Risk of Periprosthetic Joint Infection after Posttraumatic Hip Arthroplasty following Acetabular Fractures

Abstract

Background Raised complication rates have been reported for total hip arthroplasty (THA) in posttraumatic hip joints after acetabular fractures with prior open reduction and internal fixation (ORIF). The present study evaluated (I) postoperative surgical site infection and the risk of early infection following THA in posttraumatic hip joints after acetabular fractures and (II) the discriminatory ability of preoperative C-reactive protein (CRP) blood levels for periprosthetic joint infection (PJI).

Materials and Methods Patients were included who had undergone THA (2014–2019) after prior ORIF, and nonsurgically treated acetabular fractures. Patients’ demographics and the duration between fracture and THA implantation were assessed. Preoperative diagnostic testing (laboratory results, hip aspirations) as well as the results of intraoperative microbiological swabs and sonication were also evaluated. Postoperative complications were recorded.

Results Sixty-seven patients (51 men/16 women) were included, with a mean age of 54.7 ± 14.0 years (range: 18.0–82.9). The mean time between acetabular fracture and THA was 13.5 ± 14.9 years (0.2–53.5). Four subgroups were classified: subgroup I (nonsurgical, n = 15), subgroup II (complete removal of osteosynthesis, n = 8), subgroup III (partial removal of osteosynthesis, n = 15), and subgroup IV (remaining osteosynthesis, n = 29). Preoperative CRP blood levels were normal. CRP levels had no discriminatory ability to predict PJI (AUC: 0.43). Positive microbiological swabs were assessed in subgroups III (n = 1) and IV (n = 2). Complications during follow-up occurred in subgroups I (one aseptic loosening [6.7%]), III (one wound revision [6.7%], two low-grade infections [13.3%]), and IV (three low-grade infections [10.3%]).

Conclusion High infection rates were found in patients with THA after acetabular fracture with remaining implants or partial implant removal. Serum CRP alone seems to be a poor predictor. Therefore, an extensive diagnostic algorithm can help to detect an occult infection, including preoperative hip aspiration (microbiological samples and measurements of synovial CRP, WBC, and alpha-defensin levels). Intraoperative tissue samples and sonication results should be obtained during THA implantation.

Zusammenfassung

Hintergrund Die Implantation einer Hüftotalendoprothese (H-TEP) bei posttraumatischer Coxarthrose ist mit höheren Komplikationsraten behaftet, wenn zuvor eine Acetabulumfraktur durch eine offene Reposition und interner Fixierung (ORIF) versorgt wurde. In der vorliegenden Studie wurde die (I) postoperative Komplikationsrate und das Risiko einer frühen Infektion nach HTEP bei posttraumatischen Hüftgelenken nach Acetabulumfraktur, sowie (II) die diskriminierende Fähigkeit des präoperativen C-reaktiven Proteins (CRP) im Blut für periprothetische Infekte untersucht.

Material und Methoden Eingeschlossen wurden Patienten, die sich einer H-TEP-Implantation (2014–2019) nach vorheriger ORIF unterzogen, sowie konservativ behandelte Acetabulumfrakturen. Die demografischen Daten der Patienten und die Dauer zwischen Fraktur und H-TEP-Implantation wurden untersucht. Die präoperative Diagnostik (Laborergebnisse, Hüftpunktion) sowie die Ergebnisse der intraoperativen mikrobiologischen Abstriche und der Sonikation wurden ebenfalls ausgewertet. Des Weiteren wurden die postoperativen Komplikationen erfasst.

Ergebnisse 67 Patienten (51 Männer/16 Frauen) mit einem Durchschnittsalter von 54,7 ± 14,0 Jahren (Spanne: 18,0–82,9) wurden eingeschlossen. Die mittlere Zeitspanne zwischen Acetabulumfraktur und H-TEP betrug 13,5 ± 14,9 Jahre (0,2–53,5). Es wurden vier Untergruppen eingeteilt: Untergruppe I (konservativ, n = 15), Untergruppe II (vollständige Materialentfernung (ME), n = 8), Untergruppe III (partielle ME, n = 15) und Untergruppe IV (keine ME, n = 29). Präoperative CRP-Werte hatten keine Aussagekraft zur Vorhersage von PJI (AUC: 0,43). Positive mikrobiologische Abstriche wurden in den Untergruppen III (n = 1) und IV (n = 2) gefunden. Komplikationen während des Follow-Up traten in den Untergruppen I (eine aseptische Lockerung [6,7%]), III (eine Wundrevision [6,7%], zwei Low-Grade-Infektionen [13,3%]) und IV (drei Low-Grade- Infektionen [10,3%]) auf.

Schlussfolgerung Bei Patienten mit H-TEP-Implantation nach Acetabulumfraktur ohne vorherige Materialentfernung oder partieller Materialentfernung wurden höhere Infektionsraten gefunden. Das Serum-CRP allein scheint ein schlechter Prädiktor zu sein. Daher kann ein umfassender diagnostischer Algorithmus zur Erkennung einer okkulten Infektion beitragen und sollte eine präoperative Hüftaspiration (mikrobiologische Proben und Messungen des synovialen CRP-, WBC- und Alpha-Defensin-Spiegels) beinhalten. Intraoperative Gewebeproben und die Sonikation sollten während der HTEP-Implantation durchgeführt werden.

Keywords

acetabular fracture - total hip arthroplasty - PJI - posttraumatic hip osteoarthritis - THA

Schlüsselwörter

Acetabulumfraktur - Hüfttotalendoprothese - H-TEP - periprothetische Infektion - HTP

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