High infection rate outcomes in long-bone tumor surgery with endoprosthetic reconstruction in adults: a systematic review

Abstract

Background: Limb salvage surgery (LSS) with endoprosthetic replacement is the most common method of reconstruction following bone tumor resection in the adult population. The risk of a postoperative infection developing is high when compared with conventional arthroplasty and there are no appropriate guidelines for antibiotic prophylaxis.

Questions/purposes: We sought to answer the following questions: (1) What is the overall risk of deep infection and the causative organism in lower-extremity long-bone tumor surgery with endoprosthetic reconstruction? (2) What antibiotic regimens are used with endoprosthetic reconstruction? (3) Is there a correlation between infection and either duration of postoperative antibiotics or sample size?

Methods: We conducted a systematic review of the literature for clinical studies that reported infection rates in adults with primary bony malignancies of the lower extremity treated with surgery and endoprosthetic reconstruction. The search included articles published in English between 1980 and July 2011.

Results: The systematic literature review yielded 48 studies reporting on a total of 4838 patients. The overall pooled weighted infection rate for lower-extremity LSS with endoprosthetic reconstruction was approximately 10% (95% CI, 8%-11%), with the most common causative organism reported to be Gram-positive bacteria in the majority of cases. The pooled weighted infection rate was 13% after short-term postoperative antibiotics and 8% after long-term postoperative antibiotics. There was no correlation between sample size and infection rate.

Conclusions: Infection rates of 10% are high when compared with rates for conventional arthroplasty. Our results suggest that long-term antibiotic prophylaxis decreases the risk of deep infection. However, the data should be interpreted with caution owing to the retrospective nature of the studies.

Fig. 1

A flow diagram illustrates the EMBASE^® and MEDLINE^® literature review.

Fig. 2

A forest plot of deep infection rates using a random-effects model is shown. Overall, the pooled weighted infection rate is 10% (95% CI, 8%–11%).

Fig. 3

A funnel plot of publication bias for included studies appears symmetric, suggesting there is no publication bias.

Fig. 4

A forest plot of deep infection rates using a random-effects model is shown. The pooled weighted infection rate is 13% (95% CI, 9%–17%) following 0 to 24 hours of postoperative antibiotics.

Fig. 5

A forest plot of deep infection rates using a random-effects model is shown. The pooled weighted infection rate is 8% (95% CI, 6%–12%) following greater than 24 hours of postoperative antibiotics.

Fig. 6

A scatter plot of deep infection rates versus sample size is shown. No correlation is evident (correlation coefficient: −0.05).