This week’s Orthopaedic Crossfire® debate was part of the 19th Annual Current Concepts in Joint Replacement® (CCJR®), Spring meeting, which took place in Las Vegas. This week’s topic is “Ceramics Decrease the Incidence of Peri-Prosthetic Joint Infection” For is Thorsten Gehrke, M.D. – ENDO-Klinik, Hamburg, Germany. Opposing is Robert L. Barrack, M.D. – Washington University School of Medicine, St. Louis, Missouri. Moderating is Daniel J. Berry, M.D. – Mayo Clinic, Rochester, Minnesota.
Dr. Gehrke: We are talking about peri-prosthetic joint infections (PJI). Many, many risk factors, like operation duration, age, gender, etc. contribute to PJI. And, there is this question about implant material.
During the International Consensus Meeting on PJI in 2013, we came to the conclusion that metal-on-metal bearings may be associated with the higher risk of PJI, which is almost proven. But nothing about ceramics.
In a recent systematic review and meta-analysis about the bearings (Hexter, et al., BJJ, 2018), they could not find any statistically significant differences between the bearings.
In the Australian Joint Replacement Registry there is no difference between ceramic-on-poly and metal-on-poly regarding infection rate.
The Danish Registry shows a much lower rate of peri-prosthetic infection with ceramic-on-ceramic when compared to metal-on-poly.
Medicare data showed the same according to the works of Bozic, et al. (CORR, 2010; JOA, 2012). And a paper from Kurtz, et al., showed a statistical significance based on more than 315,000 Medicare total hip replacements that a ceramic bearing surface, whether on ceramic or poly, versus metal-on-poly has a much lower infection rate (JOA, 2016).
Jay Parvizi, M.D. conducted a study at the Rothman Institute comparing the PJI rate for metal-on-poly versus ceramic-on-poly and they found an almost statistically significant difference between the patient groups (p=0.04).
Robert, you might say, “Yes, of course. Ceramic-on-poly patients are younger and healthier.” So, the Rothman Institute study did a multivariate analysis controlling for age, Charlson comorbidity, BMI, etc., and they found out that a metal-on-poly bearing surface is an independent risk factor correlating with higher incident of PJI (Smith, et al., EAO, 2014). The use of a cobalt-chromium femoral head was an independent factor in causing PJI.
If we look at the international registry data – a small registry from Slovenia in Europe shows a much lower infection rate.
Hi – Super important topic and discussion. I am currently completing my Masters in Epidemiology and appreciate a sensible discussion of exposure, outcome, cause and association. But my question today, is where did the syntax “peri-prosthetic infection” come from? Years ago we were discussing PJIs – prosthetic joint infection. Has the description changed officially to “peri-prosthetic”? If so, is this to signify an infection that reaches beyond the joint into the surrounding bone?
Thanks for your consideration,
Jo Elliott