What’s New in Musculoskeletal Infection

Abstract

Periprosthetic joint infection (PJI) continues to be a devastating complication after total joint arthroplasty (TJA) and remains one of the most common causes for revision TJA. Projections are clear that primary TJA will continue to increase annually and, with it, PJI. In 2022, there was an emphasis on the global economics of PJI management, whereas, in 2023, the literature attempted to provide a more granular look at the financial burden of PJI. Wixted et al. analyzed the direct costs of PJI at a tertiary referral center, including the costs of relevant ancillary services, and demonstrated that the failure of successful reimplantation and the need for additional surgical procedures more than doubled the direct costs of PJI management ($38,865 compared with $79,223) 1 . Additionally, Charalambous et al. assessed cost drivers of 2-stage exchange for PJI treatment and found that age, illicit drug use, the Elixhauser comorbidity index, and number of surgical procedures before reimplantation were all associated with an increased cost of PJI treatment and that failure to clear infection was associated with a >50% increase in total costs at 2 years after treatment 2 . In 2023, the psychosocial impact of PJI was also highlighted. Shichman et al. demonstrated that the sequelae of PJI decreased patientreported quality of life, social satisfaction, and mental health, with approximately 1 of 4 patients regretting their initial decision to undergo primary TJA 3 . Das et al. demonstrated that patients who underwent spacer placement for PJI after TJA had a disproportionately higher incidence of mental health disorders following a surgical procedure compared with aseptic revisions and primary TJA, urging surgeons to consider collaborative management with mental health professionals in the treatment of PJI 4 .Not only are mental health disorders a consequence of PJI, but they are also likely a risk factor. Harmer et al. demonstrated that depression and anxiety were associated with an increased risk of any infection, and specifically with an increased risk of PJI after revision total knee arthroplasty (TKA) 5 .Two-stage exchange continues to be considered the mainstay treatment of PJI, although 1-stage treatment is gaining popularity. In an Australian cost-utility analysis using a Markov model, Okafor et al. found that opting for an index 2-stage revision instead of a 1-stage revision when there is no compelling indication for 2-stage exchange is not likely to be cost-effective 6 . In the United States, most surgeons are utilizing 2-stage exchange, with 75% of American Association of Hip and Knee Surgeons (AAHKS) survey respondents reporting the use of 2-stage exchange rather than 1-stage exchange and with the majority of surgeons handling <20 PJI cases per year 7 . Despite this, the use of single-stage exchange is increasing across the globe, with a single high-volume European center reporting a >30% increase in 1-stage exchange from 2008 to 2021 8 . Fehring et al. reported a 99% reimplantation rate after 2-stage exchange at the...