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Systematic Review and Meta-analysis of Antibiotic Therapy for Bone and Joint Infections

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Meta-analysis in periprosthetic joint infection: a global bibliometric analysis

  • Christina Ojeda-Thies2,
  • Chi Xu3 &
  • Andrej Trampuz1

Journal of Orthopaedic Surgery and Research volume 15, Article number:251 (2020) Cite this article

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Abstract

Groundwork

Periprosthetic articulation infection (PJI) is the about serious complexity of joint replacement surgery. Further comorbidities include bedsore, deep vein thrombosis, reinfection, or even decease. An increasing number of researchers are focusing on this challenging complexity. The aim of the nowadays study was to estimate global PJI enquiry based on bibliometrics from meta-analysis studies.

Methods

A database search was performed in PubMed, Scopus, and Spider web of Science. Relevant studies were assessed using the bibliometric analysis.

Results

A total of 117 articles were included. The most relevant literature on PJI was institute on Scopus. China fabricated the highest contributions to global research, followed by the United states and the UK. The establishment with the most contributions was the Academy of Bristol. The periodical with the highest number of publications was The Journal of Arthroplasty, whereas the Journal of Clinical Medicine had the shortest acceptance fourth dimension. Furthermore, the acme three frequently used databases were Embase, MEDLINE, and Cochrane. The about frequent number of authors in meta-analysis studies was four. About studies focused on the periprosthetic hip and knee. The alpha-defensin diagnostic test, preventive measures on antibiotics apply, and risk factors of intra-articular steroid injections were the almost pop topic in contempo years.

Conclusion

Based on the results of the nowadays study, we found that there was no unmarried database that covered all relevant articles; the optimal method for bibliometric assay is a combination of databases. The virtually pop research topics on PJI focused on alpha-defensin, antibiotic apply, risk factors of intra-articular steroid injections, and the location of prosthetic hip and human knee infection.

Introduction

Periprosthetic joint infection (PJI) is a serious and challenging complication after joint replacement. Due to the lack of consensus on the management of PJI, physicians often face uncertainty. Yet, errors in diagnosis and treatment result in increased healthcare costs, reinfection, or mortality [ane]. Publications play an essential role in guiding and improving disciplinary development. Bibliometric assay is a widely used tool that uses mathematical and statistical methods to assess research trends and growth. Another commonly used tool is meta-analysis, a statistical method of collecting and analyzing results from multiple studies to find or prove the viewpoint or relationship between variables. These ii methods have been practical extensively in orthopedic research [ii,3,four,5,6]; however, in that location were few publications on the use of meta-analysis in bibliometric studies [seven, 8]. To date, no such studies accept been performed on orthopedic research.

The choice of database and the search strategy used are a crucial step in bibliometric studies and meta-analysis. Due to differences in exporting information between unlike databases, most bibliometric studies use a single database for statistics and data analysis [9, 10]. Such differences regarding PJI enquiry remained unknown. Accordingly, the present written report performed a bibliometric assay to decide the following: (one) the nigh suitable database (PubMed, Scopus, Web of Science) for bibliometric analysis [11]; (two) global research characteristics of PJI through the assay of meta-analysis publications; (iii) countries with the most research on the meta-analysis of PJI; (4) the diagnostic method with the highest sensitivity preoperatively, intraoperatively, and before reimplantation based on meta-analysis results; (five) the effective prevention measurement or hazard factor on the meta-assay of PJI; and (vi) conclusions supported past the current meta-assay.

Materials and methods

Data sources and searches

We systematically searched PubMed, Scopus, and Web of Science from inception to December 2019. The search algorithm used was the post-obit medical bailiwick headings (MeSH) or keywords: "arthroplasty", "articulation prosthesis", "joint replacement", "periprosthetic joint", "prosthetic joint", "infection", "infectious", "infected", "meta analysis", and "meta-analysis". As this report was performed using global research, there were no language restrictions.

Data collection

Data were extracted independently by ii reviewers (LC and COT). Discrepancies were adjudicated by the tertiary author (XC). Information on all eligible publications including the championship, author, year of publication, country, institution, journal, keywords, citations, country of the manuscript, linguistic communication, number of studies, touch factor, software, database, search algorithm, and subject data were collected. The number of citations was based on the final result, in the case that no single database covered all citation information. Subsequently, citations were collected from Google scholar. Finally, 2 authors (LC and COT) manually screened and analyzed the publication data in Microsoft Excel (Microsoft, Redmond, Washington, U.s., 2010) and EndNote X7 (Thomson Reuters, New York, NY, Usa, 2013).

Results

Database results

Results from the search strategy demonstrated that the database with the most publications was Scopus (570), followed by Spider web of Scientific discipline (341), and PubMed (243). The greatest number of identical articles was through the combined database of Web of Science and Scopus (Fig. 1). Finally, a total of 117 related articles were included. Of these, the database with most publications on the meta-assay of PJI was Scopus, followed by Web of Science and PubMed. Spider web of Science and PubMed had about missed articles compared with other databases (Figs. 2 and 3).

Fig. 1
figure 1

Number of shared duplicate articles betwixt the 3 databases

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Fig. ii
figure 2

Number of shared PJI research articles of meta-analysis between the three databases (with or without search algorithms)

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Fig. iii
figure 3

Number of shared meta-analysis of PJI research in the combined databases (with or without search algorithms)

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Characteristics of meta-analysis of PJI research

Full general information

Among the 117 meta-assay articles, the earliest publications were from 2007. The greatest number of articles were published in 2018 (24), followed past 2017 and 2019 (21 each). The tendency line indicates an almanac increase in the number of articles (Fig. 4). I hundred and xiv manufactures were in English, and three other manufactures 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 8 (9) as well as 6 and 11 studies (8 each).

Fig. 4
figure 4

Total almanac number of publications and trendline in the meta-analysis of PJI

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Countries

Nineteen countries published meta-analyses on PJI. Of these, China was the most productive country, with all publications stemming from fifteen cities/provinces. The highest number of articles originated from Shanghai, followed past Beijing (Fig. five). The country with the second highest number of publications on PJI was the Usa, followed past the Great britain (Tabular array i).

Fig. 5
figure 5

Map showing the distribution of meta-assay studies on PJI from China

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Table 1 Global distribution of meta-analysis studies on PJI

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Institutions

A total of 76 institutions made contributions to this field. The institution with the greatest number of publications was the Academy of Bristol with 11 papers, followed by Shanghai Sixth People's Hospital (eight). The Rothman Establish and General Hospital of the Chinese People's Liberation Army were third, with each publishing v research articles. 14 institutions published more than than one paper, with fifty% originating from People's republic of china (Table 2).

Table two Top 14 institutions and countries of meta-assay studies on PJI

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Authors

The number of authors of a single article ranged from two to 37. The largest number of collaborating authors was four (27), followed by vi (25) and 5 authors (20; Table 3). The author with most first authorships was Setor K. Kunutsor (10), followed past Xinhua Qu (iii). Ten first authors wrote more one meta-analysis, with 50% published by inquiry institutes in China (Table 4).

Tabular array three Number of collaborating authors in meta-analysis studies on PJI

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Table 4 List of top 10 first authors with number of publications and institution of meta-analysis studies on PJI.

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Journals

Meta-assay studies were published in 54 different journals. The journal with most publications was the Journal of Arthroplasty, with 15 publications. The Periodical of Os and Articulation Surgery ranked second with eight publications, whereas PLoS ONE was tertiary with seven. Nineteen journals had more than one publication (Table five). In 2019, an impact factor was available for 42 journals. The list of top ten journals with the highest affect factors is shown in Table 6.

Table 5 Top 19 journals with number of publications and their corresponding impact factor of meta-assay studies on PJI

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Tabular array 6 List of pinnacle 10 highest impact cistron journals with number of PJI publications in meta-analysis

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From all publications, the date of receipt was bachelor for 89 papers, whereas the appointment of credence for 85, and the engagement of publication for 72. From the date of receipt to acceptance, data was bachelor for 65 manufactures, with the average number of days until acceptance 95.69. Among these 65 articles, eleven journals had more than 2 publications, whereas four journals had an average acceptance time of fewer than 100 days. These are the Periodical of Orthopaedic Surgery and Research (68 days), followed by the Journal of Hospital Infection (82 days), Journal of Clinical Microbiology (83 days), and Periodical of Arthroplasty (86 days).

The average number of days from acceptance to publication was 56.52 (66 papers). From receipt to online publication, the boilerplate number of days was 157.48 (69). In that location were six manufactures accepted in less than xxx days later on submission. The journal with the shortest acceptance fourth dimension was the Journal of Clinical Medicine (16 days), followed past the Journal of Computational and Theoretical Nanoscience (eighteen days), Journal of Clinical Medicine (22 days), Periodical of Arthroplasty (23 days), Periodical of Orthopaedic Surgery and Enquiry as well as Medical Science Monitor (27 days each).

Most cited publications

From Google Scholar, citation information was bachelor for 103 meta-analyses. Forty-i 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 AlBuhairan et al. [12] (264), followed by Parvizi et al. [13] (235; Tabular array 7).

Table seven The 50 virtually cited meta-analysis studies on PJI ranked past commendation.

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Search algorithm and keywords

One hundred and ii meta-analyses were 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), gamble cistron (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 unremarkably used keyword, followed by meta-analysis (29) and full knee arthroplasty (20; Table 8).

Table 8 List of top ten keywords of PJI publications in meta-assay

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Database and software

After combining all databases from 116 articles, there were 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 oftentimes searched (forty), followed by four (22), and five (16). The most combined database group was Cochrane Library + Embase + MEDLINE/PubMed (x), followed by Embase + MEDLINE (6), and Cochrane Library + Embase + MEDLINE + Spider web of Science (5).

Tabular array 9 List of top 10 databases of PJI in meta-analysis

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For the meta-assay, 13 softwares were exported from 106 articles. The nearly commonly used software was STATA (43), followed by REVMAN (25), and Meta-Disc (21).

Subject

Location

Information on the site of prosthetic articulation infection from the included meta-analysis were found in 112 papers. The location with the highest number was the knee (93), closely pursued past the hip (90), shoulder (23), elbow (16), and talocrural joint (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 blastoff-defensin had highest pooled sensitivities in the list of preoperative examinations, pursued by serum IL-half-dozen and bone scintigraphy. From all intraoperative examinations, tissue polymerase concatenation reaction (PCR) was the nearly sensitive method, followed by sonicate fluid into blood culture bottles (BCB) and PCR. Tissue civilisation was the most sensitive method before reimplantation, followed past the per centum of polymorphonucleocytes in synovial fluid (PMN%), and synovial fluid culture (Table ten). The most frequent diagnostic method used was synovial fluid (16), followed by imaging (ten), and periprosthetic tissue (7; Fig. vi).

Tabular array 10 Diagnostic methods used for PJI detection ranked past the sensitivity (preoperative examination, intraoperative methods, and examination before reimplantation)

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Fig. 6
figure 6

Diagnostic methods from different samples used

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Risk factor and prevention

Twenty-3 manufactures described 64 possible hazard factors. The location of the take a chance factor was outlined in 20 studies, with the majority in the hip and knee (Tabular array 11). Nine preventive measures were described in 17 articles, with all focusing on the hip and knee (Tabular array 12).

Table xi Take a chance factors of PJI based on meta-analysis studies

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Table 12 Prevention of PJI based on meta-analysis enquiry

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Comparative assay

At that place were 26 comparative analytic studies from all meta-analyses, with most related to the hip and knee joint (xi), followed by the hip likewise every bit the hip and knee (seven each). There was no statistical difference constitute in 13 comparison studies (Table xiii).

Tabular array 13 Comparing studies of PJI based on meta-assay

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Word

This bibliometric study presents 117 meta-analysis results from three databases (PubMed, Scopus, and Web of Scientific discipline), with the greatest number of relevant papers in Scopus. Furthermore, we compared all databases with or without a search strategy, with PubMed demonstrating the greatest difference among the three databases. When combined with other databases, the missing information from the search strategy could exist supplemented. All results could not exist establish with any of the databases, with or without a search strategy, whereas the combination of PubMed and Scopus enclosed all results without a search strategy. In addition, all available information from the database and search algorithm were collected and combined. Iii to five database groups were found to comprise nigh options for meta-analysis. Embase, MEDLINE, and Cochrane were the top three most normally used databases and were as well mostly used for meta-assay. The bachelor search algorithm exported from 102 publications provided a reference for scholars for a further literature search and study design.

Meta-analysis could offering a useful effective reference to support or refute controversial conclusions from multiple studies. The bibliometric assay showed that the first meta-analysis appeared in 2007, with an increasing tendency in the ensuing years. The growth number likely reflects the development of the subject area with an academic dispute, and the International Consensus Meeting on PJI also indicated the presence of disparate opinions on the management of PJI [54]. The electric current study also presented People's republic of china as having the greatest number of publications in meta-analyses. This may be attributed to the fact that Chinese physicians are placed under immense pressure to publish under the health-organization reforms [55]. Furthermore, the Chinese Association of Orthopaedic Surgeons (CAOS) play close attention to infection afterward articulation arthroplasty. CAOS, which comprises the Chinese prosthetic joint infection society, was established in 2018 and perform PJI enquiry by multiple centers. In Cathay, Beijing and Shanghai had the greatest number of publication of PJI meta-analysis than other cities and is most likely related to a larger number of research establishment concentrated in both regions. Institutions from the Uk had the largest number of publications, with the majority from the University of Bristol. Assay of author information showed that at to the lowest degree ii authors were required for meta-analysis, with the well-nigh frequent number of collaborators was iv. In meta-analysis studies, Setor K. Kunutsor from the University of Bristol had the most publications equally the get-go writer.

In all meta-analysis papers, the Journal of Arthroplasty had the nigh number of relevant papers. With more than 20 citations, PLoS ONE had the greatest number of publications from the most cited publication listing. The Journal of Clinical Medicine had the minimum time from receipt to credence. In addition, the bibliometric method written report showed most articles to be received and accepted on Wednesday.

In the top x nearly popular keywords on PJI meta-analysis, two keywords were related to treatment and diagnosis, with two-stage commutation and alpha-defensin in the top 10. Three keywords were associated with the location of PJI, with the majority on the hip and knee. Identical results were likewise institute in regard to the location, with the top three keywords human knee, hip, and shoulder. The most frequently used software in the meta-analysis were STATA, REVMAN, and Meta-Disc.

Among the diagnosis list in meta-analysis studies, the synovial fluid test was the most frequently used preoperative examination (64%). The most popular diagnostic test applied in contempo years was synovial fluid alpha-defensin and has been incorporated in the 2018 Musculoskeletal Infection Social club (MSIS) definition as one of the minor criteria [56]. When compared with conventional diagnostic methods, such as ESR, CRP, synovial fluid culture, and synovial fluid PMN%, alpha-defensin showed better sensitivity, especially in cases receiving antibiotics earlier joint puncture [57, 58]. In contempo years, synovial fluid alpha-defensin could exist detected using 2 different methods. One assay is the enzyme-linked immunosorbent assay (ELISA), which is performed in a laboratory with results obtained inside 24 h. The 2nd assay is the lateral menstruum device, which rapidly detects infection within 20 min without the need for a laboratory. Appropriately, pooled results supported the college sensitivity of the synovial fluid blastoff-defensin ELISA compared to the lateral catamenia test [16, 20, 23, 27]. The current meta-analysis demonstrated synovial fluid alpha-defensin to have the highest sensitivity in the diagnosis of PJI. As it represents a non-microbiological test, it could be used every bit a reliable reference for intraoperative microbiological diagnosis. Preoperative tests with the everyman sensitivities were synovial fluid gram staining (GS), synovial fluid procalcitonin (Per centum), serum white claret cells (WBCs), and serum PCT, which were all found to have a sensitivity of less than 60%.

Sonicate fluid and periprosthetic tissue were performed nearly intraoperatively, whereas tissue PCR and sonicate fluid BCB were the most sensitive tests in tissue and sonicate fluid, respectively. In 2013, Qu et al. [37] performed the start meta-analysis of PCR in the diagnosis of PJI. The authors found that the tissue PCR had a college sensitivity than synovial fluid PCR and sonicate fluid PCR (95% vs. 84% vs. 81%, respectively). However, tissue PCR showed the lowest specificity compared to synovial and sonicate fluid PCR (81% vs. 89% vs. 96%, respectively). However, this is in dissimilarity to the written report by Huang and colleagues [59], in which tissue PCR had lower sensitivity of 34% and the highest specificity of 100% among the 3 types. Due to express data and that the included studies on tissue PCR were performed between 1999 and 2012 [37], the diagnostic value of tissue PCR remains unclear. The meta-analysis of sonicate fluid BCB presented a sensitivity of 85% and a specificity of 86% [46]. Compared to the conventional culture of sonicate fluid, BCB culture was more sensitive in patients with or without antibiotics and also detected infection within a shorter time than normal medium sonicate fluid civilization [60,61,62,63]. All the same, the drawback of sonicate fluid BCB was the rate of imitation-positives, which was caused by contamination during the inoculation procedure of BCB with sonicate fluid. Therefore, careful handling is required to minimize contamination [64, 65]. Tissue and tissue swab GS were the ii least oftentimes practical intraoperative tests, with a sensitivity of less than 20%.

Diagnosis prior to reimplantation always posed difficulty. In the meta-analysis study by Lee and colleagues [52], tissue civilization demonstrated the highest sensitivity earlier reimplantation, which was based on two included studies (82%). Some other meta-analysis study by Bian and co-workers [53] estimated the diverse tests during the first stage and/or predicted failed reimplantation across the second stage, with tissue culture showing a sensitivity of 30%, which was based on the results of 9 studies. Synovial fluid PMN% demonstrated the highest sensitivity of seventy% in the study past Bian et al., while the specificity was low at 71%. Interestingly, the writer found that the spacer sonication fluid civilization was the nearly accurate method with an expanse under the receiver operating characteristic bend of 0.8089. There was no single examination that accomplished an ideal result, with combined multiple tests to evaluate infection still required [53].

In that location were 40 meta-analyses related to chance cistron and prevention, with the bulk of articles on preventive measures focusing on systemic or location antibiotics use. In regard to the risk factor, almost concerns focused on intra-articular steroid injections, followed by historic period, diabetes mellitus, and rheumatoid arthritis.

The top three comparing studies focused on cemented vs. cementless total articulation arthroplasty, the issue of using different types of spacers, and the outcome of one-stage vs. 2-phase exchange. Cemented fixations were revealed to increase the overall PJI risk in comparing to uncemented fixations [66,67,68]. Interestingly, there was no pregnant difference in the eradication charge per unit between articulating and static spacers in the infected knee replacement [69, 70]. The current meta-analysis supports that the infection command or reinfection rate of one-stage or two-stage substitution did not significantly differ in the hip, genu, elbow, and shoulder [71,72,73,74,75].

There are several limitations to the present study. First, the database of present bibliometric analyses was collected from three databases. Compared with results from without the search strategy, several articles were missed when using the search strategy, specially in PubMed. However, working with multiple databases could reduce this trouble. In addition, we too collected database information from all meta-analyses. Embase, MEDLINE, and Cochrane were the almost widely used databases. However, whether these databases were appropriate for bibliometric analysis remains unclear and requires farther investigation. Second, due to the consign of all meta-analysis data between different databases with disparate formats, a visualized analysis could not be performed. 3rd, although meta-analysis results on diagnosis, adventure factors, prevention, and comparative studies were shown, the heterogeneity and quality of included meta-assay studies were not considered. In the subgroup diagnosis, since there is no gold standard for the diagnosis of PJI, dissimilar civilisation results are obtained from the diverse diagnostics tests. The pooled sensitivity and specificity of meta-analysis are and so further affected by potential false positive or negative results. Fourth, the current study only presented meta-analysis results and did not reverberate the complete perspective of PJI research. The overall trends in this field are required to further ostend.

Determination

The bibliometric analysis that presented global PJI inquiry of meta-analysis studies showed an increasing trend betwixt 2007 and 2019. The Embase database and STATA software were most frequently used for meta-analysis. Nearly studies focused on the periprosthetic hip and human knee. The diagnostic blastoff-defensin test, preventive measures on antibiotics use, and run a risk factors associated with intra-articular steroid injections were the most popular topics in recent years.

Availability of data and materials

Data was extracted from references.

Abbreviations

AGS:

Antigranulocyte scintigraphy

BCB:

Blood culture bottles

CAOS:

Chinese Association of Orthopaedic Surgeons

CI:

Conviction 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

PJI:

Periprosthetic joint infection

PMN%:

Polymorphonucleocytes percentage

Sen:

Sensitivity

Spe:

Specificity

MeSH:

Medical subject area headings

MSIS:

Musculoskeletal Infection Social club

WBCs:

White blood cells

WCC:

White cell count

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Acknowledgements

This work was supported past the PRO-IMPLANT Foundation, Berlin, Germany (https://www.pro-implant.org), a non-profit arrangement supporting research, pedagogy, global networking and care of patients with bone, joint, or implant-associated infection.

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PRO-IMPLANT Foundation

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Affiliations

  1. Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Found of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, D-10117, Berlin, Germany

    Cheng Li & Andrej Trampuz

  2. Hospital Universitario 12 de Octubre, Madrid, Spain

    Christina Ojeda-Thies

  3. Section of Orthopaedic Surgery, General Hospital of People's Liberation Army, Beijing, People'due south Commonwealth of China

    Chi Xu

Contributions

LC searched the database, participated in data assay, and helped draft the manuscript. COT and XC proposed the study design and participated in information analysis. AT edited and reviewed the manuscript. All authors have seen and canonical the concluding version of the paper before submission.

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Correspondence to Andrej Trampuz.

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Li, C., Ojeda-Thies, C., Xu, C. et al. Meta-analysis in periprosthetic articulation infection: a global bibliometric analysis. J Orthop Surg Res 15, 251 (2020). https://doi.org/10.1186/s13018-020-01757-nine

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  • DOI : https://doi.org/10.1186/s13018-020-01757-9

Keywords

  • Bibliometrics
  • Arthroplasty
  • Surgical site infections
  • Periprosthetic joint infection
  • Meta-analysis
  • Inquiry

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