Microporous Polysaccharide Hemospheres in Hip and Knee Revision Arthroplasty for Periprosthetic Joint Infection: A Matched Cohort Study

Technical Summary: Microporous Polysaccharide Hemospheres in Hip and Knee Revision Arthroplasty for Periprosthetic Joint Infection

Problem Statement
Septic revision arthroplasty for periprosthetic joint infection (PJI) presents a complex clinical challenge characterized by extensive soft-tissue dissection, compromised local tissue quality, and a high risk of postoperative wound complications. A critical concern in this setting is postoperative hematoma formation, which can lead to prolonged wound secretion, impaired healing, and the necessity for early reoperation. Such reoperations are particularly detrimental as they may further compromise reconstructive outcomes and increase the risk of infectious complications. While microporous polysaccharide hemospheres (MPH; Arista™) are established topical hemostatic agents in various surgical disciplines, their efficacy and safety specifically within the context of septic hip and knee revision arthroplasty remain under-investigated.

Methodology
The authors conducted a single-center, retrospective matched cohort study at a tertiary academic referral center specializing in musculoskeletal surgery. The study compared two groups of patients undergoing septic revision total hip (THA) or knee (TKA) arthroplasty:

• MPH Cohort: 89 patients treated between May 2021 and July 2022 who received intraoperative local application of 5 grams of MPH (Arista™) to periarticular soft tissues and subcutaneous tissue prior to closure.
• Control Cohort: 102 historical patients treated between January 2013 and April 2018 who underwent the same procedures without MPH application.

Both groups received standardized perioperative management, including tranexamic acid (intravenous and topical) and low-molecular-weight heparin thromboprophylaxis. PJI diagnosis followed European Bone and Joint Infection Society (EBJIS) criteria.

To address potential confounding variables inherent in a non-randomized, historical control design, the authors performed 1:1 propensity-score matching based on sex, age, body mass index (BMI), and American Society of Anesthesiologists (ASA) classification. This resulted in a matched analysis of 82 pairs.

Key Contributions and Outcomes
The study evaluated primary outcomes including repeat revision due to wound healing disorders or hematoma, perioperative hemoglobin decrease, packed red blood cell (PRBC) transfusion rates, and length of hospital stay (LOS). Secondary outcomes included adverse events and early infection relapse.

• Repeat Revision Rates: The most significant finding was a reduction in repeat revisions necessitated by hematoma or wound healing disorders. In the unmatched cohort, this occurred in 6.7% (6/89) of the MPH group versus 18.6% (19/102) of the control group. In the propensity-matched analysis, MPH use was associated with a statistically significant reduction in the odds of repeat revision (Odds Ratio [OR] 0.312; 95% CI 0.090–0.893; p = 0.027).
• Hemostatic and Systemic Parameters: No statistically significant differences were observed between the matched groups regarding mean perioperative hemoglobin decrease (difference of −0.40 g/dl, p = 0.137), PRBC transfusion rates (OR 1.083, p = 1.000), or length of hospital stay (mean difference 1.02 days, p = 0.586).
• Safety Profile: The study reported no intraoperative or postoperative adverse events attributable to MPH. Furthermore, no infection relapses occurred during the inpatient stay following MPH application.

Significance and Claims
The authors posit that the primary clinical value of MPH in septic revision arthroplasty lies in the stabilization of the local wound environment rather than the reduction of systemic blood loss parameters. By mitigating diffuse postoperative bleeding and preventing hematoma formation, MPH may reduce the incidence of wound complications that necessitate early reoperation. This is particularly relevant in septic revisions where tissue quality is already compromised and additional surgical trauma can jeopardize infection control and reconstructive success.

The paper concludes that intraoperative MPH application appears safe and is associated with fewer hematoma-related repeat revisions in this high-risk population. However, the authors maintain a modest stance, acknowledging limitations such as the retrospective nature of the study, the use of a historical control group, and the heterogeneity of septic revision procedures. They emphasize that while the reduction in reoperation rates is clinically meaningful, the findings represent preliminary evidence warranting confirmation through prospective studies in more homogeneous cohorts. The study does not claim MPH alters global blood loss metrics or long-term infection control rates, but rather suggests it serves as a useful adjunct for local hemostasis in complex septic revision surgery.