Influence of Fixation Methods on Prosthetic Joint Infection Following Primary Total Knee Replacement: Meta-Analysis of Observational Cohort and Randomised Intervention Studies.

Setor K Kunutsor,Andrew D Beswick,Ashley W Blom,Michael R Whitehouse,Vikki Wylde,Erik Lenguerrand

doi:10.3390/jcm8060828

Abstract

The type of fixation used in primary total knee replacement (TKR) may influence the risk of prosthetic joint infection (PJI). We conducted a systematic review and meta-analysis to assess published evidence linking type of fixation (cemented, uncemented, or hybrid) with the risk of PJI following primary TKR. Randomised controlled trials (RCTs) and observational cohort studies comparing fixation methods and reporting PJI incidence following primary TKR were identified in MEDLINE, Embase, Web of Science, and Cochrane Library up until November 2018. Summary measures were relative risks (RR) with 95% confidence intervals (CIs). We identified 32 eligible articles (24 observational studies and 8 RCTs) involving 1,161,292 TKRs. In pooled analysis of observational studies, uncemented fixation was associated with a decreased overall PJI risk when compared with cemented fixation at 0.76 (0.64–0.89). Comparing antibiotic-loaded cemented fixation with plain cement, there was no significant difference in overall PJI risk at 0.95 (0.69–1.31), but PJI risk was increased in the first 6-month postoperative period to 1.65 (1.12–2.43). Limited data from RCTs showed no differences in PJI risk among the fixation types. Observational evidence suggests uncemented fixation may be associated with lower PJI risk in primary TKR when compared with cemented fixation. In the early postoperative period, antibiotic-loaded cemented fixation may be associated with increased PJI risk when compared with plain cement. This may either reflect appropriate selection of higher risk patients for the development of PJI to cemented and antibiotic-loaded cement or may reflect a lower PJI risk in uncemented TKR due to factors such as shorter operative time.

Highlights

Total knee replacement (TKR) is one of the most common elective surgical procedures performed worldwide
Based on a larger number of studies and more detailed analyses, our review presents new observational findings which show that uncemented fixations are associated with lower prosthetic joint infection (PJI) risk when compared with cemented fixations and the effects of antibiotic-loaded and plain cemented fixations seem to depend on the timing of the postoperative period following primary TKR, geographical location, and the source of the data
In our recent review conducted in primary total hip replacement (THR) patients, we have shown that uncemented fixations are associated with lower PJI risk when compared with cemented fixations [15]

Summary

Introduction

Total knee replacement (TKR) is one of the most common elective surgical procedures performed worldwide. In 2017 alone, 102,777 TKRs were performed in England, Wales, Northern Ireland, and the Isle of Man, as recorded in the National Joint Registry (NJR) [1]. TKR is often a successful intervention for alleviating pain and improving function in joint disease, such as osteoarthritis [2], some patients experience complications, such as aseptic loosening, prosthetic joint infection (PJI), chronic pain, instability, malalignment, and wear [1]. With increasing life expectancy and number of people who will be affected by osteoarthritis, there will be a rise in the numbers of TKRs and the number of patients affected by PJI is expected to increase in a proportionate manner [10,11]. In England and Wales, over a thousand revision operations are performed annually due to PJI of the knee [12]

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