COVID-19 Collateral Damage: Management of Periprosthetic Joint Infection in Malaysia

Background and objective Periprosthetic joint infection (PJI) is one of the dreaded complications in patients after arthroplasty surgeries, owing to the risk of morbidity and arduous investigations and management associated with it. Nevertheless, as Malaysia is currently battling against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-induced coronavirus disease 2019 (COVID-19) pandemic head-on, the treatment for other non-life-threatening diseases including PJI has taken a backseat. In this study, we present a case series of 11 patients with PJI who were managed surgically at the largest tertiary hospital in Malaysia and we hope to shed some light on the difficulties we have encountered during this trying period. Patients and methods Patients with PJIs who underwent surgical intervention during the ongoing COVID-19 pandemic (March 1, 2020, to June 30, 2021) were reviewed and included in this study. The demographic profile of the patients, presenting complaints, prosthesis topography, biochemical investigative findings, surgical interventions, and short-term outcomes were summarized. Results A total of 11 patients were treated surgically at Hospital Kuala Lumpur for PJI. Among them, five patients are still awaiting their second-stage surgeries despite the completion of their antibiotic regimes, and they are fit for the procedure. Conclusion The COVID-19 pandemic has wreaked havoc on the treatment of patients with PJI. In a setting with scarce resources, surgeons should strongly consider single-stage revision surgeries for the treatment of patients with PJI.


Introduction
As the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-induced coronavirus disease 2019 (COVID-19) pandemic sweeps through the whole world like a wildfire, crumbling most of the healthcare and other crucial sectors along the way, many countries are scrambling to manage and contain this debilitating disease [1][2][3]. As the healthcare system is stretched to the brink of collapse in many countries, the management of COVID-19 patients has taken precedence over other patients [1][2][3]. Elective surgical interventions have been postponed indefinitely, ranging from those for patients with cardiac diseases to patients with surgical illnesses [1][2][3]. While the administrators are justified in focusing on COVID-19 infections and associated mortality rates, the collateral damage of COVID-19 infection in the healthcare sector remains obscured to the public.
In Malaysia, elective surgeries such as joint replacement surgeries have been postponed throughout this pandemic period in many tertiary centers. Nevertheless, complications of joint replacement surgeries, such as periprosthetic joint infection (PJI), are considered to be orthopaedic emergencies, which require urgent surgical intervention. In patients who undergo primary joint replacement, the infection rate in the first two years usually ranges from 0.5 to 2% and revision surgeries normally have higher rates of infection, ranging from 2.5 to 4% [4,5]. PJI is a devastating condition associated with a high rate of mortality, increased risk of morbidity, decreased quality of life, and potentially decreased level of mobility and ambulation 1 2 1 1 [4,5]. Common risk factors for joint replacement surgery are postoperative surgical site infection, previous arthroplasty, advanced age, malnutrition, joint disease, obesity, diabetes mellitus, and remote infection [4][5][6]. Management of PJI can be done via single-or two-stage revision surgery, with each having its pros and cons [7,8]. During the COVID-19 pandemic, surgeons have to improvise and adjust accordingly, depending on the surge of patients infected with the SARS-CoV-2 virus. We present a case series of 11 patients with PJI who were managed surgically during the ongoing pandemic at the largest tertiary hospital in Malaysia and we hope to highlight the difficulties we have encountered during this trying period.

Materials And Methods
All patients who were treated surgically at Hospital Kuala Lumpur from March 1, 2020, to June 30, 2021, for PJI were included in this study. Written consents were obtained from all patients for the publication of this article. They were diagnosed to have PJI based on the Musculoskeletal Infection Society (MSIS) criteria, whereby at least one of the following criteria was present ( Table 1) [8].  All patients were followed up for a minimum of four months after the surgical intervention. The demographic data, investigative results, and types of surgical interventions were obtained from the medical records. Patients who did not fulfill the MSIS criteria or those who were lost to follow-up were excluded from this case series.

Results
A total of 11 patients were enrolled in this study, with ages ranging from 39 to 79 years. Most patients were males (n=7, 63.6%) with Chinese being the most predominant ethnicity (n=6, 54.5%). All patients had preexisting comorbidities, with a majority of them having identifiable risk factors (n=9, 81.8%). Most of the PJIs involved the knee joint (n=7, 63.6%), followed by the hip joint (three total hip replacements and one bipolar hemiarthroplasty). Their presenting complaint was mostly pain or pain with joint swelling with a variable duration ranging from two days to six months.   Table 3 illustrates the patients' investigation results such as serum parameters (white cell count, C-reactive protein level, and erythrocyte sedimentation rate), plain radiographic findings, samples obtained and pathogens isolated, and their subsequent surgical intervention and chemotherapy details.  Five patients (45.4%) underwent wound debridement, implant removal, and antibiotic cement spacer insertion, while another five patients (45.4%) underwent single-stage surgeries. One patient refused implant removal and underwent wound debridement and joint washout twice. Despite the completion of antibiotics with subsequent improvement in septic parameters, their second-stage surgeries were postponed indefinitely due to the COVID-19 pandemic affecting the availability of operation theatres. Among the patients who underwent single-stage surgeries, two were able to ambulate without a walking aid while another three patients were ambulating with a walking aid.

Discussion
PJI remains a significant challenge for arthroplasty surgeons in terms of diagnosis as well as management [9]. A combination of detailed clinical findings, blood and radiological investigations, coupled with synovial or tissue culture are required to properly diagnose a PJI. In the midst of the ongoing COVID-19 pandemic, patients with SARS-CoV-2 infection can present with atypical symptoms masquerading as PJI to further complicate the process of PJI diagnosis [10]. The dilemma we encounter was represented by case 8 in this series, wherein the patient who had undergone a bilateral total knee replacement 11 years ago presented with fever for one day associated with right knee pain and swelling for two weeks. She had a history of right lower limb cellulitis requiring admission and intravenous antibiotics two years ago. Clinically, her right knee was warm and tender with signs of effusion and limited range of movement. Her septic parameters were all elevated, further suggesting a PJI. Nevertheless, she had been in close contact with a patient with the COVID-19 infection, making her a person-under-investigation (PUI). While waiting for her polymerase chain reaction (PCR) result, arthrocentesis from the affected joint yielded Gram-positive pathogens. As she was relatively stable, she was scheduled for surgery after the period of quarantine and a repeat PCR test. She subsequently underwent wound debridement, synovectomy, joint washout, and polyethylene insert exchange.
Besides the admitted patients being at risk of COVID-19 infection, as the COVID-19 pandemic stretches the healthcare resources to the brink of collapse, most of the hospitals place their focus solely on treating patients with life-threatening conditions. All elective surgeries have been postponed to channel the resources, in terms of manpower, bed availability, and medications, toward the management of patients with SARS-CoV-2 infection. This has created an imbroglio, wherein patients who have undergone first-stage surgery and have completed antibiotic chemotherapy have to wait indefinitely for the second-stage surgery as COVID-19 shows no sign of abating. Throughout this pandemic period, there have been five patients in our center who are still awaiting their second-stage surgeries despite the completion of their antibiotic regimens and although their septic parameters are appropriate for second-stage surgery. Patients who have had first-stage revision are initially planned for revision surgeries six weeks after their first-stage surgeries.
In view of the delay in the second-stage surgery, we have decided to stop antibiotics three months after the first-stage surgery despite the fact that the routine practice in our center is to continue antibiotics until the second-stage surgery. A comparative analysis of different issues encountered during the COVID-19 pandemic versus the pre-pandemic period regarding the management of patients with PJI is presented in Table 4.  In this difficult time, the question remains as to how to optimize the recovery of patients with PJI without increasing the burden on the healthcare system. This prompts us to favor single-stage revision surgery instead of the cumbersome two-stage revision surgery. There is now evidence from several comparative case series that complications and reinfection rates after single-stage revisions are similar to those in two-stage revisions [11][12][13][14]. Revision surgery protocols of PJI, designed to address the nature of these infections, were first introduced over three decades ago. The fundamental concepts for the treatment of PJI entail the necessity for implants, foreign bodies, and cement removal in combination with radical debridement. This is coupled with the use of antibiotic-loaded cement. It is based on these principles that today's limb salvage protocols have evolved. Surgeons are now able to take advantage of growing technological innovations and employ aggressive surgical techniques for debridement followed by the restoration of function in patients with PJI. The surge in COVID-19 cases has shortened the operation list and surgery time is significantly reduced. Wise decisions should be made and resources available should be utilized smartly and judiciously to provide the best care to patients. In our center, those who underwent single-stage surgeries have achieved relatively good short-term outcomes.

Limitations of the study
This study was limited by the small number of patients included from a single institution. Nevertheless, this was the first-of-its-kind study to shed some light on an important aspect of the COVID-19 collateral damage.