Total Knee Periprosthetic Joint Infection in the Setting of Hematologic Malignancy: Considerations for Management

Abstract

Patients with malignancy are often profoundly immunocompromised due to chemotherapy, placing them at potential increased risk for periprosthetic joint infection (PJI). However, there is little information regarding PJI management in these patients. We describe 4 patients with a history of primary total knee arthroplasty followed by diagnosis of multiple myeloma or Waldenstr€ om macroglobulinemia who received chemotherapy within 4 months prior to PJI. The Musculoskeletal Infection Society major and minor criteria and either debridement, antibiotics, and implant retention or a 2-stage approach appear to be effective for acute or chronic PJI, respectively. We recommend an anticoagulant be administered concomitantly with antineoplastics that significantly increase deep vein thrombosis risk, and we recommend long-term oral suppressive antibiotics postoperatively, especially if chemotherapy will be resumed. Additional studies are needed to investigate risks and benefits of PJI prophylaxis during chemotherapy and long-term suppressive antibiotics after PJI treatment.

The Development of Multiple Periprosthetic Joint Infections in Conjunction With Ibrutinib Therapy

“…Joint aspiration and culture are often used to confirm the diagnosis of PJI, and studies have shown that it is both sensitive and specific in patients at moderate-to-high risk. Direct aspiration revealed an overall sensitivity of 81% (71-88%) and a specificity of 90% (85-93%) in a previous study [ 4 ]. This method allows for susceptibility testing of relevant organisms, guiding antibiotic therapy.…”

“…This case presents a patient with a five-year history of Waldenström macroglobulinemia who developed PJIs in bilateral shoulders and knees following a one-year course of ibrutinib treatment. Four joints concurrently undergoing PJI is a unique finding, and few cases have been reported [ 4 ]. These previously reported cases presented clinically similar to our patient, and the diagnosis was primarily made and confirmed via joint aspiration [ 4 ].…”

“…Four joints concurrently undergoing PJI is a unique finding, and few cases have been reported [ 4 ]. These previously reported cases presented clinically similar to our patient, and the diagnosis was primarily made and confirmed via joint aspiration [ 4 ]. The patients were additionally managed initially with surgical intervention and aspiration, followed by antibiotics for treatment and prophylaxis [ 4 ].…”

“…Clarifying the patient’s history including the history of prosthetic placement as well as oncologic history is important in diagnosing PJI [ 4 ]. Our patient had undergone prosthetic placements in bilateral knees due to osteoarthritis and in bilateral shoulders due to rotator cuff injuries, eliminating the correlation between her diagnosis of Waldenström macroglobulinemia.…”

“…There is no single test for diagnosis rather a combination of tests may be used to increase the accuracy of diagnosis. The European Bone and Joint Infection Society criteria are the most sensitive for diagnosing PJI compared to other criteria, as shown in Table 1 [ 4 ].…”