Failure rates in surgical treatment in adults with bacterial arthritis of a native joint: a systematic review of 8,586 native joints

Abstract

Introduction Most adult cases of bacterial–septic–arthritis of a native joint are effectively managed with a single surgical debridement, but some cases may require more than one debridement to control the infection. Consequently, this study assessed the failure rate of a single surgical debridement in adults with bacterial arthritis of a native joint. Additionally, risk factors for failure were assessed. Materials and Methods The review protocol was registered on PROSPERO (CRD42021243460) before data collection and conducted in line with the ‘Preferred Reporting Items for Systematic Reviews and Meta-Analyses’ (PRISMA) guidelines. Multiple libraries were systematically searched to identify articles including patients reporting on the incidence of failure (i.e. persistence of infection requiring reoperation) of the treatment of bacterial arthritis. The quality of individual evidence were assessed using the Quality in Prognosis Studies (QUIPS) tool. Failure rates were extracted from included studies and pooled. Risk factors for failure were extracted and grouped. Moreover, we evaluated which risk factors were significantly associated with failure. Results Thirty studies (8,586 native joints) were included in the final analysis. The overall pooled failure rate was 26% (95% CI 20 to 32%). The failure rate of arthroscopy and arthrotomy was 26% (95% CI 19 to 34%) and 24% (95% CI 17 to 33%), respectively. Seventy-nine potential risk factors were extracted and grouped. Moderate evidence was found for one risk factor (synovial white blood cell count), and limited evidence was found for five risk factors (i.e. sepsis, large joint infection, the volume of irrigation, blood urea nitrogen-test, and blood urea nitrogen/creatinine ratio). Conclusion A single surgical debridement fails to control bacterial arthritis of a native joint in approximately a quarter of all adult cases. Limited to moderate evidence exists that risk factors associated with failure are: synovial white blood cell count, sepsis, large joint infection, and the volume of irrigation. These factors should urge physicians to be especially receptive to signs of an adverse clinical course.

Consensus on the definition and criteria for failure of surgical treatment in bacterial arthritis of a native joint: An international Delphi study

“…Patients with bacterial arthritis may require reinterventions, with a reported failure rate of approximately 26% in the literature [2]. Diagnosis is challenging due to the lack of clear standards and unreliable tests, making it even more difficult to determine if reintervention is necessary [6].…”

“…Although positive synovial fluid or blood cultures do not directly correlate with a higher reintervention risk, a positive joint culture itself confirms bacterial arthritis. Given the reported 26% failure rate, physicians must monitor patients with positive cultures for the potential persistence of the infection [2]. Furthermore, once the infection is confirmed, it is more likely to be a matter of persistence or recurrence rather than a noninfectious condition (e.g., gout).…”

“…This Delphi study aimed to organise two separate rounds to reach consensus on (1) the definition of failure of a single surgical treatment of bacterial arthritis and (2) what criteria (e.g., physical or systemic signs) play a role in deciding on reintervention after a single surgical treatment for bacterial arthritis. Potential criteria were rated on a five-point Likert scale (1-being not important and 5-being very important).…”

“…The survey was sent using Castor Electronic Data Capture software, which facilitates distribution of online questionnaires and data collection (Castor EDC). Consensus was defined as ≥80% agreement (i.e., ≥80% rated the item as either 'not important' [Likert score [1][2][3] or 'important' [Likert score [4][5]) among experts, whereas strong consensus was defined as 90%-99% agreement and a unanimous consensus as 100%. A third round was only conducted when there was no consensus on the definition of failure and/or when there was no consensus on at least five criteria that could determine whether a reintervention is needed.…”

“…This approach is effective for the majority of patients. The success rate of a single surgical intervention, however, varies widely in the literature, with reported reintervention rates ranging from 7% to 72% and a pooled failure rate of 26% [2]. This variation in failure rates might be attributed to the lack of a clear definition of treatment failure and when to decide on reintervention.…”