Letter to the editor regarding “Immunosuppressive status stratifies risk for periprosthetic joint infection and long-term mortality after revision arthroplasty”

Dear Editor, We read with great interest the recent article by Yao et al[1] entitled “Immunosuppressive status stratifies risk for periprosthetic joint infection and long-term mortality after revision arthroplasty.” Based on clinical data from 1218 patients undergoing total joint arthroplasty (TJA), the study found immunosuppression to be a significant predictor of periprosthetic joint infection (PJI) and long-term mortality in TJA recipients. The study conclusions underscore the necessity of preoperative immunosuppression assessment in TJA patients, and we fully endorse the findings. To further advance the clinical application of these results, we offer several recommendations. This article has been published in accordance with the TITAN Guideline conducted a transparency review of AI reporting[2]. Firstly, this study primarily investigates the impact of immunosuppression on PJI and long-term mortality. Consequently, the core research focus lies in how to evaluate immunosuppression. The study primarily builds upon the work of McPherson EJ et al[3] to construct an immunosuppression assessment framework. The development of this framework represents a breakthrough research achievement and holds significant research value. We therefore contend that the assessment process warrants detailed elaboration, including specifying which grade should be assigned when multiple criteria are concurrently met. Furthermore, future studies should adopt concrete scoring systems (such as APACHE II score) to evaluate this framework, thereby enabling quantitative characterization of patients immunosuppression status. Secondly, the study found that infection-related mortality was higher in immunosuppressed patients than in non-immunosuppressed patients. We also believe that immunosuppression may render patients more susceptible to fatal infections. However, given that the total number of infection-related deaths in this study was nine, the sample size is relatively small. We therefore recommend that the authors cite relevant literature in the discussion section addressing the relationship between immunosuppression and infection-related mortality to validate the accuracy of their findings. Furthermore, we suggest that the authors define “long-term mortality” to clarify the specific timeframe beyond which mortality should be considered long-term. Finally, the patients selected for this study all underwent TJA, with surgical sites including knee and hip joints. Surgical techniques for these two sites exhibit certain differences. Furthermore, the immunosuppression assessment employed in the study primarily referenced hip-related PJI status[3]. We therefore recommend that the authors focus their subgroup analysis on comparing the differences in PJI and long-term mortality under different immunosuppression statuses in two surgical approaches. This would facilitate subsequent research into the prognostic impact of immunosuppression on specific surgical approach. In conclusion, We commend the findings of Yao et al[1]. This study employed extensive clinical data to construct an effective predictive model, establishing that immunosuppression assessment constitutes a crucial preoperative evaluation metric for TJA. The immunosuppression assessment methodology developed in this research holds significant implications for reducing the incidence of PJI and long-term mortality. However, we maintain that further quantification and additional research validation are required before this assessment method can be applied in clinical practice.