Global publication analysis
General data
Among the 117 articles, the earliest publications were from 2007. The greatest number of articles were published in 2018 (24), followed by 2017 and 2019 (21 each). The trend line indicates an annual increase in the number of articles (Fig. 4). One hundred and fourteen articles were in English, and three other articles were each published in Chinese, German, and Persian. In all meta-analyses, the number of studies included ranged from 4 to 203, with the highest number 12 (n = 11 publications), followed by eight (9) as well as six and eleven studies (8 each).
Countries
Nineteen countries published articles on PJI. Of these, China was the most productive country, with all publications stemming from 15 cities/provinces. The highest number of articles originated from Shanghai, followed by Beijing (Fig. 5). The country with the second-highest number of publications on PJI was the US, followed by the UK (Table 1).
Table 1
Global distribution of PJI research
Country | Number of articles |
China | 48 |
USA | 20 |
UK | 18 |
Germany | 4 |
South Korea | 4 |
Italy | 3 |
Netherlands | 3 |
Canada | 3 |
Australia | 2 |
Colombia | 2 |
Greece | 2 |
Brazil | 1 |
Denmark | 1 |
Iran | 1 |
Portugal | 1 |
South Africa | 1 |
Spain | 1 |
Sweden | 1 |
Switzerland | 1 |
Institutions
A total of 76 institutions made contributions to this field. The institution with the greatest number of publications was the University of Bristol with 11 papers, followed by Shanghai Sixth People’s Hospital (8). The Rothman Institute and General Hospital of the Chinese People’s Liberation Army were third, with each publishing five research articles. Fourteen institutions published more than one paper, with 50% originating from China (Table 2).
Table 2
Top 14 institutions and countries
Name of institution | Publication | Country |
University of Bristol | 11 | UK |
Shanghai Sixth People’s Hospital | 8 | China |
Rothman Institute | 5 | USA |
General Hospital of Chinese People’s Liberation Army | 5 | China |
The Third Hospital of Hebei Medical University | 4 | China |
Tianjin Hospital | 3 | China |
Mayo Clinic Hospital | 3 | USA |
Charité - Universitätsmedizin Berlin | 3 | Germany |
West China Hospital | 2 | China |
Medical Centre Alkmaar | 2 | Netherlands |
McMaster University | 2 | Canada |
Federico II University | 2 | Italy |
Beijing Jishuitan Hospital | 2 | China |
Beijing Friendship Hospital of Capital Medical University | 2 | China |
Authors
The number of authors of a single article ranged from 2 to 37. The largest number of collaborating authors was four (27), followed by six (25) and 5 authors (20; Table 3). The author with most first authorships was Setor K. Kunutsor (10), followed by Xinhua Qu (3). Ten first authors wrote more than one meta-analysis, with 50% published by research institutes in China (Table 4).
Table 3
Number of collaborating authors
Number of authors | Total number |
4 | 27 |
6 | 25 |
5 | 20 |
3 | 15 |
7 | 10 |
8 | 6 |
10 | 3 |
2 | 2 |
9 | 2 |
13 | 2 |
27 | 2 |
11 | 1 |
18 | 1 |
37 | 1 |
Table 4
List of top 10 first authors with number of publications and institution.
First author | Publications | Institution |
Setor K. Kunutsor | 10 | University of Bristol |
Qu Xinhua | 3 | Shanghai Ninth People’s Hospital |
Giovanni Balato | 2 | Federico II University |
Yong Seuk Lee | 2 | Rothman Institute |
Li Cheng | 2 | Charité Universitätsmedizin Berlin |
Steven J. Verberne | 2 | Medical Centre Alkmaar |
Wang Chi | 2 | General Hospital of Chinese People’s Liberation Army |
Xu Chi | 2 | General Hospital of Chinese People’s Liberation Army |
Dan Xing | 2 | Tianjin Hospital |
Xie Kai | 2 | Shanghai Ninth People’s Hospital |
Journals
Meta-analysis studies were published in 54 different journals. The journal with most publications was the Journal of Arthroplasty, with 15 publications. The Journal of Bone and Joint Surgery ranked second with eight publications, whereas PLoS ONE was third with seven. Nineteen journals had more than one publication (Table 5). In 2019, an impact factor was available for 42 journals. The list of top 10 journals with the highest impact factors are shown in Table 6.
Table 5
Top 19 journals with number of publications and their corresponding impact factor.
Journal | Number of publications | Impact factor |
Journal of Arthroplasty | 15 | 3.524 |
Journal of Bone and Joint Surgery-American Volume | 8 | 4.716 |
PLoS ONE | 7 | 2.776 |
Surgical Infections | 6 | 1.921 |
International Orthopaedics | 5 | 2.384 |
Bone and Joint Journal | 5 | 4.301 |
Archives of Orthopaedic and Trauma Surgery | 3 | 1.973 |
BMC Musculoskeletal Disorders | 3 | 2.002 |
Clinical Orthopaedics and Related Research | 3 | 4.154 |
International Journal of Clinical and Experimental Medicine | 3 | 0.181 |
Journal of Clinical Microbiology | 3 | 4.959 |
Journal of Hospital Infection | 3 | 3.704 |
Journal of Orthopaedic Surgery and Research | 3 | 1.907 |
Knee Surgery Sports Traumatology Arthroscopy | 3 | 3.149 |
Medicine | 3 | 1.87 |
Orthopedics | 3 | 1.608 |
Table 6
List of top 10 highest impact factor journals with number of publications.
Journal | Number of publications | Impact factor |
Radiology | 1 | 7.608 |
European Journal of Nuclear Medicine and Molecular Imaging | 1 | 7.182 |
European Journal of Epidemiology | 1 | 6.529 |
Journal of Clinical Medicine | 2 | 5.688 |
Journal of Antimicrobial Chemotherapy | 1 | 5.113 |
Regional Anesthesia and Pain Medicine | 1 | 5.113 |
Journal of Infection | 1 | 5.099 |
Journal of Clinical Microbiology | 3 | 4.959 |
Journal of Bone and Joint Surgery-American Volume | 8 | 4.716 |
Antimicrobial Agents and Chemotherapy | 1 | 4.715 |
From all publications, the date of receipt was available for 89 papers, whereas the date of acceptance for 85, and the date of publication for 72. From the date of receipt to acceptance, information was available for 65 articles, with the average number of days until acceptance 95.69. Among these 65 articles, 11 journals had more than two publications, whereas four journals had an average acceptance time of fewer than 100 days. There are the Journal of Orthopaedic Surgery and Research (68 days), followed by the Journal of Hospital Infection (82 days), Journal of Clinical Microbiology (83 days), and Journal of Arthroplasty (86 days).
The average number of days from acceptance to publication was 56.52 (66 papers). From receipt to online publication, the average number of days was 157.48 (69). The month with the highest number of publications received was May (13), closely followed by March (11), and June (10), whereas the day with the highest number of publications received was Wednesday (24), pursued by Friday (16), and Tuesday (14). Most papers were accepted during February (12), October (11), and August (10), whereas most papers were accepted on Wednesday (22), followed by Monday (19), and Tuesday (15). The majority of papers were published in March (10), August (9), and January (8), and on the weekdays Thursday (19), Friday (16), and Wednesday (14; Figs. 6 and 7).
Six articles were accepted in less than 30 days after submission. The journal with the shortest acceptance time was the Journal of Clinical Medicine (16 days), followed by the Journal of Computational and Theoretical Nanoscience (18 days), Journal of Clinical Medicine (22 days), Journal of Arthroplasty (23 days), Journal of Orthopaedic Surgery and Research as well as Medical Science Monitor (27 days each).
Most-cited publications
From Google scholar, citation information was available for 103 articles. Forty-one articles were cited more than 20 times, with the highest number in 2014 (9), followed by 2013, 2016, and 2017 (7 each). The most cited article was published by Al Buhairn et al. [12] (264), followed by Parvizi et al. [13] (235; Table 7).
Table 7
The 50 most cited publications ranked by citation.
Rank | Title | Times Cited |
1 | Antibiotic prophylaxis for wound infections in total joint arthroplasty: A systematic review | 264 |
2 | Efficacy of antibiotic-impregnated cement in total hip replacement: A meta-analysis | 235 |
3 | Incidence and risk factors for surgical site infection following total knee arthroplasty: A systematic review and meta-analysis | 172 |
4 | Utility of intraoperative frozen section histopathology in the diagnosis of periprosthetic joint infection: A systematic review and meta-analysis | 145 |
5 | FDG-PET for diagnosing prosthetic joint infection: Systematic review and metaanalysis | 144 |
6 | Patient-related risk factors for periprosthetic joint infection after total joint arthroplasty: A systematic review and meta-analysis | 139 |
7 | Chronic infections in hip arthroplasties: Comparing risk of reinfection following one-stage and two-stage revision: A systematic review and meta-analysis | 117 |
8 | Risk factors for periprosthetic joint infection after total joint arthroplasty: A systematic review and meta-analysis | 114 |
9 | The alpha-defensin immunoassay and leukocyte esterase colorimetric strip test for the diagnosis of periprosthetic infection a systematic review and meta-analysis | 90 |
10 | A systematic review and meta-analysis of antibiotic-impregnated bone cement use in primary total hip or knee arthroplasty | 88 |
11 | Risk factors for deep infection after total knee arthroplasty: A meta-analysis | 81 |
12 | Infection after primary total hip arthroplasty | 79 |
13 | Re-infection outcomes following one- and two-stage surgical revision of infected knee prosthesis: A systematic review and meta-analysis | 78 |
14 | Prosthesis infection: Diagnosis after total joint arthroplasty with antigranulocyte scintigraphy with99mTc-labeled monoclonal antibodies - A meta-analysis | 76 |
15 | Allogeneic Blood Transfusion Is a Significant Risk Factor for Surgical-Site Infection Following Total Hip and Knee Arthroplasty: A Meta-Analysis | 74 |
16 | Inflammatory blood laboratory levels as markers of prosthetic joint infection: A systematic review and meta-analysis | 74 |
17 | Meta-analysis of sonication fluid samples from prosthetic components for diagnosis of infection after total joint arthroplasty | 68 |
18 | Re-infection outcomes following one- and two-stage surgical revision of infected hip prosthesis: A systematic review and meta-analysis | 65 |
19 | Use of static or articulating spacers for infection following total knee arthroplasty | 61 |
20 | PCR-based diagnosis of prosthetic joint infection | 57 |
21 | Preoperative aspiration culture for preoperative diagnosis of infection in total hip or knee arthroplasty | 56 |
22 | Synovial fluid biomarkers for the diagnosis of periprosthetic joint infection: A systematic review and meta-analysis | 47 |
23 | Evaluation of white cell count and differential in synovial fluid for diagnosing infections after total hip or knee arthroplasty | 35 |
24 | Prosthesis infection: diagnosis after total joint arthroplasty with three-phase bone scintigraphy | 35 |
25 | Diagnostic performance of FDG PET or PET/CT in prosthetic infection after arthroplasty: A meta-analysis | 34 |
26 | Procalcitonin and a-Defensin for Diagnosis of Periprosthetic Joint Infections | 34 |
27 | The accuracy of imaging techniques in the assessment of periprosthetic hip infection: A systematic review and meta-analysis | 32 |
28 | Control strategies to prevent total hip replacement-related infections: A systematic review and mixed treatment comparison | 30 |
29 | Outcomes following debridement, antibiotics and implant retention in the management of periprosthetic infections of the hip: A review of cohort studies | 30 |
30 | Total joint arthroplasty following intra-articular steroid injection: A literature review | 30 |
31 | Do intra-articular steroid injections increase infection rates in subsequent arthroplasty? A systematic review and meta-analysis of comparative studies | 29 |
32 | Postoperative antibiotic prophylaxis in total hip and knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials | 28 |
33 | What is the Accuracy of Nuclear Imaging in the Assessment of Periprosthetic Knee Infection? A Meta-analysis | 28 |
34 | Does previous intra-articular steroid injection increase the risk of joint infection following total hip arthroplasty or total knee arthroplasty? A meta-analysis | 27 |
35 | Systematic review and meta-analysis of randomized controlled trials of antibiotics and antiseptics for preventing infection in people receiving primary total hip and knee prostheses | 25 |
36 | Diagnostic accuracy of C-Reactive protein for periprosthetic joint infection: A meta-analysis | 24 |
37 | Use of Anti-Granulocyte Scintigraphy with 99mTc-Labeled Monoclonal Antibodies for the Diagnosis of Periprosthetic Infection in Patients after Total Joint Arthroplasty: A Diagnostic Meta-Analysis | 24 |
38 | Serum and Synovial Fluid Interleukin-6 for the Diagnosis of Periprosthetic Joint Infection | 23 |
39 | The application of sonication in diagnosis of periprosthetic joint infection | 22 |
40 | The impact of neuraxial versus general anesthesia on the incidence of postoperative surgical site infections following knee or hip Arthroplasty a meta-analysis | 22 |
41 | Do 'Surgical Helmet Systems' or 'Body Exhaust Suits' Affect Contamination and Deep Infection Rates in Arthroplasty? A Systematic Review | 21 |
Search algorithm and keywords
There were 102 articles retrieved from the search strategy, which were exported to Microsoft Excel. All keywords or MeSH were combined. PJI-related keywords were 196, followed by diagnosis (179), prevention (82), risk factor (74), and outcome (60). All keywords are presented in Supplementary 1. From 71 publications, 389 keywords were exported. Periprosthetic joint infection (41) was the most commonly used keyword, followed by meta-analysis (29) and total knee arthroplasty (20; Table 8).
Table 8
Keywords | Occurrence (n) |
Periprosthetic joint infection | 41 |
Meta analysis | 29 |
Total knee arthroplasty | 20 |
Arthroplasty | 18 |
Infection | 17 |
Total hip arthroplasty | 13 |
Two stage | 10 |
Alpha-defensin | 9 |
Total joint arthroplasty | 9 |
Knee | 9 |
Database and software
After combining all databases from 116 articles, there was a total of 52 databases. Embase was the most described database (101), followed by MEDLINE (80), and Cochrane (74; Table 9). Three databases were most frequently searched (40), followed by four (22), and five (16). The most combined database group was Cochrane Library + Embase + MEDLINE/PubMed (10), followed by Embase + MEDLINE (6), and Cochrane Library + Embase + MEDLINE + Web of Science (5).
Table 9
Database | Occurrence (n) |
Embase | 101 |
MEDILINE | 80 |
Cochrane | 74 |
PubMed | 57 |
Web of Science | 36 |
OVID | 14 |
Scopus | 14 |
Science Direct | 12 |
Google Scholar | 9 |
CNKI | 8 |
For the meta-analysis, 13 software was exported from 106 articles. The most commonly used software was STATA (43), followed by REVMAN (25), and Meta-Disc (21).
Subject
Location
Information on the site of prosthetic joint infection from the included meta-analysis were found in 112 papers. The location with the highest number was the knee (93), closely pursued by the hip (90), shoulder (23), elbow (16), and ankle (3).
Diagnosis of PJI
From 40 diagnosis-related meta-analyses, 72 tests were related to preoperative examination, followed by intraoperative methods (12), and test prior to reimplantation (14). Synovial fluid alpha-defensin had highest pooled sensitivities in the list of preoperative examinations, pursued by serum IL-6 and bone scintigraphy. From all intraoperative examinations, tissue polymerase chain reaction (PCR) was the most sensitive method, followed by sonicate fluid into blood culture bottles (BCB) and PCR. Tissue culture was the most sensitive method before reimplantation, followed by the percentage of polymorphonucleocytes in synovial fluid (PMN%), and synovial fluid culture (Table 10). The most frequent diagnostic method used was synovial fluid (16), followed by imaging (10), and periprosthetic tissue (7; Fig. 8).
Table 10
Diagnostic method used for PJI detection (preoperative examination, intraoperative methods, and test before reimplantation).
Preoperative examination | Reference | Year | No. of studies | Sen (95% CI) | Spe (95% CI) |
Synovial fluid alpha-defensin immunoassay | [28] | 2016 | 6 | 1.00 (0.82–1.00) | 0.96 (0.89–0.99) |
Synovial fluid ELISA | [29] | 2018 | 4 | 0.98 (0.94–1.00) | 0.97 (0.95–0.99) |
Synovial fluid alpha-defensin immunoassay | [14] | 2019 | 7 | 0.98 (0.94–0.99) | 0.96 (0.94–0.98) |
Synovial fluid a-defensin | [30] | 2017 | 7 | 0.97 (0.93–0.99) | 0.96 (0.94–0.98) |
Serum IL-6 | [31] | 2010 | 3 | 0.97 (0.93–0.99) | 0.91 (0.87–0.94) |
Synovial fluid ELISA | [32] | 2018 | 4 | 0.97 (0.91–0.99) | 0.97 (0.94–0.98) |
Synovial fluid alpha-defensin immunoassay | [15] | 2018 | 4 | 0.96 (0.90–0.98) | 0.96 (0.93–0.97) |
Synovial fluid alpha-defensin | [33] | 2017 | 11 | 0.96 (0.87–0.99) | 0.95 (0.91–0.97) |
Synovial fluid alpha-defensin | [34] | 2016 | 6 | 0.96 (0.85–0.99) | 0.95 (0.89–0.98) |
Synovial fluid alpha-defensin immunoassay | [16] | 2018 | 7 | 0.95(0.87–0.98) | 0.97 (0.94–0.98) |
Synovial fluid ELISA | [35] | 2018 | 4 | 0.95 (0.91–0.98) | 0.97 (0.95–0.98) |
Bone scintigraphy | [36] | 2017 | 6 | 0.93 (0.85–0.98) | 0.56 (0.47–0.64) |
Synovial fluid CRP | [37] | 2016 | 6 | 0.92 (0.86–0.96) | 0.90 (0.87–0.93) |
Synovial fluid ELISA | [17] | 2019 | 4 | 0.92 (0.86–0.96) | 0.99 (0.98–1.00) |
Synovial fluid LE | [38] | 2015 | 4 | 0.92(0.86–0.96) | 0.95 (0.93–0.97) |
Synovial fluid PMN% | [39] | 2018 | 10 | 0.91 (0.87–0.93) | 0.86 (0.81–0.90) |
Synovial fluid IL-6 | [40] | 2017 | 8 | 0.91 (0.82–0.96) | 0.90 (0.84–0.95) |
Synovial fluid WCC / PMN% | [41] | 2014 | 9 | 0.91 (0.82–0.95) | 0.89 (0.81–0.94) |
Synovial fluid WBC | [39] | 2018 | 10 | 0.90 (0.87–0.92) | 0.90 (0.81–0.95) |
Synovial fluid PMN% | [41] | 2014 | 14 | 0.90 (0.84– 0.93) | 0.88 (0.83–0.92) |
AGS | [36] | 2017 | 5 | 0.90 (0.78–0.96) | 0.95 (0.88–0.98) |
Synovial fluid LE | [42] | 2018 | 8 | 0.90 (0.76–0.96) | 0.97 (0.95–0.98) |
Synovial fluid Leukocyte count | [30] | 2017 | 12 | 0.89 (0.86–0.91) | 0.86 (0.80–0.90) |
Synovial fluid PMN% | [30] | 2017 | 10 | 0.89 (0.82–0.93) | 0.86 (0.77–0.92) |
Serum CRP | [31] | 2010 | 23 | 0.88 (0.86–0.90) | 0.74 (0.71–0.76) |
Synovial fluid WCC | [41] | 2014 | 15 | 0.88 (0.81–0.93) | 0.93 (0.88–0.96) |
Leukocyte scintigraphy | [36] | 2017 | 6 | 0.88 (0.81–0.93) | 0.77 (0.69–0.85) |
Leukocyte scintigraphy | [43] | 2016 | 6 | 0.88 (0.81– 0.94) | 0.92 (0.88–0.96) |
18F-FDG PET or PET/CT | [44] | 2017 | 16 | 0.87(0.83–0.90) | 0.87 (0.85–0.89) |
Serum CRP | [45] | 2017 | 11 | 0.87 (0.84–0.90) | 0.79 (0.77–0.80) |
Bone and leukocyte scintigraphy | [36] | 2017 | 4 | 0.87 (0.71–0.96) | 0.82 (0.72–0.90) |
Synovial fluid IL-8 | [30] | 2017 | 3 | 0.87 (0.67–0.96) | 0.94 (0.88–0.97) |
Serum ESR | [45] | 2017 | 12 | 0.86 (0.83–0.89) | 0.72 (0.70– 0.74) |
FDG PET or PET/CT | [46] | 2013 | 14 | 0.86 (0.82–0.90) | 0.86(0.83–0.89) |
Synovial fluid CRP | [32] | 2018 | 9 | 0.86 (0.81–0.91) | 0.90 (0.86–0.93) |
FDG PET | [43] | 2016 | 12 | 0.86 (0.80–0.90) | 0.93 (0.90–0.95) |
Synovial fluid lateral flow test | [17] | 2019 | 12 | 0.85 (0.80–0.89) | 0.96 (0.94–0.97) |
Synovial fluid CRP | [30] | 2017 | 10 | 0.85 (0.78–0.90) | 0.88 (0.78–0.94) |
Synovial fluid lateral flow test | [35] | 2018 | 6 | 0.85 (0.74–0.92) | 0.90 (0.91–0.98) |
Synovial fluid /serum CRP | [38] | 2015 | 15 | 0.845 (0.82–0.87) | 0.795 (0.78–0.81) |
Synovial fluid PCR | [47] | 2013 | 6 | 0.84 (0.75–0.93) | 0.89 (0.81–0.97) |
Synovial fluid lateral flow test | [14] | 2019 | 6 | 0.84 (0.74–0.91) | 0.94 (0.89–0.97) |
AGS | [43] | 2016 | 5 | 0.84 (0.70–0.93) | 0.75 (0.66–0.82) |
AGS with monoclonal antibodies | [48] | 2007 | 13 | 0.83(0.75–0.89) | 0.80 (0.75–0.84) |
Anti-Granulocyte Scintigraphy with 99 m Tc-Labeled Monoclonal Antibodies | [49] | 2013 | 19 | 0.83 (0.79–0.87) | 0.79 (0.75–0.83) |
Synovial fluid /serum IL-6 | [50] | 2018 | 18 | 0.83 (0.74–0.89) | 0.91 (0.84–0.95) |
Three-phase bone scintigraphy | [51] | 2014 | 20 | 0.83 (0.72–0.90) | 0.73 (0.65–0.80) |
Synovial fluid /serum IL-6 | [38] | 2015 | 11 | 0.824 (0.78–0.87) | 0.85 (0.82–0.88) |
FDG-PET | [52] | 2008 | 11 | 0.82(0.68–0.91) | 0.87 (0.80–0.91) |
Serum CRP | [53] | 2014 | 25 | 0.82 (0.80–0.84) | 0.77 (0.76–0.78) |
Synovial fluid IL-6 | [30] | 2017 | 5 | 0.81 (0.70–0.89) | 0.94 (0.88–0.97) |
Synovial fluid LE | [28] | 2016 | 5 | 0.81 (0.49–0.95) | 0.97(0.82–0.99) |
Bone scintigraphy | [43] | 2016 | 8 | 0.80 (0.72–0.86) | 0.69 (0.64–0.73) |
Leukocyte and bone marrow scintigraphy | [36] | 2017 | 7 | 0.80 (0.66–0.91) | 0.93 (0.86–0.97) |
Synovial fluid Synovasure™ | [32] | 2018 | 6 | 0.80 (0.65–0.89) | 0.89 (0.76–0.96) |
Synovial fluid LE | [17] | 2019 | 12 | 0.79 (0.75–0.82) | 0.96 (0.95–0.97) |
Synovial fluid LE | [32] | 2018 | 12 | 0.79 (0.67–0.87) | 0.92 (0.87–0.92) |
Synovial fluid lateral flow test | [16] | 2018 | 3 | 0.77 (0.64–0.87) | 0.91 (0.83–0.96) |
Synovial fluid LE | [30] | 2017 | 5 | 0.77 (0.63–0.87) | 0.95 (0.86–0.98) |
Synovial fluid IL-6 | [32] | 2018 | 11 | 0.76 (0.65–0.84) | 0.91 (0.88–0.94) |
Serum ESR | [31] | 2010 | 25 | 0.75 (0.72–0.77) | 0.70 (0.68–0.72) |
Synovial fluid culture | [54] | 2013 | 34 | 0.72 (0.65–0.78) | 0.95 (0.93–0.97) |
Serum IL-6 | [40] | 2017 | 11 | 0.72 (0.63–0.80) | 0.89 (0.77–0.95) |
Synovial fluid lateral flow test | [15] | 2018 | 3 | 0.71 (0.55–0.83) | 0.90 (0.81–0.95) |
FDG-PET | [36] | 2017 | 5 | 0.70 (0.56–0.81) | 0.84 (0.76–0.90) |
Leukocyte and bone marrow scintigraphy | [43] | 2016 | 3 | 0.69 (0.58–0.79) | 0.96 (0.93–0.98) |
Synovial fluid Culture | [30] | 2017 | 5 | 0.62 (0.50–0.74) | 0.94 (0.91–0.96) |
Serum PCT | [50] | 2018 | 6 | 0.58 (0.31–0.81) | 0.95 (0.63–1.00) |
Serum PCT | [34] | 2016 | 6 | 0.53 (0.24–0.80) | 0.92 (0.45–0.99) |
Serum WBC | [31] | 2010 | 15 | 0.45 (0.41–0.49) | 0.87 (0.85–0.89) |
Synovial fluid PCT | [38] | 2015 | 3 | 0.35(0.28–0.43) | 0.994 (0.97–1.00) |
Synovial fluid GS | [55] | 2015 | 4 | 0.30 (0.17–0.48) | 1.00 (0.88–1.00) |
Intraoperative examination | Reference | Year | No. of studies | Sen (95% CI) | Spe (95% CI) |
Tissue PCR | [47] | 2013 | 5 | 0.95 (0.91–0.99) | 0.81 (0.66–0.90) |
Sonicate fluid BCB | [56] | 2018 | 4 | 0.85 (0.77–0.91) | 0.86 (0.81–0.91) |
Sonicate fluid PCR | [47] | 2013 | 4 | 0.81 (0.71–0.91) | 0.96 (0.92–1.00) |
Sonicate fluid | [57] | 2014 | 12 | 0.80 (0.74–0.84) | 0.95 (0.90–0.98) |
Sonicate fluid | [58] | 2017 | 16 | 0.79 (0.76–0.81) | 0.95 (0.94–0.96) |
Synovial fluid WCC/PMN% | [41] | 2014 | 4 | 0.77 (0.51–0.91) | 0.97 (0.93–0.99) |
Sonicate fluid PCR | [59] | 2018 | 9 | 0.75 (0.71–0.79) | 0.96 (0.94–0.97) |
Tissue-frozen section [five leukocytes per high power field (400×)] | [60] | 2013 | 10 | 0.73 (0.65–0.80) | 0.90 (0.88–0.93) |
Tissue BCB | [61] | 2019 | 4 | 0.70 (0.66–0.75) | 0.97 (0.95–0.98) |
Tissue-frozen section [ten leukocytes per high power field (400×)] | [60] | 2013 | 5 | 0.64 (0.54–0.74) | 0.95 (0.93–0.97) |
Tissue GS | [55] | 2015 | 5 | 0.16 (0.08–0.29) | 0.99 (0.98–1.00) |
Tissue swab GS | [55] | 2015 | 3 | 0.14 (0.07–0.24) | 1.00 (0.97–1.00) |
Before reimplantation | Reference | Year | No. of studies | Sen (95% CI) | Spe (95% CI) |
Tissue culture | [62] | 2018 | 2 | 0.82 (0.72–0.90) | 0.91 (0.89–0.95) |
Synovial fluid PMN% | [62] | 2018 | 2 | 0.77 (0.46–0.95) | 0.74 (0.67–0.81) |
Synovial fluid PMN% | [63] | 2018 | 4 | 0.70 (0.58–0.81) | 0.71 (0.66–0.77) |
Synovial fluid culture | [62] | 2018 | 2 | 0.64 (0.52–0.74) | 0.96 (0.93–0.98) |
Serum ESR | [63] | 2018 | 5 | 0.57 (0.45–0.68) | 0.50 (0.45–0.56) |
Serum ESR | [62] | 2018 | 3 | 0.56 (0.40–0.72) | 0.60 (0.53–0.66) |
Serum CRP | [62] | 2018 | 3 | 0.53 (0.39–0.67) | 0.72 (0.66–0.78) |
Spacer sonication fluid culture | [63] | 2018 | 4 | 0.53 (0.38–0.68) | 0.84 (0.76–0.90) |
Synovial fluid WBC | [63] | 2018 | 5 | 0.52 (0.41–0.63) | 0.66 (0.61–0.71) |
Serum CRP | [63] | 2018 | 8 | 0.45 (0.36–0.55) | 0.73 (0.69–0.77) |
Synovial fluid WBC | [62] | 2018 | 2 | 0.37 (0.19–0.58) | 0.49 (0.41–0.57) |
Tissue culture | [63] | 2018 | 9 | 0.30 (0.23–0.38) | 0.90 (0.87–0.92) |
Frozen section | [63] | 2018 | 4 | 0.29 (0.17–0.44) | 0.93 (0.89–0.96) |
Synovial fluid culture | [63] | 2018 | 5 | 0.18 (0.11–0.28) | 0.97 (0.94–0.99) |
AGS: Antigranulocyte scintigraphy; BCB: Blood culture bottles; CI: Confidence interval; CRP: C-reactive protein; CT: Computed tomography; ELISA: Enzyme-linked immunosorbent assays; ESR: erythrocyte sedimentation; GS: Gram staining; LE: leukocyte esterase; IL: interleukin; PCR: Polymerase chain reaction; PCT: Procalcitonin; PET: Positron emission tomography; PMN%: Polymorphonucleocyte percentage; Sen: Sensitivity; Spe: Specificity; WBC: White blood cell; WCC: white cell count. |
Table 11
Title | Location | Y/N | Topic |
The incidence of and risk factors for deep infection after primary shoulder arthroplasty: an updated systematic review and meta-analysis | Shoulder | Y | Male gender, avascular necrosis, rotator cuff arthropathy, proximal humerus fracture, nonunion of humerus fracture |
Allogeneic Blood Transfusion Is a Significant Risk Factor for Surgical-Site Infection Following Total Hip and Knee Arthroplasty: A Meta-Analysis | Hip, knee | Y | Allogeneic Blood Transfusion |
Association of malnutrition with periprosthetic joint and surgical site infections after total joint arthroplasty: a systematic review and meta-analysis | Hip, knee and other undefined location | Y | Malnutrition |
Current evidence does not support systematic antibiotherapy prior to joint arthroplasty in patients with asymptomatic bacteriuria-a meta analysis | Hip, knee | Y | Asymptomatic bacteriuria |
Do intra-articular steroid injections increase infection rates in subsequent arthroplasty? A systematic review and meta-analysis of comparative studies | Hip, knee | N | Intra-Articular Steroid Injections |
Does previous intra-articular steroid injection increase the risk of joint infection following total hip arthroplasty or total knee arthroplasty? A meta-analysis | Hip, knee | N | Intra-Articular Steroid Injections |
Dose intraarticular steroid injection increase the rate of infection in subsequent arthroplasty: grading the evidence through a meta-analysis | Hip, knee | Y | Intra-Articular Steroid Injections |
Genetic susceptibility to prosthetic joint infection following total joint arthroplasty: A systematic review | NA | Y | C allele and genotype C/C for MBL-550SNP, genotype A/A for MBL-54SNP,G allele for MBL-221SNP |
Genetic susceptibility to prosthetic joint infection following total joint arthroplasty: A systematic review | NA | N | G allele and genotype G/G for MBL-550SNP |
Higher age, female gender, osteoarthritis and blood transfusion protect against periprosthetic joint infection in total hip or knee arthroplasties: a systematic review and meta-analysis | Hip, knee | Y | Male gender, coagulopathy, alcohol abuse, surgical site infection (highest score) and high NNIS system surgical patient index score |
Inadequate Glycemic Control Is Associated With Increased Surgical Site Infection in Total Joint Arthroplasty: A Systematic Review and Meta-Analysis | Hip, knee, shoulder | Y | Inadequate glycemic control |
Incidence and risk factors for surgical site infection following total knee arthroplasty: A systematic review and meta-analysis | Knee | N | steroid use, bilateral surgery, drain usage, bone graft, urinary tract infection, hypertension, and rheumatoid arthritis |
Incidence and risk factors for surgical site infection following total knee arthroplasty: A systematic review and meta-analysis | Knee | Y | Male gender, age, obesity, smoking, American society of anesthesiologists scale (ASA) > 2, operative time, transfusion, diabetes mellitus, obesity |
Intra-articular steroid injections and risk of infection following total hip replacement or total knee replacement: A meta-analysis of cohort studies | Hip, knee | Y | Intra-Articular Steroid Injections |
Is hemoglobin A1c and perioperative hyperglycemia predictive of periprosthetic joint infection following total joint arthroplasty?: A systematic review and meta-analysis | Hip, knee | Y | High HbA1c and perioperative hyperglycemia |
Meta-analysis shows that obesity may be a significant risk factor for prosthetic joint infections | Hip | Y | Obesity |
Patient-related risk factors for periprosthetic joint infection after total joint arthroplasty: A systematic review and meta-analysis | NA | N | Age, high alcohol intake |
Patient-related risk factors for periprosthetic joint infection after total joint arthroplasty: A systematic review and meta-analysis | NA | Y | Histories of diabetes, rheumatoid arthritis, depression, steroid use, and previous joint surgery |
Positive Culture During Reimplantation Increases the Risk of Reinfection in Two-Stage Exchange Arthroplasty Despite Administrating Prolonged Antibiotics: A Retrospective Cohort Study and Meta-Analysis | Hip, knee | Y | Positive culture at reimplantation |
Preoperative Malnutrition Negatively Correlates With Postoperative Wound Complications and Infection After Total Joint Arthroplasty: A Systematic Review and Meta-Analysis | Hip, knee | Y | Preoperative malnutrition |
Risk factors for deep infection after total knee arthroplasty: A meta-analysis | Knee | Y | BMI, diabetes mellitus, hypertension, steroid therapy, rheumatoid arthritis |
Risk factors for deep infection after total knee arthroplasty: A meta-analysis | Knee | N | Gender, osteoarthritis, urinary tract infection, fixation method, American Society of Anesthesiologists, bilateral operation, age, transfusion, antibiotics, bone graft |
Risk factors for periprosthetic joint infection after hip or knee arthroplasty in mainland of China: A meta-analysis | Hip, knee | Y | Diabetic mellitus, long-term use of steroids, long operation time (> 90 minutes), age (> 65 years), and previous history of hip or knee surgery |
Risk factors for periprosthetic joint infection after total joint arthroplasty: A systematic review and meta-analysis | NA | Y | Body mass index, diabetes mellitus; corticosteroid therapy, hypoalbuminemia, history of rheumatoid arthritis, blood transfusion, presence of a wound drain, wound dehiscence, superficial surgical site infection, coagulopathy, malignancy, immunodepression, National Nosocomial Infections Surveillance Score ≥ 2, other nosocomial infection, prolonged operative time, previous surgery |
Risk factors for periprosthetic joint infection after total joint arthroplasty: A systematic review and meta-analysis | NA | N | Cirrhosis, hypothyroidism, urinary tract infection, illicit drug abuse, alcohol abuse, hypercholesterolemia, hypertension, ischemic heart disease, peptic ulcer disease, hemiplegia or paraplegia, dementia, operation performed by a staff surgeon (vs. a trainee) |
Risk of Surgical Site Infection in Patients with Asymptomatic Bacteriuria or Abnormal Urinalysis before Joint Arthroplasty: Systematic Review and Meta-Analysis | Hip, knee | Y | Asymptomatic bacteriuria |
Tobacco Use and Risk of Wound Complications and Periprosthetic Joint Infection: A Systematic Review and Meta-Analysis of Primary Total Joint Arthroplasty Procedures | Hip, knee | Y | Tobacco |
Total joint arthroplasty following intra-articular steroid injection: A literature review | Hip, knee | N | Intra-Articular Steroid Injections |
NA, not available. N: The present study supported the topic not to be a risk factor of PJI; Y: The present study supported the topic not to be a risk factor of PJI. |
Risk factor and prevention
Twenty-three articles described 64 possible risk factors. The location of the risk factor was outlined in 20 studies, with the majority in the hip and knee (Table 10). Nine preventive measures were described in 17 articles, with all focusing on the hip and knee (Tale 11).
Comparative analysis
There were 26 comparative analytic studies from all meta-analyses, with most related to the hip and knee (11), followed by the hip as well as the hip and knee (7 each). There was no statistical difference found in 13 comparison studies (Table 12).
Table 12
Title | Location | Y/N | Topic |
Negative pressure wound therapy in total hip and knee arthroplasty: A meta-analysis | Hip, knee | Y | Negative pressure wound therapy |
A systematic review and meta-analysis of antibiotic-impregnated bone cement use in primary total hip or knee arthroplasty | Hip, knee | Y | Antibiotic-impregnated bone cement |
Antibiotic bone cement's effect on infection rates in primary and revision total knee arthroplasties | Knee | N | Antibiotic-impregnated bone cement |
Antibiotic prophylaxis for wound infections in total joint arthroplasty: A systematic review | Hip, knee, and other undefined location | Y | Antibiotic prophylaxis |
Antibiotic-impregnated bone cement for preventing infection in patients receiving primary total hip and knee arthroplasty: A meta-analysis | Hip, knee | Y | Antibiotic-impregnated bone cement |
Control strategies to prevent total hip replacement-related infections: A systematic review and mixed treatment comparison | Hip | Y | Systemic antibiotic prophylaxis in conjunction with antibiotic-impregnated cement and conventional ventilation |
Efficacy of antibiotic-impregnated cement in total hip replacement: A meta-analysis | Hip | Y | Antibiotic-impregnated bone cement |
Efficacy of prophylactic cefazoline and vancomycin in hip and knee surgery: A systematic review and meta-analysis | Hip, knee | Y | Antibiotic prophylaxis |
Lack of efficacy of prophylactic application of antibiotic-loaded bone cement for prevention of infection in primary total knee arthroplasty: Results of a meta-analysis | Knee | N | Antibiotic-impregnated bone cement |
Perioperative antibiotic prophylaxis in total joint arthroplasty: A systematic review and meta-analysis | Hip, knee | N | Postoperative antibiotic prophylaxis or continuation beyond 24 hours |
Postoperative antibiotic prophylaxis in total hip and knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials | Hip, knee | N | Postoperative antibiotic prophylaxis |
Preoperative bathing with chlorhexidine reduces the incidence of surgical site infections after total knee arthroplasty | Knee | Y | Chlorhexidine |
Preoperative chlorhexidine reduces the incidence of surgical site infections in total knee and hip arthroplasty: A systematic review and meta-analysis | Hip, knee | Y | Chlorhexidine |
Prophylaxis with nasal decolonization in patients submitted to total knee and hip arthroplasty: systematic review and meta-analysis | Hip, knee | Y | Prophylaxis with nasal decolonization |
Systematic review and meta-analysis of randomized controlled trials of antibiotics and antiseptics for preventing infection in people receiving primary total hip and knee prostheses | Hip, knee | N | Antibiotics and/or antiseptics |
The Hidden Cost of Commercial Antibiotic-Loaded Bone Cement: A Systematic Review of Clinical Results and Cost Implications Following Total Knee Arthroplasty | Knee | N | Antibiotic-impregnated bone cement |
N: The present study did not support the topic to be an effective prevention measure for PJI. Y: The present study supported the topic to be an effective prevention measure for PJI. |
Table 13
Comparison studies of PJI
Title | Location | Topic |
Infection and revision rates following primary total knee arthroplasty in patients with rheumatoid arthritis versus osteoarthritis: a metaanalysis | Knee | Rheumatoid arthritis | Q | Osteoarthritis | R |
Simultaneous Versus Staged Bilateral Total Knee Arthroplasty A Meta-Analysis Evaluating Mortality, Peri-Operative Complications and Infection Rates | Knee | Simultaneous bilateral total knee arthroplasty | ™ | Staged bilateral total knee arthroplasty | ™ |
Comparison of infection eradication rate of using articulating spacers containing bio-inert materials versus all-cement articulating spacers in revision of infected TKA: a systematic review and meta-analysis | Knee | Articulating spacers containing bio-inert materials | Q | All-cement articulating spacers | R |
Comparison of the efficacy of static versus articular spacers in two-stage revision surgery for the treatment of infection following total knee arthroplasty: A meta-analysis | Knee | Articulating spacers | ™ | Static spacers | ™ |
Do Culture-Negative Periprosthetic Joint Infections Have a Worse Outcome Than Culture-Positive Periprosthetic Joint Infections? A Systematic Review and Meta-Analysis | Hip, knee | Culture-positive infections | ™ | Culture-negative infections | ™R |
Does cemented or cementless single-stage exchange arthroplasty of chronic periprosthetic hip infections provide similar infection rates to a two-stage? A systematic review | Hip | Single-stage exchange | ™ | Two-stage exchange | ™ |
Single-stage cementless | ™ | Single-stage cemented | ™ |
Does simultaneous bilateral total joint arthroplasty increase deep infection risk compared to staged surgeries? A meta-analysis | Hip, knee | Staged bilateral total joint arthroplasty | Q | Simultaneous bilateral total joint arthroplasty | R |
Dynamic versus static cement spacer in periprosthetic knee infection: A meta-analysis [Dynamischer vs. statischer Zementspacer in der Knietotalendoprotheseninfektion: Eine Metaanalyse] | Knee | Dynamic knee spacer | ™ | Static knee spacer | ™ |
External Fixation vs Intramedullary Nailing for Knee Arthrodesis After Failed Infected Total Knee Arthroplasty: A Systematic Review and Meta-Analysis | Knee | External fixation | ™ | Intramedullary nailing | ™ |
Implant Fixation and Risk of Prosthetic Joint Infection Following Primary Total Hip Replacement: Meta-Analysis of Observational Cohort and Randomised Intervention Studies | Hip | Cemented fixations (plain and antibiotic combined, plain cemented fixations, hybrid fixations, reverse hybrid fixations) | Q | Uncemented fixations | R |
Influence of Fixation Methods on Prosthetic Joint Infection Following Primary Total Knee Replacement: Meta-Analysis of Observational Cohort and Randomised Intervention Studies | Knee | Cemented fixations (plain and antibiotic combined, plain cemented fixations, hybrid fixations, reverse hybrid fixations) | Q | Uncemented fixations | R |
One- And two-stage surgical revision of infected elbow prostheses following total joint replacement: A systematic review | Elbow | Single-stage exchange | ™ | Two-stage exchange | ™ |
One- and two-stage surgical revision of infected shoulder prostheses following arthroplasty surgery: A systematic review and meta-analysis | Shoulder | Single-stage exchange | ™ | Two-stage exchange | ™ |
One- and two-stage surgical revision of peri-prosthetic joint infection of the hip: a pooled individual participant data analysis of 44 cohort studies | Hip | Single-stage exchange | ™ | Two-stage exchange | ™ |
Postoperative Deep Infection After Cemented Versus Cementless Total Hip Arthroplasty: A Meta-Analysis | Hip | Cemented total hip arthroplasty | Q | Cementless total hip arthroplasty | R |
Re-infection outcomes following one- and two-stage surgical revision of infected hip prosthesis: A systematic review and meta-analysis | Single-stage exchange (unselected patients) | ™ | Two-stage exchange (unselected patients) | ™ |
Re-infection outcomes following one- and two-stage surgical revision of infected knee prosthesis: A systematic review and meta-analysis | Knee | Single-stage exchange (unselected patients) | ™ | Two-stage exchange (unselected patients) | ™ |
Re-infection rates and clinical outcomes following arthrodesis with intramedullary nail and external fixator for infected knee prosthesis: A systematic review and meta-analysis. | Knee | Arthrodesis with intramedullary nail | Q | Arthrodesis with external fixator | R |
Use of static or articulating spacers for infection following total knee arthroplasty | Knee | Articulating spacers | ™ | Static spacers | ™ |
The effect of wound dressings on infection following total joint arthroplasty | Hip, knee | Standard, absorbent dressings | Q | Hydrofibre dressings | R |
Human Immunodeficiency Virus and Total Joint Arthroplasty: The Risk for Infection Is Reduced | Hip, knee | HIV and hemophilia | Q | HIV | R |
The impact of neuraxial versus general anesthesia on the incidence of postoperative surgical site infections following knee or hip Arthroplasty a meta-analysis | Hip, knee | General anesthesia | Q | Neuraxial anesthesia | R |
Tobacco Use and Risk of Wound Complications and Periprosthetic Joint Infection: A Systematic Review and Meta-Analysis of Primary Total Joint Arthroplasty Procedures | Hip, knee | Current tobacco users | Q | Former tobacco users | R |
™: The meta-analysis results showed that there was no significant relationship between the two topics. Q: The meta-analysis results demonstrated that the topic had a higher infection/reinfection rate, further compounded results, represented a risk factor, or was not an effective method of preventing infection; R: The meta-analysis results showed that the topic had a lower infection rate/reinfection rate, more optimal result, represented an effective prevention measure against infection, or was not a risk factor. |