Risk Factors for Periprosthetic Joint Infection Following Primary Total Hip Arthroplasty: A Case Control Study

doi:10.1016/j.arth.2013.04.015

The Journal of Arthroplasty

Volume 29, Issue 1, January 2014, Pages 154-156

https://doi.org/10.1016/j.arth.2013.04.015 Get rights and content

Abstract

The purpose of this study was to identify the specific comorbidities and demographic factors that are independently associated with an increased risk of periprosthetic joint infection (PJI) in total hip arthroplasty (THA) patients. A case–control study design was used to compare 88 patients who underwent unilateral primary THA and developed PJI with 499 unilateral primary THA patients who did not develop PJI. The impact of 18 comorbid conditions and other demographic factors on PJI was examined. Depression, obesity, cardiac arrhythmia, and male gender were found to be independently associated with an increased risk of PJI in THA patients. This information is important to consider when counseling patients on the risks associated with elective THA, and for risk-adjusting publicly reported THA outcomes.

Section snippets

Methods

Data from 587 unilateral primary THA patients performed between 1990 and 2011 were compiled from 5 clinical sites (University of California, San Francisco Medical Center; Rush University Medical Center, Chicago, Illinois; Rubin Institute for Advanced Orthopaedics, Sinai Hospital of Baltimore, Maryland; Minneapolis Veterans Administration Medical Center, Minneapolis, Minnesota, OrthoCarolina Charlotte, North Carolina).

Eight-eight patients who developed a PJI were matched to 499 patients who did

Results

Data were examined for 587 total hip arthroplasty (THA) patients including 88 patients diagnosed with PJI. Of the 499 patients without PJI, 269 (54%) were men and 225 (45%) were over the age of 65 years. Of the 88 patients diagnosed with a PJI, 54 (61%) were men and 38 (43%) were over the age of 65 years (Table 1). There was no significant difference in the age, gender, and race distribution, between patients with or without PJI following THA (age P = 0.57, gender P = 0.19, race P = 0.83). Median time

Discussion

The results from our study show that depression, obesity, cardiac arrhythmia, and male gender are independently associated with an increased risk of PJI in THA patients. Our study is the largest retrospective, multi-center study to date conducted using direct chart review to compare THA patients with and without PJI. Though previous studies have found associations with diabetes, rheumatologic disease, and increased patient age with increased risk of PJIs, we did not find these conditions to be

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Cited by (64)

Higher 2-Year Cumulative Incidence of Mental Health Disorders Following Antibiotic Spacer Placement for Chronic Periprosthetic Joint Infection following Total Joint Arthroplasty
2023, Journal of Arthroplasty
The relationship of chronic periprosthetic joint infection (PJI) treatment on the development and relapse of mood disorders remains largely unreported. This study aims to compare the incidence of different mental health disorders following antibiotic spacer placement for chronic PJI when compared to aseptic revisions and primary procedures.
Patients who underwent antibiotic spacer for septic total hip and knee arthroplasty (PJI THA/TKA) were identified in the PearlDiver Database using Current Procedure Terminology (CPT) codes for hip and knee antibiotic spacers. Patients who underwent aseptic revision and primary-THA/TKA were also identified using CPT codes. The incidences of depressive, anxiety, bipolar, psychotic, and stress disorders were identified within 2 years following the index procedures via Kaplan–Meier Analysis.
The risk of depressive (hazard ratio (HR): 1.5; P < .001) and stress (HR: 1.5; P < .001) disorders were significantly higher in those who underwent PJI-THA when compared to aseptic revision, with the added risk of bipolar when compared to primary THA. The risk of depressive (HR: 1.6; P < .001), stress (HR: 1.4; P < .001), bipolar (HR: 1.3; P < .001), and psychotic disorders (HR: 1.5; P = .003) were significantly higher in those who underwent PJI-TKA when compared to aseptic revision, with the added risk of anxiety when compared to primary TKA.
Patients who undergo spacer placement for septic-THA/TKA have a disproportionately higher incidence of mental health disorders within 2 years following surgery when compared those undergoing aseptic revisions and primary procedures. Due to this higher risk, physicians should strongly consider collaborative care with psychiatrists or mental health professionals.
III.
Infection and Mechanical Complications Are Risk Factors for New Diagnosis of a Mental Health Disorder After Total Joint Arthroplasty
2021, Arthroplasty Today
Citation Excerpt :
Pre-existing mental health disorders are a risk factor for the development of prosthetic joint infection (PJI) after total hip and knee arthroplasty (THA and TKA). This correlation has been demonstrated in multiple cohort, database, and meta-analysis studies [2-5], with some authors advocating for routine preoperative screening for depression and other psychiatric conditions. Literature on the consequences of PJI and aseptic failure after total joint arthroplasty (TJA) has been well documented.
Prior studies have demonstrated that depression is an independent risk factor for developing a prosthetic joint infection (PJI) after total joint arthroplasty (TJA). To our knowledge, there is no literature examining whether PJI or aseptic failure increases the risk of developing a new mental health diagnosis.
PearlDiver Patient Database (Colorado Springs, CO) was used to identify 80,826 patients who underwent TJA without a pre-existing diagnosis of depression, anxiety, a stress and/or adjustment disorder, and/or current use of a selective serotonin reuptake inhibitor within the year prior to surgery. The odds of developing a new mental health issue or being prescribed a selective serotonin reuptake inhibitor within 1 year of an uncomplicated TJA was compared to those who developed PJI or mechanical failure within 90 days after TJA as well as to those who subsequently underwent revision surgery within 30 days of either complication using Fisher’s exact test and Baptista-Pike.
A total of 6474 (8%) patients were diagnosed with a new mental health issue after TJA. PJI or mechanical failure led to significantly higher odds of new diagnoses with an odds ratio of 1.67 (95% confidence interval = 1.26, 2.22) and 1.57 (1.24, 2.00), respectively. Undergoing revision surgery for PJI or mechanical failure increased the odds of developing a new mental health diagnosis to 2.10 (1.29, 3.42) and 2.24 (1.36, 3.72), respectively. There was no significant difference comparing those who developed PJI vs those who sustained mechanical complications.
Patients who sustain complications after TJA are at increased odds of receiving a new mental health diagnosis, an effect further amplified if revision surgery is required.
Preoperative Allergy Testing for Patients Reporting Penicillin and Cephalosporin Allergies is Cost-Effective in Preventing Infection after Total Knee and Hip Arthroplasty
2021, Journal of Arthroplasty
Citation Excerpt :
Lastly, our study found that baseline PJI rate does not impact cost-effectiveness. PJI rates may vary considerably based on a number of institution-related and patients-specific factors [18,30–40]. Here we demonstrate that the ARR needed for cost-effectiveness remained constant at 0.810% for TKA and 0.655% for THA for initial infection rates between 1% and 10%.
Routine preoperative allergy testing in patients reporting penicillin and cephalosporin allergies increases the number able to receive cefazolin, which should reduce the risk of infection after total knee and hip arthroplasty (TKA/THA), but it remains unclear whether this practice is cost-effective. Using a break-even analysis, we calculated the cost-effectiveness of routine preoperative allergy testing for infection prevention in total joint arthroplasty patients reporting penicillin and cephalosporin allergies.
The cost of a penicillin allergy evaluation, the cost of revision arthroplasty for prosthetic joint infection (PJI), and baseline rates of PJI in patients receiving a noncefazolin antibiotic in the perioperative period were derived from existing literature. A break-even economic model using these variables was constructed to calculate the absolute risk reduction (ARR) in infection rate needed for preoperative allergy testing to be cost-effective. The number needed to treat (NNT) was calculated from the ARR.
Preoperative allergy testing before TKA and THA in patients reporting penicillin and cephalosporin allergies was cost-effective if the initial infection rate decreased by an ARR of 0.810% (NNT = 123) and 0.655% (NNT = 153) for TKA and THA, respectively. Cost-effectiveness was maintained with varying allergy consultation costs, infection rates, and costs associated with PJI treatment.
Routine preoperative allergy testing and clearance are cost-effective infection prevention strategies among patients reporting penicillin and cephalosporin allergies in the setting of elective joint arthroplasty. Widespread adoption of this practice may considerably reduce the economic and societal burden associated with prosthetic infections.
Intraoperative and Postoperative Infection Prevention
2020, Journal of Arthroplasty
Implementation of strategies for prevention of surgical site infection and periprosthetic joint infection is gaining further attention. We provide an overview of the pertinent evidence-based guidelines for infection prevention from the World Health Organization, the Centers for Disease Control and Prevention, and the second International Consensus Meeting on Musculoskeletal Infection. Future work is needed to ascertain clinical efficacy, optimal combinations, and the cost-effectiveness of certain measures.
Low Body Mass Index and Low Intelligence Quotient Are Infection Risk Factors in Vagus Nerve Stimulation
2019, World Neurosurgery
Risk factors for infection after vagus nerve stimulation (VNS) device implantation represent an important issue but remain unclear. We hypothesized that specific risk factors for infection would be associated with VNS device implantation. This study reviewed patients with epilepsy who underwent VNS device implantation and undertook a statistical analysis of risk factors for surgical site infection (SSI).
We reviewed all medical records for patients who underwent VNS therapy in our facility between August 2011 and May 2018. Age, sex, height, body weight, body mass index (BMI), intelligence quotient (IQ), surgical incision opening time, blood loss, epilepsy classification, activities of daily living, and generator replacement were statistically compared between cases with and without SSI.
We performed 208 VNS device implantation surgeries at our facility during the study period. Among these, 150 patients underwent initial implantation, 56 patients underwent first generator replacement, and 2 patients underwent second replacement. Six patients (2.7%) with initial implantation and 3 patients (5.4%) with first replacement showed SSI. Low BMI was a risk factor for infection at initial implantation (P < 0.0012) using a BMI within 1.78 kg/m² of the cutoff for being underweight (100% sensitivity, 25% specificity). Low IQ (P = 0.0015) was also a risk factor for SSI.
This study identified low BMI and low IQ at initial implantation as risk factors for infection.
Impact of patient comorbidities on surgical site infection within 90 days of primary and revision joint (hip and knee) replacement
2019, American Journal of Infection Control
Citation Excerpt :
When Grammatico et al23 examined the impact after TJR, but not specific procedure type, they found a similar association (OR, 2.47; 95% CI, 1.67-3.63; P < .001) as we did in our study. Conversely, chronic pulmonary disorders,9 deficiency anemia,5,8,34 uncontrolled hypertension,21,31 metastatic cancer,34 peripheral vascular disease,31,34 and renal failure8,21,23 were evaluated in numerous studies and reported as increasing risk factors for SSI after TJR. The authors did not stratify the type of surgery, as we did in our study, but confirmed our findings with regard to these comorbidities in a broader perspective.
The frequency of primary and revision total knee and hip replacements (pTKRs, rTKRs, pTHRs, and rTHRs, respectively) is increasing in the United States due to demographic changes. This study evaluated the impact of preoperative patient and clinical factors on the risk of surgical site infection (SSI) within the 90-day period after primary and revision total joint replacements (TJR).
A retrospective observational cohort study was designed using the IBM MarketScan and Medicare databases, 2009-2015. Thirty-four comorbidities were assessed for all patients, and multivariable logistic regression models were used to evaluate factors associated with higher odds of SSI after adjusting for other patient and clinical preoperative conditions.
The study included a total of 335,134 TKRs and 163,547 THRs. SSI rates were 15.6% and 8.6% after rTKR and rTHR, respectively, compared with 2.1% and 2.1% for pTKR and pTHR, respectively. Comorbidities with the greatest adjusted effect on SSI across all TJRs were acquired immunodeficiency syndrome (odds ratio [OR], 1.58; 95% confidence interval [CI], 1.06-2.34; P = .0232), paralysis (OR, 1.56; 95% CI, 1.26-1.94; P < .0001), coagulopathy (OR, 1.48; 95% CI, 1.36-1.62; P < .0001), metastatic cancer (1.48; 95% CI, 1.24-1.76; P < .0001), and congestive heart failure (OR, 1.39; 95% CI, 1.30-1.49; P < .0001).
SSI occurred most commonly among patients after revision TJR and were related to many patient comorbidities, including diabetes, congestive heart failure, and coagulopathy, which were significantly associated with a higher risk of SSI after TJR.

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: The Conflict of Interest statement associated with this article can be found at http://dx.doi.org/10.1016/j.arth.2013.04.015.

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Risk Factors for Periprosthetic Joint Infection Following Primary Total Hip Arthroplasty: A Case Control Study

Abstract

Section snippets

Methods

Results

Discussion

Lancet

J Arthroplasty

J Arthroplasty

J Arthroplasty

Semin Arthritis Rheum

J Arthroplasty

J Arthroplasty

Twenty-five-year survivorship of two thousand consecutive primary Charnley total hip replacements: factors affecting survivorship of acetabular and femoral components

J Bone Joint Surg Am

The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization

J Bone Joint Surg Am