Abstract
BackgroundThe rate of postoperative infection developing is higher after limb salvage surgery (LSS) following sarcoma resection compared with conventional arthroplasty. The goal of this study is to summarize our experience in management of periprosthetic joint infection (PJI) and the risk factors of early PJI after LSS.MethodsBetween January 2010 and July 2019, 53 patients with osteosarcoma in the lower extremities who encountered periprosthetic infection after segmental tumor endoprosthetic replacement in our center were analyzed. Detailed patient characteristics and therapeutic information were collected from database of our institution or follow-up data and we divided patients according to the interval time between infection and tumor resection (surgery-infection interval) and investigate potential risk factors.ResultsA total of 53 (5.08%) patients were suffered postoperative infection. The average interval between surgery and clinical signs of deep infections are 27.5 days. For the drainage culture, positive results were only presented in 11 patients (20.8%). Almost half of this study’s (47.2%) patients underwent a traditional two-stage revision, that was, after the removal of the infected prosthesis, we applied antibiotic-loaded bone cements as a spacer. The mean blood loss during initial implantation surgery and operation time both correlated with interval period between PJI and initial implantation significantly (P = 0.028, P = 0.046). For several patients which infection marker was hardly back to normal after spacer implantation, we conservatively introduced an improved combination of bone cement and prosthesis for the second-stage surgery (5.6%). There were six patients needing re-operation, of which three were due to the aseptic loosening of the prosthesis, one developed periprosthetic infection again, and two patients encountered local recurrence and underwent amputation. Two patients were dead from distal metastasis.ConclusionsA two-stage revision strategy remains effective and standardized methods for PJI patients. Total operation time and blood loss during LSS of osteosarcoma are the main risk factors of early PJI. For the patients without confirmed eradiation of microorganisms, an improved combination of bone cement and prosthesis applied in the second-stage surgery could achieve satisfied functional and oncologic results.
Highlights
With advances in neoadjuvant and adjuvant chemotherapy, the long-term survival rate of patients with osteosarcoma has increased to almost 70% [1, 2]
In addition to symptoms and signs, serological examinations including white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and blood and tissue cultures can assist in the diagnosis [11, 12]
Swelling, heat, and pain were observed in 28 patients (52.8%), malodorous drainage occurred in 26 patients (49.1%), and fever only was seen in 15 patients
Summary
With advances in neoadjuvant and adjuvant chemotherapy, the long-term survival rate of patients with osteosarcoma has increased to almost 70% [1, 2]. More than 95% of patients with osteosarcoma of lower extremities are candidates for a limb salvage surgery (LSS) [3, 4], in which an endoprosthesis is used for reconstruction after tumor resection. Compared with traditional arthroplasty of the lower limb, the rate of periprosthetic joint infection (PJI) is markedly higher in patients who undergo LSS, with a reported incidence of 8% to 19.5% [5,6,7,8,9]. Risk factors for PJI include a poorer condition of the soft tissue, a greater number of cycles of chemotherapy, longer length of bone resection, longer operation time, and the size of the primary tumor [5, 7, 10]. The goal of this study is to summarize our experience in management of periprosthetic joint infection (PJI) and the risk factors of early PJI after LSS
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