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Research Article | DOI: https://doi.org/10.31579/2693-4779/260
Lv Shun South Road No 9, DalianCity, Liaoning Province, China.
*Corresponding Author: Pak Hyon-U, Lv Shun South Road No 9, Dalian City, Liaoning Province, China.
Citation: Pak Hyon-U, (2025), Reinforcement Learning Techniques for Autonomous Robots in Virtual Environments with Llm-Based Multimodal Data Integration and Virtual Embodiment, Clinical Research and Clinical Trials, 13(1); DOI:10.31579/2693-4779/260
Copyright: © 2025, Pak Hyon-U. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited
Received: 08 March 2025 | Accepted: 28 March 2025 | Published: 07 July 2025
Keywords: bipolar hip hemiarthroplasty; total knee arthroplasty; periprosthetic joint infection; antibiotic susceptibility; failure cause
Background: Failures of bipolarhip hemiarthroplasty (BHA) and total knee arthroplasty (TKA) lead to time- or energy-consuming revision arthroplasty, which is considered as a big challenge to arthroplasty surgeons and patients. Periprosthetic joint infection (PJI) has been identified as one of the most difficult causes to treat. This study aims to examine the potential causes of failure following BHA/TKA and microbiological testing results with antibiotic susceptibility in PJI cases.
Materials and Method: We retrospectively reviewed the causes of failures after BHA in 92 patients and after TKA in 48 patients admitted to Pyongyang University of Medical Sciences Hospital. Then we investigated the microbiological etiology of 53 hip and 26 knee periprosthetic joint infections that were treated with the two- staged revision and analyzed the antibiotic susceptibility of causative bacteria.
Results: The main reasons for failures of primary BHA were aseptic loosening (43/92) and periprosthetic joint infection (34/92), whereas in revision BHA they were infection (8/14) and dislocation of the inner head (3/14). The main reasons for failures of primary TKA were infection (25/48) and aseptic loosening (8/48), whereas in revision TKA they were infection (9/13)and flexion contracture (2/13). Staphylococcus aureus and E. coli were themost common causativemicroorganisms in hip and knee PJI cases. Gram-positive bacteriawere sensitive to ceftriaxone + gentamicin +rifampicin and levofloxacin/cefotaxime was susceptible to gram-negative bacteria.
Conclusion: The present study might be helpful to expand our knowledge about the failure modes of BHA and TKA and to establish the antibiogram for empiric regimens based on the antibiotic susceptibility results.
Hip and knee arthroplasties are the most successful orthopedic procedures that have relieved pain and improved joint function in millions of patients worldwide. Despite the success of modern prosthetic designs and bearing surfaces, a considerable amount of hip and knee prostheses still fail within
15 years [1]. Improved surgical technique and prosthesis design have decreased the incidence of deep infection, dislocation, and fracture,however aseptic loosening, periprosthetic joint infection (PJI) and the clinical endpoint of osteolysis remain as the most frequent complications and in the UK account for 63% of all revision surgery [1].
In literature, potential causes involved in the failure of bipolar hip hemiarthroplasty (BHA) have been reported as the following: aseptic loosening, periprosthetic infection, liner wear, periprosthetic fracture, implant breakage, heterotopic ossification, and unexplained pain [2-6]. The failure causes of total knee arthroplasty (TKA)are categorized into 3 groups:
(1) extra-articular causes of failure including heterotopic ossification; (2) intra-articular mechanical causesincluding poor sizing,component breakage due to wear and poor stress distribution, impaired extensor mechanism, aseptic loosening, periprosthetic osteolysis, and instability; (3) intra-articular
biological causes including infection, metal hypersensitivity, ankylosis, arthrofibrosis, and recurrent hemarthrosis. [7-10]. Osteolysis and resulting prosthesis loosening have been major complications after BHA and TKA, in which wear debris could account for their development [11, 12]. Implant- related failures have been known to be caused by poor tribological characteristics and designs of prostheses [13-15].
Among the aforementioned causes of failure following BHA and TKA, periprosthetic joint infection is considered as one of the most catastrophic and frequent causes [16]. Due to high cost and time-consuming of management in the revisionsetting for failurecases [17-19], there have been increasing researches on its early diagnosis, evaluation and management over the whole world [20-25]. Different microbiological profiles have been reported not only between hip and knee but also between different authors, indicating that bacterial species and antibiotic susceptibility could be various in different arthroplasties and regions[21]. Although proper identification of the offending organism with antibiotic susceptibility obtained from microbiological results is pivotal for guiding long-term antibiotic selection, empiric antibiotic therapyis often utilized while antibiotic susceptibility is
pending or negative [26, 27]. In this setting, many institutions and regions have cumulative antibiograms created by testing antibiotic sensitivities of previously infecting organisms that have been treated in the institution or region [28]. These antibiograms represent the general sensitivity of antibiotics to commonly infecting organisms and can be an invaluable resource when determining what antibiotics to use for empiric therapy in many clinicalscenarios with pendingsensitivities [29]. The microbiological testing results are essential in setting up the database for the management guideline of periprosthetic joint infection [30].
There has been little literature on failure causes and microbiological characteristics of cemented BHA and cemented TKA among the Korean population. Therefore, this study is designed to analyze the failure causes, microbiological testingresults including antibiotic susceptibility and optimal combination of antibiotics through the retrospective survey of BHA and TKA cases.
We retrospectively reviewed failure causesin the medical records of 92 BHA cases and 48 TKA cases who underwent revision in the clinical orthopedic instituteof Pyongyang University of Medical SciencesHospital between 1st February 2015 and 30th April 2021. An Institutional Review/Ethics Board approval was obtainedfor the present study. In BHA failurecases, all BHAs were performed by H. U. Pak and H. J. Li using a kind of bipolar head and two kinds of cemented, double-tapered, polished femoral stems. Knee prosthesis used in primary and revision TKA cases was the total-condylar, PCL-sparing, patellar resurfacing knee prosthesis, and all of them were implanted by two surgeons. All components were implanted using a three- generation cementing technique and all the patients were placed on the same pre-and postoperative management. The demographic data of the BHA and TKA failure cases is summarized in Table 1.
| Hip | Knee | P | ||
| Number of failure cases | 92(100) | 48(100) | ||
| after primary arthroplasty | 78(84.8) | 35(72.9) | 0.09 | |
| after first revision | 14(15.2) | 13(27.1) | ||
| Gender | ||||
| Male | 71(77.2) | 9(18.8) | <0> | |
| Female | 21(22.8) | 39(81.2) | ||
| Age | ||||
| Mean | 59.3 | 57.8 |
0.08 | |
| SD | 7.2 | 8.4 | ||
| Range(min-max) | 51-67 | 50-65 | ||
| Primary diagnosis | ONFH | 28(30.4) | PA | 6(12.5) |
| OA | 6(6.6) | OA | 26(54.2) | |
| Nonunion of FN | 58(63.0) | RA | 16(33.3) | |
 |
BHA: Bipolar Hip Hemiarthroplasty, TKA: Total Knee Arthroplasty, ONFH:Osteonecrosis of the femoral head,OA: Osteoarthritis, FN: Femoral neck,PA: Posttraumatic ankylosis, RA: Rheumatoid arthritis, SD: Standard deviation. The numbers in brackets show percentages.
Major causes of cemented BHA failure used in this analysis were the following: aseptic loosening (AL), periprosthetic joint infection (PJI), liner wear (LW), periprosthetic fracture (PF), breakage of component (stem or bipolar head), heterotopic ossification (HO) and ankylosis [31, 32]. The percentage of failure causeswas evaluated in every parameteramong failure cases and also was assessed according to the time point of revision: early failure with <5>>10 years. Analysis of failure causes in revision cases was identical to primary cases and revision included entire exchange of either bipolar head or liner, partial exchangeof components, and one- or two-stage revision[3].
Major causes of cemented TKA in this study were chosen as the following: periprosthetic joint infection (PJI), aseptic loosening(AL), ankylosis/flexion contracture (FC), instability, impaired extensor mechanism (impaired EM), tibial insert wear (TIW), periprosthetic fracture (PF), dislocation and implant breakage [33]. Like failed BHA cases,the percentage of TKA failurecauses was assessed by time point of revision: early failure with <2>5 years [2,3].
Inclusion criteria for failure analysis
The patients were included when they followed the regular visit protocol after arthroplasty and they were still alive during follow-up.
Exclusion criteriafor failure analysis
We excluded patients missed from follow-up due to the death or revision performed by the other hospital’s surgeons after primary arthroplasty in Pyonyang University of Medical Sciences Hospital.
We performed a retrospective review of 53 hips and 26 knees with PJI that were managedwith two-staged revisionin our institution between 1st March 2019 and 25th May 2024, through the screening of medical records.
Inclusion criteriafor PJI: ICM diagnostic criteria(2018)[21]
When one of the 2 major criteria or minor criteria scoring≧6 was fulfilled, PJI was confirmed. In the case with minor criteria scoring of 3 to 5, it was evaluated as possibly infected, whereas with minor criteria scoring of <3>Exclusion criteriafor PJI
Excluded patientswere the death cases duringthe follow-up periodand HIV (Human Immunodeficiency Virus) cases.
Demographic data of hip and knee PJI caseswas summarized in Table 2.
| Hip | Knee | P |
| Number of infected cases | 53(100) | 26(100) | ||
| after primary arthroplasty | 45(84.9) | 15(57.7) | <0> | |
| after first revision | 8(15.1) | 11(42.3) | ||
| Gender | ||||
| Male | 36(67.9) | 4(15.4) | <0> | |
| Female | 17(32.1) | 22(84.6) | ||
| Age | ||||
| Mean | 56.3 | 57.8 |
0.09 | |
| SD | 6.2 | 7.4 | ||
| Range(min-max) | 50-64 | 49-66 | ||
| Past history of surgery/therapy | 22(41.5) | 4(15.2) |
<0> | |
| Surgery | 15(28.3) | 1(3.8) | ||
| Steroid | 6(11.3) | 2(7.6) | ||
| Immunosuppressant | 1(1.9) | 1(3.8) | ||
| Comorbidity | 13(24.5) | 5(19.0) |
0.59 | |
| Diabetes | 6(11.3) | 2(7.6) | ||
| Hypertension | 5(9.4) | 2(7.6) | ||
| Coronary disease | 1(1.9) | - | ||
| Rheumatism | 1(1.9) | 1(3.8) | ||
| Primary diagnosis | ONFH | 23(43.4) | OA | 18(69.2) |
| OA | 3(5.6) | RA | 3(11.6) | |
| AS | 1(1.9) | AS | 1(3.8) | |
| RA | 1(1.9) | TBA-related contracture | 1(3.8) | |
| Fracture | 25(50.9) | PA | 3(11.6) | |
BHA: Bipolar Hip Hemiarthroplasty, TKA: Total Knee Arthroplasty, ONFH: Osteonecrosis of the femoral head, OA: Osteoarthritis, AS: Ankylosing spondylitis, PA: Posttraumatic ankylosis, RA: Rheumatoid arthritis, TBA: Tuberculous arthritis, SD: Standard deviation. The numbers in parentheses show percentages.
Evaluation
According to every failure cause, failure time (time interval between arthroplasty date and the onset of first sign) was yielded as Mean±SD with 95% confidence interval using SPSS 27.0 in BHA and TKA groups.
We evaluated the causative bacteria, antibiotic susceptibility, culture- negative rate, and the interval between the arthroplasty and the onset of infection signs in every medical record of hip and knee PJI cases. Medical records with culture test results based on non-standard guidelines were excluded to minimize the deviation of analysis. Through microbiological tests, the bacterial specieswere identified and categorized into three groups: gram-negative, -positive, and mixed infection. The case number and percentage of each causative microorganism were recorded in the hip and knee PJI cases. According to three categories, the susceptible case numbers and the percentage were recorded with regard to 12 antibiotics including Penicillin, Streptomycin, Ciprofloxacin, Cefotaxime, Ceftriaxone, Tetracycline, Gentamicin, Ampicillin, Rifampicin, Chloramphenicol, Amikacin, and Levofloxacin in hip and knee PJI cases.
In analyzing demographic data of failed cases and PJI cases, we used chi-test to determine the statistical difference of composition according to number, gender, and age between hip and knee cases. We also evaluated the differencesbetween three infections (Gram-negative: Gram-positive: Mixed infection) between hip and knee cases by chi-test. Composition differences of bacterial species were assessed by chi-test in each infection group.
Hip and knee arthroplasties are the most successful procedures in orthopedic surgery and have remarkably increased the QOL of patients with advanced osteoarthritis. There has been an increasing number of hip and knee arthroplasties due to improved survivorship and prosthetic designs [1, 2]. However, the annual number of revision arthroplasty tends to increase with primary arthroplasty. Revision arthroplasty indicates the failure of primary arthroplasty and therefore, many authors are attempting to find out the causes of revision in every possible side.
Many arthroplasty registries reported the annual number of revisions with every failurecause [1, 2]. It is important to systematically identifythe failure causes of primary arthroplasty and upgrade the implant design as well as surgical technique for prevention of their occurrence. Therefore, we performed the analysis of failure causes in BHA and TKA cases.
The most common cause was asepticloosening (76%) in primary BHA, and it was observed in 7.1% of failed revision cases, which was similar to the previous studies [2, 31, 34-36]. Malchau et al. reported that 75% of failed cases were due to aseptic loosening in the analysis of 14081 failed hip arthroplasty cases, while Melvin et al. suggested that it was the most common cause of 1168 revision arthroplasty cases with failed primary arthroplasty [2, 32]. The second most common causewas periprosthetic joint infection (36.9%) in primary BHA, and it was the most frequent cause (57.2%) in failed revision cases. Previous studies suggested that PJI was observed in 7% of failed arthroplasty cases [2, 33]. Such a difference in infection rate might be produced by the fact that retractable arthroplasty cases must be dealt with in our institution. Several authors insisted that the pathogen was discovered in failed cases with aseptic loosening [34-36]. It might be anotherreason why the infection rate was so high, considering the recently improvedtesting sensitivity of inflammation markersand novel
diagnostic criteria of PJI. In addition, the most common causes were followed by dislocation of the inner head due to liner wear, periprosthetic fracture, and heterotopic ossification, incidence rates of which were below or comparable to the other studies [37-41].Of note, the low incidence rate of HO and stem breakage might be related to the celecoxib-based institutional guideline for HO prevention and the small BMI of patients. According to the time interval between BHA and failure, various failure causes were identified as the most common one in the present study.We found out that early failure cases accounted for 33% of all failure cases in which the most frequent causes were PJI, AL and dislocation. In delayed and late cases AL and PJI and LW were the most common causes.
In TKA, the most common failure causes were PJI, FC, and AL regardless of primary and revision, which were consistent with previous results[8, 15, 42, 43]. PJI accounted for 52.1% of all primary failure cases and 78% of revision failure cases,which occurred 38.9 months afterarthroplasty. FC due to arthrofibrosis was observed in 10.4 and 15.4% of primary and revision failures, which occurred 3.7 months after arthroplasty. AL was observedin
16.6 and 7.7% of primary and revision failures, with the onset time of 52.1 months. The incidence rate of TIW and PF in primary failures were 4.2 and 2.1%, respectively, which were similar to the previous studies [44-46]. Failure with <2years><5>PJI, one of the common failure causes, remains a serious complication in orthopedic surgery, and a remarkably heterogeneous spectrum of microbiological testingresults have been reported across the world. Many institutions and regions have cumulative antibiograms created by testing antibiotic sensitivities of previously infecting organisms that have already been treatedin the institution or region[47]. Culture-negative rates were 26.4 and 19.2%, respectively, in hip and knee PJI cases, which was in the range reported in previous studies[21, 34]. Our patients with culture-negative had a history of antibiotic use and it emphasizes the necessity of a well- established antibiogram based on antibiotic susceptibility database for empiric regimen. The mean onset times of infection were different between hip and knee PJI cases, which were caused by the depth of the surgical wound. Infection rates were 64.2/61.6% and 15.1/19.2%, respectively, for Staphylococcus aureus and E. coli in hip and knee PJI cases. Gram-positive bacilli were detected in 71.7 and 69.2% in hip and knee, whereas 28.3 and 30.8% for gram-negative bacilli. Enterococcus spp and streptococcus spp showed infection ratesof 5.6/1.9% and 3.8/3.8%, respectively, in the hip and knee, while Klebsiella pneumonia and pseudomonas aeruginosa were detected in 11.3/1.9% and 11.6/0% of hip and knee PJI cases. Such microbiological features were similar to previous reports except for a considerably higherinfection rate of Klebsiella pneumonia[48, 49]. It might be due to the characteristics of our institutional nosocomial infection. Mixed infection rates were 9.45% and 11.55%, respectively, in hip and knee PJI cases in which the predominant bacteriawere Staphylococcus aureus and E. coli. There was no difference in antibiotic susceptibility between hip and knee PJI cases. Our susceptibility results suggested that ceftriaxone plus rifampicin could be the most optimal empiric regimen for PJI cases with Staphylococcus aureus. We recommend ceftriaxone plus rifampicin plus gentamicin for PJI cases with Enterococcus spp and Streptococcus spp, based on our antibiotic susceptibility results. Interestingly, our recommendation (amikacin plus levofloxacin) on Klebsiella, E. coli, and Pseudomonas aeruginosa was somewhat different from the other institutional data, which consists of a vancomycin-based regimen [17, 27, 47]. Taking cost- effectiveness into consideration, our recommendation might be reasonable in our study population.
However, this study has certain limitations. First, it is an institutional study with a small sample size. Second, it is a retrospective study of PJI cases without MRSA. Despite such limitations, this study could give not only a better understanding of the failure mode in BHA and TKA but also detailed information about microbiological features and antibiotic susceptibility among KoreanPJI cases. It might contribute to the improvement of implant design, survivorship, and empiric antibiotic regimen.
We are indebted to Hui-Man Kim for his invaluable help with data processing. We thank the teams of the arthroplasty services and microbiology laboratories.
This study provides information about failure causes of BHA and TKA, causative microorganisms, and antibiotic susceptibility which might be helpful to the improvement of the outcome of arthroplasty and the establishment of an empiric antibiotic regimen.
None.
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