours, especially those who received chemotherapy, often have deficiencies in their immune systems and are therefore more exposed to the risk of post-operative infections 6 , 7 . All these factors, together, explain the high complication rates of infective nature that burden megaprosthetic implants in orthopaedic oncology ( Fig.…”