Periprosthetic Joint Infections Linked to Increased Mortality in Rheumatoid Arthritis Patients

Patients with rheumatoid arthritis (RA) presenting with periprosthetic joint infections are at significantly greater risk of mortality and complication rates, according to new data.

A cohort retrospective study from an international team of investigators showed that approximately 1 in 5 patients with periprosthetic join infections due to total joint arthroplasty died following their infection; among that population, the cause of death was directly attributed to the infection. The findings show the need for improved diagnosis timing and treatment onset in at-risk patients.

Led by Lucio Cappelli Toledo de Araujo, of the department of orthopedic surgery at the ENDO Klinik Buch in Berlin, investigators aimed to report the complication and mortality rates among a cohort of RA patients with periprosthetic joint infections, as well a clinical characterization of such patients.

“Periprosthetic joint infection remains the most devasting complication after total joint arthroplasty,” investigators wrote. “There has been a significant focus on this topic in recently-published medical literature. However, relatively little has been published about (such infections) in patients with RA, which are often physiologically frail and immunocompromised. A better understanding of PJI in this patient population is therefore crucial.”

Indeed, the incidence of periprosthetic joint infection is only approximately 1 – 2% of patients with RA. “Unfortunately, periprosthetic joint infection is not a straightforward diagnosis; there is no uniformly accepted definition of periprosthetic joint infection, and periprosthetic joint infection can occur anywhere from 4 weeks to 2 years following primary arthroplasty,” a recent analysis noted. “(It) has a profound physical, social, and emotional impact on affected patients and significantly increases healthcare expenditures, patient morbidity, and overall mortality.”

De Araujo and colleagues retrospectively reviewed the medical and surgical records of all patients with RA to report periprosthetic joint infections treated surgically from 2003 – 2020. They defined relevant infections based on medical history; physical examinations; reactive protein (CRP) levels; procalcitonin; white blood cell counts; joint aspirations results; and cultures.

Their analysis included 54 instances of periprosthetic joint infections among 53 patients with RA. Among the infections, 49 were chronic. Mean patient age was 65 years old (range, 32 – 88); 33 (62.3%) patients were female. Staphylococci was the primary form of infection, account for two-thirds of all cases (n = 34 [63%]); another 11 (20.4%) infections were multiorganism and 6 were culture-negative.

Investigators observed mortality in 10 patients (18.9%); among them, periprosthetic joint infections were directly attributed to the cause of death in 5 patients (9.4%). Following treatment, three-fourths (n = 43 [79.6%]) of patients retained an implanted total joint replacement.

Another 4 (7.4%) of treated patients had spacers; 3 (5.6%) had undergone resection arthroplasty; 2 (3.7%) had arthrodesis; and 1 patient each had an amputation and exarticulation.

The team concluded the findings show a particularly high mortality rate among patients with RA who develop a periprosthetic joint infection.

"Delays to diagnosis and treatment may explain some of these poor outcomes," they noted.

References

1. ^{de Araujo LCT, Westerholt A, Sandiford AN, Gursche A, Kendoff D. Periprosthetic joint infections in patients with rheumatoid arthritis are associated with higher complication and mortality rates. Arch Orthop Trauma Surg. Published online March 19, 2024. doi:10.1007/s00402-024-05248-y}
2. ^{Ayoade F, Li DD, Mabrouk A, et al. Periprosthetic Joint Infection. [Updated 2023 Oct 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448131/}