Preoperatively elevated serum inflammatory markers increase the risk of periprosthetic joint infection following total knee arthroplasty in patients with osteoarthritis

Asymptomatic Elevated Inflammatory Markers: Is There a Risk for Infection or Revision in Primary Total Knee Arthroplasty?

BACKGROUND

Total knee arthroplasty (TKA) is the treatment of choice for advanced knee osteoarthritis. Long-term studies report high patient satisfaction, while complications such as periprosthetic joint infection (PJI) can be devastating. Knowledge regarding risk factors for PJI is critical to minimize and ideally avoid complications. The purpose of this study was to investigate the risk of PJI and revision in patients who had preoperative asymptomatic high C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels in primary TKAs.

METHODS

Patients undergoing primary TKA between 2010 and 2022 were eligible. Inclusion criteria were patients who had preoperative complete biochemical parameters and a minimum follow-up of 12 months. Patients who died during the first year, and those who had a history of inflammatory arthritis, autoimmune disease, renal pathologies or septic arthritis, were excluded. Patients who had elevated blood CRP and ESR levels taken within 48 hours before surgery underwent a thorough medical examination with a focus on infection symptoms. After screening and consultation, residual elevated CRP and ESR levels were classified as asymptomatic. After exclusions, 1,528 patients were included. The mean age was 66 years (range, 35 to 92) and the mean follow-up time was 6.4 years (range, 1.6 to 12.3).

RESULTS

The rate of revision within one year after surgery was 1.6%, whereas the rate of revision in the first five years was 3.8%. The PJI rates for the 1st and 5th postoperative years were 1.7 and 2.9% respectively. Regression analysis did not show any of the potential variables to be a risk factor for revision or PJI.

CONCLUSION

Asymptomatic elevated acute-phase reactants are not a risk factor for periprosthetic joint infection or aseptic revision. At a mean follow-up of 6.4 years, overall survival was 96.7%, with only 2.2% of patients revised due to a PJI.

Inflammatory Marker Changes Following Total Knee Arthroplasty for Rheumatoid Arthritis with Vancomycin-loaded Calcium Sulfate Bone Filling

Rheumatoid arthritis (RA) patients undergoing total knee arthroplasty (TKA) face infection risk. The study evaluates vancomycin-loaded calcium sulfate bone as infection prevention. Patients with RA treated with TKA who had their femoral canal filled using either vancomycin-loaded calcium sulfate bone (experimental group [n = 35]) or the patient's own excised autologous bone (control group [n = 30]) at the Qingdao University Affiliated Hospital, Qingdao, China from January 1, 2017, to March 1, 2023, were retrospectively enrolled in this study. An experienced surgeon used midvastus approach. Surgeries included disinfection, antibiotics, and femoral filling. The age, gender, body mass index (BMI), comorbidities, and intraoperative details were extracted from the patient's medical records. Preoperation and postoperation markers (C-reactive protein [CRP], erythrocyte sedimentation rate [ESR]), pain scale (Visual Analog Scale [VAS]), infection rate, and Knee Society Score (KSS) were collected. Groups matched in age, gender, and BMI. No preoperative inflammatory marker differences were observed. However, compared to the control group, the postoperative inflammatory markers were significantly lower in the experimental group at 1-week postsurgery (CRP: 40.80 ± 23.17 vs. 60.80 ± 43.12 mg/L, p = 0.021; ESR: 72.06 ± 17.52 vs. 83.87 ± 21.52 mm/h, p = 0.012) and at 1-month postsurgery (CRP: 15.63 ± 6.56 vs. 21.17 ± 13.16 mg/L, p = 0.032; ESR: 25.25 ± 20.44 vs. 38.40 ± 25.26 mm/h, p = 0.024). There were no significant differences in the VAS (2.79 ± 0.90 vs. 2.70 ± 0.84 score, p = 0.689) and KSS (64.31 ± 17.88 vs. 66.57 ± 12.36) at 1-month postsurgery. Experimental group: zero infections; control group: only one infection. Administering vancomycin and calcium sulfate during TKA in RA patients reduces postoperative inflammation, but does not significantly affect infection risk; further research may be necessary for validation.

The Development and Evaluation of a Prediction Model for Kidney Transplant-Based Pneumocystis carinii Pneumonia Patients Based on Hematological Indicators

BACKGROUND

This study aimed to develop a simple predictive model for early identification of the risk of adverse outcomes in kidney transplant-associated Pneumocystis carinii pneumonia (PCP) patients.

METHODS

This study encompassed 103 patients diagnosed with PCP, who received treatment at our hospital between 2018 and 2023. Among these participants, 20 were categorized as suffering from severe PCP, and, regrettably, 13 among them succumbed. Through the application of machine learning techniques and multivariate logistic regression analysis, two pivotal variables were discerned and subsequently integrated into a nomogram. The efficacy of the model was assessed via receiver operating characteristic (ROC) curves and calibration curves. Additionally, decision curve analysis (DCA) and a clinical impact curve (CIC) were employed to evaluate the clinical utility of the model. The Kaplan-Meier (KM) survival curves were utilized to ascertain the model's aptitude for risk stratification.

RESULTS

Hematological markers, namely Procalcitonin (PCT) and C-reactive protein (CRP)-to-albumin ratio (CAR), were identified through machine learning and multivariate logistic regression. These variables were subsequently utilized to formulate a predictive model, presented in the form of a nomogram. The ROC curve exhibited commendable predictive accuracy in both internal validation (AUC = 0.861) and external validation (AUC = 0.896). Within a specific threshold probability range, both DCA and CIC demonstrated notable performance. Moreover, the KM survival curve further substantiated the nomogram's efficacy in risk stratification.

CONCLUSIONS

Based on hematological parameters, especially CAR and PCT, a simple nomogram was established to stratify prognostic risk in patients with renal transplant-related PCP.

Elevated ESR and CRP Prior to Second-Stage Reimplantation Knee Revision Surgery for Periprosthetic Joint Infection Are Associated with Increased Reinfection Rates

Although two-stage revision surgery is considered as the most effective treatment for managing chronic periprosthetic joint infection (PJI), there is no current consensus on the predictors of optimal timing to second-stage reimplantation. This study aimed to compare clinical outcomes between patients with elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) prior to second-stage reimplantation and those with normalized ESR and CRP prior to second-stage reimplantation. We retrospectively reviewed 198 patients treated with two-stage revision total knee arthroplasty for chronic PJI. Cohorts included patients with: (1) normal level of serum ESR and CRP (n = 96) and (2) elevated level of serum ESR and CRP prior to second-stage reimplantation (n = 102). Outcomes including reinfection rates and readmission rates were compared between both cohorts. At a mean follow-up of 4.4 years (2.8-6.5 years), the elevated ESR and CRP cohort demonstrated significantly higher reinfection rates compared with patients with normalized ESR and CRP prior to second-stage reimplantation (33.3% vs. 14.5%, p < 0.01). Patients with both elevated ESR and CRP demonstrated significantly higher reinfection rates, when compared with patients with elevated ESR and normalized CRP (33.3% vs. 27.6%, p = 0.02) as well as normalized ESR and elevated CRP (33.3% vs. 26.3%, p < 0.01). This study demonstrates that elevated serum ESR and/or CRP levels prior to reimplantation in two-stage knee revision surgery for chronic PJI are associated with increased reinfection rate after surgery. Elevation of both ESR and CRP were associated with a higher risk of reinfection compared with elevation of either ESR or CRP, suggesting the potential benefits of normalizing ESR and CRP prior to reimplantation in treatment of chronic PJI.

The 2018 New Definition of Periprosthetic Joint Infection is Valuable for Diagnosis of Persistent Infection at Reimplantation in Patients without Synovial Fluid

BACKGROUND

Diagnosis of persistent infection at reimplantation of 2-stage exchange revision is a challenging problem. The aim of our study is to evaluate the performance of the 2018 new definition and Musculoskeletal Infection Society (MSIS) criteria in determining the persistent infection at reimplantation in patients without synovial fluid.

METHODS

We retrospectively reviewed 150 patients who underwent 2-stage exchange revision from 2014 to 2018. Two models were used to define persistent infection-model 1: identical major criteria of the MSIS criteria and new definition and model 2: identical major criteria of 2 criteria and/or subsequent infection after reimplantation. The predictive accuracy of the new definition and MSIS criteria was compared by using receiver operating characteristic curves.

RESULTS

The receiver operating characteristic curves showed that the new definition had good performance in determining the persistent infection, with the area under the curve (AUC) of 0.871 in model 1 and 0.835 in model 2. The optimal threshold for aggregate scores in new definition was 4. The MSIS criteria had limited diagnostic value in both model 1 (AUC = 0.708) and model 2 (AUC = 0.664). In model 1, the sensitivity and specificity were 86.96% and 84.25% in new definition, and 47.83% and 93.70% in MSIS criteria in patients without synovial fluid. In model 2, the sensitivity and specificity were 78.57% and 85.25% in new definition, and 39.29% and 93.44% in MSIS criteria.

CONCLUSION

The 2018 new definition of PJI is valuable in the diagnosis of persistent infection, which can improve diagnostic accuracy compared with the MSIS criteria in patients without synovial fluid.

Comparison of Postoperative Effects between Medial Pivot Prosthesis and Posterior Stabilized Prosthesis

Objective

To compare the postoperative inflammation and pain response between medial pivot (MP) and posterior stabilized (PS) prostheses among total knee arthroplasty (TKA) patients.

Methods

A prospective cohort study was conducted from January 2019 to May 2019 at the Affiliated Hospital of Qingdao University. The study included patients diagnosed with stage III or IV Kellgren–Lawrence knee osteoarthritis (KOA) who had failed conservative treatment, had undergone no previous knee surgeries, had varus substantial deformities (11°–20° deviation), and had received their first unilateral TKA. A total of 109 patients who underwent PS prosthesis TKA and 98 patients who underwent MP prosthesis TKA were continuously enrolled. Inflammation biomarkers, such as leukocyte (white blood cells), erythrocyte sedimentation rate (ESR), and C‐reactive protein (CRP), together with hemoglobin (Hb), the visual analog pain score (VAS) and range of motion (ROM) were compared between the two groups. The Student t‐test was applied to analyze continuous parameters, and the χ²‐test was used for categorical parameters. The linear mixed model was used for the repeated measurement data from the follow‐up visits. Multivariate backward logistic and linear regression models were used to determine the factors potentially influencing prostheses and VAS scores.

Results

All these enrolled patients were followed up at 2, 4, 7, and 30 days after TKA. There were no significant differences between the PS group and the MP group in body mass index (BMI), gender, laterality, usage of nonsteroidal anti‐inflammatory drugs (NSAIDs) and opioids, and drain tube extubation time (P > 0.05). Compared with the PS group, the MP group were older (67.5 years vs 65.4 years), and had a higher mid‐vastus approach rate (67.3% vs 26.6%), a shorter tourniquet duration (68.3 ± 10.2 h vs 73.9 ± 11.2 h), a larger prosthetic pad (10.8 ± 1.2 mm vs 10.4 ± 1.2 mm), and a lower drain tube diversion volume (187.6 ± 119.3 mL vs 234.0 ± 155.7 mL). In the linear mixed model, MP prostheses had less CRP and ESR elevation and less Hb decrease than PS prostheses (P for group × time < 0.001). There were no significant differences in the changing trends between MP and PS prostheses by time for VAS scores and ROM. In the multivariate logistic regression model, MP prostheses showed significant differences compared with PS prostheses in treatment approach (odds ratio [OR] = 3.371, 95% confidence interval [CI]: 1.953–7.127; P < 0.001), ultrasound treatment start time (OR = 2.669, 95% CI: 1.385–5.141; P = 0.003), and tourniquet duration (OR = 0.954, 95% CI: 0.925–0.984; P = 0.003). Higher VAS scores on the second day postoperatively were related to high VAS scores preoperatively, use of opioids, high drain tube diversion, long tourniquet duration, and long drain tube extubation (P < 0.05), respectively.

Conclusion

The MP prostheses showed potential advantages compared with PS prostheses in TKA in inflammatory responses.

Prevalence of idiopathically elevated ESR and CRP in patients undergoing primary total knee arthroplasty as a function of body mass index

BACKGROUND

Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are commonly used inflammatory markers utilized to aid in the diagnosis of periprosthetic infection (PJI). Patients with obesity, however, are known to have elevated baseline levels of these inflammatory markers. Therefore, this retrospective study aimed to determine the relationship between elevated ESR and CRP and body mass index (BMI) in patients undergoing total knee arthroplasty (TKA). In doing so, physicians can better determine whether BMI should be taken into account when evaluating the prognostic value of elevated preoperative ESR and CRP levels for risk of PJI in primary TKA patients.

METHODS

This is a retrospective case series of 181 patients who had undergone primary TKA at a single institution. Patients undergoing primary unilateral TKA were eligible unless they had undergone previous TKA, contralateral knee symptoms, or elevated white blood cell (WBC) count. A linear regression model was utilized to demonstrate the relationship between proportions of patients with elevated biomarker values and categories of BMI. Analysis of variance and independent two-sample t-tests were utilized to assess differences in mean ESR, CRP, and WBC levels between the "healthy patients" and "patients with comorbidities" subgroups within each BMI category.

RESULTS

Eligible patients (n = 181) were stratified by BMI category. Elevated ESR was associated significantly with BMI (ESR: r2 = 0.89, P < 0.001) unlike elevated CRP (r2 = 0.82, P = 0.133) and WBC count (r2 = .01; P = .626). No statistically significant differences in ESR values and WBC count between the "healthy patients" versus "patients with comorbidities" were demonstrated within any BMI category. In patients of normal weight (BMI 20-25 kg/m2), "healthy patients" had a statistically significantly higher mean CRP level than "patients with comorbidities" (1.73 mg/L vs. 0.70 mg/L, P < 0.001). There were no other statistically significant differences in mean CRP levels by health status.

CONCLUSION

Caution is advised when utilizing ESR and CRP to diagnose periprosthetic joint infection without considering BMI given that increasing preoperative levels of ESR and CRP are correlated with higher BMI.

Changes in serum markers failed to predict persistent infection after two-stage exchange arthroplasty

Background

The proper timing of reimplantation is importation to treatment success in the two-stage exchange revision. The 2018 International Consensus Meeting suggested that a variation trend toward normalization in serum markers was useful for determining the proper timing of reimplantation. However, the opposite results were found by previous studies, and the normalization of serum markers was reported to fail to predict infection control. We investigated whether value changes and percent changes in four common serum markers (erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), interleukin-6 (IL-6), and fibrinogen) can predict persistent infection.

Methods

A retrospective review of 141 patients treated with the two-stage revision from 2014 to 2018 was conducted. The variation trend in serum indicators was evaluated by the percent changes (using values of serum markers pre-reimplantation divided by values pre-resection) and value changes (using values of serum markers pre-resection minus values pre-reimplantation). Treatment success was defined according to the Delphi-based consensus criteria with a minimum follow-up of 1 year, and the receiver operator characteristic (ROC) was used to examine the usefulness of changes in serum markers.

Results

Twenty-two patients (15.60%) were persistently infected. No significant difference was found in either the value change or percent change in serum markers between reinfection and non-reinfection patients. When predicting persistent infection, the area under the curves (AUC) demonstrated that both percent changes and value changes in serum markers were poor indicators. The AUC of value changes was 0.533 for the CRP, 0.504 for the IL-6, 0.508 for the ESR, and 0.586 for fibrinogen when predicted persistent PJI. In addition, the AUC indicated that percent changes in the CRP (0.464), the IL-6 (0.534), the ESR (0.527), and fibrinogen (0.586) were all poor markers.

Conclusions

We have shown that both value changes and percent changes in serum markers were not sufficiently rigorous to aid in persistent infection diagnosis. The proper timing of reimplantation must, therefore, take into account various clinical tests rather than the downward trend of serum markers only.

Factors associated with the length of stay in total knee arthroplasty patients with the enhanced recovery after surgery model

Objectives

The purpose of this study is to identify the factors that influence the length of stay (LOS) in total knee arthroplasty (TKA) patients with an enhanced recovery after surgery (ERAS) program.

Methods

Information from 167 patients (31 males and 136 females, range from 43 years to 88 years old) who underwent the unilateral elective primary TKA from January 2017 to January 2019 were reviewed retrospectively. Factors were analyzed by single-factor variance and multi-factor linear regression.

Results

By single-factor variance analysis, American Society of Anesthesiologists (ASA) physical status classification system, pre-operation albumin, pre-operation erythrocyte sedimentation rate (ESR), primary and merge diseases, hidden blood loss, and length of operation were correlated with LOS (P < 0.05). Multi-factor linear regression results suggested that gender, ASA class, pre-operation Alb, and pre-operation ESR were associated with LOS (P < 0.05). Moreover, ASA class 3 (B value 4.84), pre-operation Alb < 30 g/L (B value 18.33), and pre-operation ESR > 15 mmol/h (B value 2.21) could increase the LOS, while males (B value − 3.56) had a shortened LOS.

Conclusions

Overall, our research found that female, ASA class 3, pre-operation Alb < 30 g/L, and pre-operation ESR > 15 mmol/h could extend LOS in TKA patients with ERAS.

Rosa canina - Rose hip pharmacological ingredients and molecular mechanics counteracting osteoarthritis - A systematic review

BACKGROUND

The successful use of rose hip for the treatment of osteoarthritis is well documented. Several randomized placebo controlled double-blind studies, as mono or combination therapy, have demonstrated treatment efficacy as well as excellent tolerability.

PURPOSE

This review focuses on the molecular mechanism underlying the clinical effects of rose hip in osteoarthritis (OA).

METHODS

The database Medline was screened - using the search term "Rosa canina" or "rose hip" - for publications on pharmacological or mechanistic studies with relevance to OA; in addition for findings on pharmacologically active constituents as well as clinical studies. The screening results were complemented by following-up on cited literature.

RESULTS

In particular, 24 pharmacological studies on Rosa canina or preparations thereof were considered relevant. Potent antioxidant radical scavenging effects are well documented for numerous rose hip constituents besides Vitamin C. Furthermore, anti-inflammatory activities include the reduction of pro-inflammatory cytokines and chemokines, reduction of NF-kB signaling, inhibition of pro-inflammatory enzymes, including COX1/2, 5-LOX and iNOS, reduction of C-reactive protein levels, reduction of chemotaxis and chemoluminescence of PMNs, and an inhibition of pro-inflammatory metalloproteases.

CONCLUSION

The antioxidant and anti-inflammatory effects of Rosa canina match its clinical action - especially considering new findings on the pharmacological disease pattern of OA. The entirety of several compounds including phenolics, terpenoids, galactolipids, carotenoids, fruit acids and fatty oils can be considered responsible for the observed pharmacological and clinical effects. Further research is needed to eludicate how and in which manner single rose hip compounds interact with their molecular pharmacological targets.