“Rare but devastating” are words often used to describe periprosthetic joint infection (PJI). To make a substantial dent in this ongoing issue, researchers from what is likely the only official Prosthetic Joint Infection Center in the U.S.—OrthoCarolina—along with researchers from Atrium Health and OrthoCarolina, got to work.
Their study, “Regional Periprosthetic Joint Infection Centers: The Time Has Come for a Paradigm Change in the Treatment of Periprosthetic Joint Infection,” appears in the July 30, 2024, issue of The Journal of Arthroplasty.
“Five years ago, I initiated a prospective randomized OREF [Orthopaedic Research and Education Foundation]-funded study comparing 1-stage vs 2-stage treatment for PJI,” co-author and director of the OrthoCarolina Prosthetic Joint Infection Center Thomas Fehring, M.D. told OTW.
“Over 300 patients needed to be enrolled in this study to have enough statistical power to determine which treatment path was best for patients with a PJI. Since this complication is rare (approximately 1%), most orthopedic surgeons only treat a few PJIs per year. In order to obtain sufficient numbers for our 1-stage, 2-stage study, I contacted all the orthopedic surgeons in North and South Carolina offering to see their patients afflicted with this serious problem. We implemented a system for rapid access and care coordination for their PJI patients. Since its inception, we have been referred over 1,000 patients for treatment.”
Using the OrthoCarolina PJI registry, the researchers identified 172 patients (182 joints) who had a chronic PJI treated with a 2-stage exchange arthroplasty from 2017 to 2021.
Sooner Is Absolutely Better – Reduces Failure 50%
“Because this complication is relatively rare,” stated Dr. Fehring to OTW, “most orthopedic surgeons who only treat a few PJIs per year are frequently unaware of the latest evidence-based guidelines concerning the diagnosis and treatment of prosthetic joint infection. Therefore, delayed referral to our PJI Center was common. We found that there was a significantly higher failure rate in patients referred greater than 90 days after the diagnosis of chronic PJI (23%) compared to those patients referred in a timely fashion less than 90 days from diagnosis (11%).”
Cut 90-day Mortality to Zero?
“We also noted a significant decrease in the mortality rate of patients treated at our PJI Center compared to national averages. There were no deaths within 90 days of surgery at our PJI Center. This compares favorably to the national 90-day mortality rate of 5%. Our 1-year mortality rate was 3.9%, which also compares favorably with the 1-year national mortality rate of 9.7%.”
“Finally, we found that the cost of treatment prior to referral was substantial. The cost of nonevidence-based treatments such as multiple irrigation and debridements, multiple rounds of IV antibiotics, and long-term wound Vacuum-Assisted Closure therapy averaged approximately $80,000 per patient before they were referred to us. If one projects this cost over the 20,000 or so patients treated for PJI in the U.S., the cost to our healthcare system for ineffective PJI treatment prior to referral is nearly $800 million dollars.”
To Succeed, Follow Best Practices
“Currently in the United States there is well-documented precedent for improved outcomes when patients are treated in Centers of Excellence such as Trauma Centers or Cancer Centers. These improved outcomes are directly related to higher volumes seen in these Centers, which results in improved surgical techniques and familiarity with complex care. Given the significant morbidity and mortality associated with treatment of PJI, it is reasonable to expect that similar benefits can be seen by establishing Centers of Excellence specifically for the treatment of this complex problem.”
“In France, they have established a 24-Center National Network of PJI Centers concentrating surgeons, infectious disease consultants, microbiologists, radiologists and internists in order to optimize patient care, promote education and bolster research efforts. A similar national effort has been instituted in the Netherlands.”
“I am currently working with CMS [Centers for Medicare and Medicaid Services] to help establish Regional Prosthetic Joint Infection Centers across the country that would improve patient care and provide significant cost savings to the healthcare system as a whole. Our proposed model of care serves as an example for other healthcare institutions throughout the United States seeking to optimize PJI treatment, improve the patient experience, and reduce spending in the healthcare system. A National Network of PJI Centers, like the successful network established in France, would accomplish these goals. The time has come for a paradigm change in the treatment of PJI.”
“As far as I know,” commented Dr. Fehring to OTW, “we are the only formalized Prosthetic Joint Infection Center in the U.S. In other areas of the country, tertiary academic orthopedic departments have been the de facto referral choice for PJIs when encountered by general orthopedists.”
