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

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.     

Rate and Risk Factors for Periprosthetic Joint Infection Among 36,494 Primary Total Hip Arthroplasties

Background

As periprosthetic joint infections (PJIs) can have tremendous health and socioeconomic implications, recognizing patients at risk before surgery is of great importance. Therefore, we sought to determine the rate of and risk factors for deep PJI in patients undergoing primary total hip arthroplasty (THA).

Two-Stage Revision Total Hip Arthroplasty With a Specific Articulating Antibiotic Spacer Design: Reliable Periprosthetic Joint Infection Eradication and Functional Improvement

Background

Two-stage revision utilizing spacers loaded with high-dose antibiotic cement prior to reimplantation remains the gold standard for treatment of periprosthetic joint infections (PJI) in total hip arthroplasty (THA) in North America, but there is a paucity of data on mid-term outcomes. We sought to analyze the survivorship free of infection, clinical outcomes, and complications of a specific articulating spacer utilized during 2-stage revision.

The Utility of Serum d-Dimer for the Diagnosis of Periprosthetic Joint Infection in Revision Total Hip and Knee Arthroplasty

BackgroundThere is scarce and contradicting evidence supporting the use of serum d-dimer for the diagnosis of periprosthetic joint infection in revision total hip (THA) and knee (TKA) arthroplasty. Therefore, the purpose of this study is to test the accuracy of serum d-dimer against the 2013 International Consensus Meeting (ICM) criteria.MethodsA retrospective review was performed on a consecutive series of 172 revision THA/TKA surgeries performed by 3 fellowship-trained surgeons at a single institution (August 2017 to May 2019) and that had d-dimer performed during their preoperative workup. Of this cohort, 111 (42 THAs/69 TKAs) cases had complete 2013 ICM criteria tests and were included in the final analysis. Septic and aseptic revisions were categorized per 2013 ICM criteria (“gold standard”) and compared against serum d-dimer using an established threshold (850 ng/mL). Sensitivity, specificity, likelihood ratios, and positive/negative predictive values were determined. Independent t-tests, Fisher’s exact tests, chi-squared tests, and receiver operating characteristic curve analysis were performed.ResultsThere was no statistically significant difference in baseline demographics between septic and aseptic cases per 2013 ICM criteria. When compared to ICM criteria, d-dimer demonstrated high sensitivity (95.9%) and negative predictive value (90.9%) but low specificity (32.3%), positive predictive value (52.8%), and overall, poor accuracy (61%) to diagnose periprosthetic joint infection. Positive likelihood ratio was 1.42 while negative likelihood ratio was 0.13. The area under the curve (AUC) was 0.742.ConclusionSerum d-dimer has poor accuracy to discriminate between septic and aseptic cases using a described threshold in the setting of revision THA and TKA.     

Multiple Hip Intra-Articular Steroid Injections Increase Risk of Periprosthetic Joint Infection Compared With Single Injections

Background

Patients with hip osteoarthritis often temporize their symptoms with multiple intra-articular steroid hip injections (IASHIs) before undergoing total hip arthroplasty (THA). Although there is recent evidence to suggest that IASHI can lead to an increased risk of future periprosthetic joint infection (PJI), the potential increase in risk of PJI after multiple IASHIs compared with single IASHI remains largely unknown. The aim of the study was to evaluate whether multiple IASHIs are associated with increased risk of PJI compared with single IASHI in THA patients.

Anatomic and Patient Risk Factors for Postoperative Periprosthetic Hip Fractures: A Case-Control Study

BackgroundPeriprosthetic fracture remains a major source of reoperation following total hip arthroplasty (THA). Within 90 days of surgery, fractures may occur spontaneously or with minor injury and are therefore more likely related to patient factors including anatomic variation.MethodsFrom 2008 to 2018, 16,254 primary THAs were performed at our institution; of those, 48 were revised for periprosthetic fracture within 90 days of surgery. A control group of 193 patients undergoing THA for hip osteoarthritis (OA) was randomly selected from the source population. We excluded patients with genetic bone disease and THA performed for hip fracture. We used logistic regression to analyze associations between patient factors (demographics, anatomical factors, comorbidities, surgical technique, and implants) and odds of 90-day periprosthetic fracture.ResultsIncreased age was significantly associated with fracture (P = .002), as was female gender (P = .046). After adjusting for age and gender, absence of contralateral OA was associated with increased odds of fracture relative to patients with contralateral OA (odds ratio [OR] 3.85, 95% confidence interval [CI] 1.60-9.29), as was having a contralateral THA in place (OR 3.70, 95% CI 1.59-8.60). The neck-shaft angle, femoral offset, and the Dorr classification were not associated with increased odds of fracture. Additionally, the distance from the tip of the trochanter to the top of the femoral head was associated with increased odds of fracture per half centimeter (OR 1.48, 95% CI 1.14-1.93).ConclusionRisk of early postoperative periprosthetic fracture following THA is increased with age, female gender, and increasing distance from the greater trochanter to the top of the femoral head; and decreased in the setting of contralateral hip OA. The trochanter-head distance correlation with periprosthetic hip fracture indicates that the preoperative anatomy may influence PPF, particularly regarding how that anatomy is reconstructed.     

In-Hospital Mortality in Patients With Periprosthetic Joint Infection

Background

While periprosthetic joint infection (PJI) has a huge impact on patient function and health, only a few studies have investigated its impact on mortality. The purpose of this large-scale study was to (1) determine the rate and trends of in-hospital mortality for PJI and (2) compare the in-hospital mortality rate of patients with PJI and those undergoing revision arthroplasty for aseptic failure and patients undergoing other nonorthopedic major surgical procedures.

Synovial Fluid Alpha-Defensin Is an Adjunctive Tool in the Equivocal Diagnosis of Periprosthetic Joint Infection

Background

Synovial fluid alpha-defensin has shown to be a reliable diagnostic test for the diagnosis of periprosthetic joint infection (PJI), but its use in equivocal cases has yet to be established. The purpose of this study was to determine the reliability of alpha-defensin testing in patients, where the diagnosis of PJI was unclear.

Periprosthetic Joint Infection in Patients with Inflammatory Joint Disease: a Review of Risk Factors and Current Approaches to Diagnosis and Management

Background

Prevention, early identification, and effective management of periprosthetic joint infection (PJI) in patients with inflammatory joint disease (IJD) present unique challenges for physicians. Discontinuing disease-modifying anti-rheumatoid drugs (DMARDs) perioperatively may reduce immunosuppression and infection risk at the expense of increasing disease flares. Interpreting traditional diagnostic markers of PJI can be difficult due to disease-related inflammation.

Purposes

This review is designed to answer how to (1) manage immunosuppressive/DMARD therapy perioperatively, (2) diagnose PJI in patients with IJD, and (3) treat PJI in this population.

Methods

The PubMed database was searched for relevant articles with subsequent review by independent authors.

Results

While there is evidence to support the use of methotrexate perioperatively in RA patients, it remains unclear whether using anti-tumor necrosis factor medications perioperatively increases the risk of surgical site infections. Serum erythrocyte sedimentation rate and C-reactive protein can be useful for diagnosis of PJI in this population, but only as part of comprehensive workup that ultimately relies upon sampling of joint fluid. Management of PJI depends on several clinical factors including duration of infection and the likelihood of biofilm presence, the infecting organism, sensitivity to antibiotic therapy, and host immune status. The evidence suggests that two-stage revision or resection arthroplasty is more likely to eradicate infection, particularly when MRSA is the pathogen.

Conclusion

Immunosuppression and baseline inflammatory changes in the IJD population can complicate the prevention, diagnosis, and treatment of PJI. Understanding the increase in risk associated with IJD and its treatment is essential for proper management when patients undergo lower extremity arthroplasty.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-013-9338-8) contains supplementary material, which is available to authorized users.     

Less Than 1-Year Quiescent Period After Septic Arthritis of the Hip is Associated With High Risk of Periprosthetic Joint Infection Following Total Hip Arthroplasty

BackgroundApproximately 20,000 patients are diagnosed with septic arthritis annually, with 15% specifically affecting the hip joint. These cases exacerbate arthritic changes, often warranting a total hip arthroplasty (THA). Given their prior history of infection, these patients are predisposed to subsequent periprosthetic joint infections (PJIs). Multiple studies suggest delaying THA after a native septic hip, but no study utilizing a large cohort examined the specific timing to mitigate post-THA PJI risk within a short (<1 year) quiescent period after septic arthritis. We sought to compare patients who were diagnosed with septic hip arthritis at time intervals (0-6, or 6-12 months) prior to an ipsilateral primary THA to a cohort of THA patients who never had a septic hip history. Specifically, we assessed: from 90 days to 2 years (1) revisions due to PJI and (2) associated risk factors for PJI at 2-years.MethodsA national, all-payer database was queried to identify all patients who underwent a primary THA between 2010 and 2021 and patients who had prior ipsilateral septic hip arthritis were characterized using International Classification of Disease and Current Practice Terminology codes (n = 1,052). A randomized sample of patients who never had a history of septic arthritis prior to undergoing THA was used as a nonseptic group comparison (n = 5,000). The incidences of PJI at 90 days through two years were then identified and compared using bivariate chi-square analyses. Risk factors for post-THA PJIs were then analyzed using multivariate regression models.ResultsThe septic arthritis cohorts were more likely to require revisions due to PJIs, as compared to the non-septic group at 90 days, 1 year, and 2 years (all P < .0001). Patients who were diagnosed with septic arthritis between 0 and 6 months prior to THA were at greater PJI risk at both one-year (odds ratio (OR) of 43.1 versus 29.6, P < .0001) and two years (OR of 38.3 versus 22.1, P < .0001) compared to patients who had diagnoses between 6 and 12 months. Diabetes mellitus, obesity, and tobacco use were associated risk factors for PJIs at 2 years in the septic hip cohort in comparison to the cohort without a septic hip history.ConclusionLess than a 1-year quiescent period after septic arthritis is associated with a 38 times increased risk and a 22 times risk for post-THA PJI, at 0 and 6 months and 6 and 12 months, respectively. Though patients who undergo THA greater than 6 months after their septic arthritis treatment have a decreased risk compared to those between 0 and 6 months the risks are still high. Orthopaedic surgeons should be aware of the increased risks of PJIs when considering performing a THA in patients with a history of septic arthritis.     

Concomitant Hip and Knee Periprosthetic Joint Infection in Periprosthetic Fracture: Diagnostic Utility of Serum and Synovial Fluid Markers

BackgroundDiagnosing periprosthetic joint infection (PJI) in patients with a periprosthetic fracture can be challenging due to concerns regarding the reliability of commonly used serum and synovial fluid markers. This study aimed at determining the diagnostic performance of serum and synovial fluid markers for diagnosing PJI in patients with a periprosthetic fracture of a total joint arthroplasty.MethodsA total of 144 consecutive patients were included: (1) 41 patients with concomitant PJI and periprosthetic fracture and (2) 103 patients with periprosthetic fracture alone. Serum markers erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), and synovial markers white blood cell (WBC) count and polymorphonuclear percentage were assessed.ResultsESR demonstrated 87% sensitivity and 48% specificity at the Musculoskeletal Infection Society threshold, area under the curve (AUC) of 0.74, and optimal threshold of 45.5 mm/h (76% sensitivity, 68% specificity). CRP showed 94% sensitivity and 40% specificity, AUC of 0.68 with optimal threshold of 16.7 mg/L (84% sensitivity, 51% specificity). Synovial WBC count demonstrated 87% sensitivity and 78% specificity, AUC of 0.90 with optimal threshold of 4552 cells/μL (86% sensitivity, 85% specificity). Polymorphonuclear percentage showed 79% sensitivity and 63% specificity, AUC of 0.70 with optimal threshold of 79.5% (74% sensitivity, 63% specificity). The AUC of all combined markers was 0.90 with 84% sensitivity and 79% specificity.ConclusionThe diagnostic utility of the serum and synovial markers for diagnosing PJI was lower in the setting of concomitant periprosthetic fracture compared to PJI alone. Using the Musculoskeletal Infection Society thresholds, ESR, CRP, and WBC count showed high sensitivity, yet low specificity, thus higher thresholds and utilizing all serum and synovial markers in combination should be considered.     

Direct Anterior Approach to the Hip Does Not Increase the Risk for Subsequent Periprosthetic Joint Infection

BackgroundRecent studies suggest an increased risk for periprosthetic joint infection (PJI) utilizing the direct anterior (DA) approach to the hip. The purpose of this study was to investigate whether such an increased risk does indeed exist on a large cohort of patients, operated by experienced surgeons and taking into account various confounders.MethodsThis was a single institutional study, including all patients who underwent primary total hip arthroplasty during the last decade, who were operated on by four high-volume arthroplasty surgeons utilizing a single surgical approach. Three of them utilized the direct lateral (DL) approach while one of them used the DA approach throughout the entire study. Patient characteristics, demographics, and comorbidities were assessed as well as operative and perioperative factors and their association with PJI. Association between surgical approach and PJI was evaluated in a univariate followed by a multivariate regression analysis.ResultsA total of 10,201 patients were included in the study. Of those, 4390 (43.0%) underwent total hip arthroplasty through the DA approach and 5811 (57.0%) through the DL approach. PJI rates were 0.9% (38/4390) in the DA group compared with 1.3% (73/5811) in the DL group (P = .068). Results from a regression analysis showed no significant association between PJI and DA approach (adjusted odds ratio 0.760, 95% confidence interval 0.428-1.348, P = .348). The risk remained nonsignificant in patients with higher body mass index. There were also no significant differences in the infecting organisms between the two groups.ConclusionThe DA approach to the hip does not increase the risk for subsequent PJI.     

The 2018 International Consensus Meeting Minor Criteria for Chronic Hip and Knee Periprosthetic Joint Infection: Validation From a Single Center

BackgroundRecently, a revised definition of the minor criteria scoring system for diagnosing periprosthetic joint infection (PJI) was developed by the second International Consensus Meeting on musculoskeletal infection. The new system combines preoperative and intraoperative findings, reportedly achieving high sensitivity and specificity. We aimed to validate the modified scoring system at a high-volume center.MethodsWe retrospectively reviewed patients who underwent a revision total hip or knee arthroplasty at our institution from May 2015 to August 2018. Serum C-reactive protein, synovial white blood cell count and polymorphonuclear percentage, leukocyte esterase test, alpha-defensin, microbiological and histologic results, and documented existence of sinus tract and intraoperative purulence were available for all patients. Cases with at least 1 major criterion were considered as infected. Using the new minor criteria, a score of ≥6 reflects PJI, while a score <3 can be considered as noninfected. Sensitivity, specificity, mean accuracy (ACC), positive predictive value (PPV), and negative predictive value (NPV) were analyzed.ResultsA total of 345 cases were included. A cutoff score of ≥6 points had the following diagnostic performance: area under the curve (AUC) = 0.90; ACC = 0.88; sensitivity = 0.96; specificity = 0.84; PPV = 0.70; NPV = 0.98. Diagnostic performance was better for the hip (AUC = 0.92; ACC = 0.90; sensitivity = 0.96; specificity = 0.86; PPV = 0.81; NPV = 0.98) than the knee (AUC = 0.89; ACC = 0.85; sensitivity = 0.95; specificity = 0.83; PPV = 0.59; NPV = 0.98).ConclusionThe modified scoring system proposed by the 2018 International Consensus Meeting in diagnosing PJI showed high sensitivity and a good performance, especially as rule-out diagnostic criteria. The cutoff level seems to be different between the hip and knee. Further validation studies considering the acknowledged limitations are recommended.     

Patient-Related Risk Factors for Periprosthetic Ankle Joint Infection: An Analysis of 6977 Total Ankle Arthroplasties

Periprosthetic joint infection (PJI) after total ankle arthroplasty (TAA) is a devastating complication that often results in explantation to resolve the infection. The purpose of the present investigation was to determine the patient-related risk factors for PJI after TAA. A national insurance database was queried for patients undergoing TAA using the Current Procedural Terminology and International Classification of Diseases, ninth revision, procedure codes from 2005 to 2012. Patients undergoing TAA with concomitant fusion procedures or more complex forefoot procedures were excluded. PJI within 6 months was then assessed using the International Classification of Diseases, ninth revision, codes for diagnosis or treatment of postoperative PJI. Multivariate binomial logistic regression analysis was performed to evaluate the patient-related risk factors for PJI. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for each risk factor, with p?<?.05 considered statistically significant. A total of 6977 patients were included in the present study. Of these 6977 patients, 294 (4%) had a diagnosis of, or had undergone a procedure for, PJI. The independent risk factors for PJI included age <65 years (OR 1.44; p?=?.036), body mass index <19?kg/m² (OR 3.35; p?=?.013), body mass index >30?kg/m² (OR 1.49; p?=?.034), tobacco use (OR 1.59; p?=?.002), diabetes mellitus (OR 1.36; p?=?.017), inflammatory arthritis (OR 2.38; p?<?.0001), peripheral vascular disease (OR 1.64; p?<?.0001), chronic lung disease (OR 1.37; p?=?.022), and hypothyroidism (OR 1.32; p?=?.022). The independent patient-related risk factors identified in the present study should help guide physicians and patients considering elective TAA and develop risk stratification algorithms that could decrease the risk of deep, postoperative infection.     

Mortality During Total Knee Periprosthetic Joint Infection

Background

Periprosthetic joint infections (PJIs) are fraught with multiple complications including poor patient-reported outcomes, disability, reinfection, disarticulation, and even death. We sought to perform a systematic review asking the question: (1) What is the mortality rate of a PJI of the knee undergoing 2-stage revision for infection? (2) Has this rate improved over time? (3) How does this compare to a normal cohort of individuals?

Two-Stage Exchange Arthroplasty for Periprosthetic Joint Infection Following Total Hip or Knee Arthroplasty Is Associated With High Attrition Rate and Mortality

BackgroundWe sought to determine the ultimate fate of patients undergoing resection arthroplasty as a first stage in the process of 2-stage exchange and evaluate risk factors for modes of failure.MethodsA retrospective case study was performed including all patients with minimum 2-year follow-up who underwent first-stage resection of a hip or knee periprosthetic joint infection from 2008 to 2015. Patient demographics, laboratory, and health status variables were collected. The primary outcome analyzed was defined as failure to achieve an infection-free 2-stage revision. Univariate pairwise comparison followed by multivariate regression analysis was used to determine risk factors for failure outcomes.ResultsEighty-nine patients underwent resection arthroplasty in a planned 2-stage exchange protocol (27 hips, 62 knees). Mean age was 64 years (range, 43-84), 56.2% were males, and mean follow-up was 56.3 months. Also, 68.5% (61/89) of patients underwent second-stage revision. Of the 61 patients who complete a 2-stage protocol, 14.8% (9/61) of patients failed with diagnosis of repeat or recurrent infection. Mortality rate was 23.6%. Multivariate analysis identified risk factors for failure to achieve an infection-free 2-stage revision as polymicrobial infection (P < .004; adjusted odds ratio [AOR], 7.8; 95% confidence interval [CI], 2.1-29.0), McPherson extremity grade 3 (P < .024; AOR, 4.1; 95% CI, 1.2-14.3), and history of prior resection (P < .013; AOR, 4.7; 95% CI, 1.4-16.4).ConclusionPatients undergoing resection arthroplasty for periprosthetic joint infection are at high risk of death (24%) and failure to complete the 2-stage protocol (32%). Those who complete the 2-stage protocol have a 15% rate of reinfection at 4.5-year follow-up.     

Visceral Fat as a Risk Factor for Periprosthetic Joint Infection After Total Hip and Knee Arthroplasty

BackgroundVisceral obesity, a strong indicator of chronic inflammation and impaired metabolic health, has been shown to be associated with poor postoperative outcomes and complications. This study aimed to evaluate the relationship between visceral fat area (VFA) and periprosthetic joint infection (PJI) in total joint arthroplasty (TJA) patients.MethodsA retrospective study of 484 patients who had undergone a total hip or knee arthroplasty was performed. All patients had a computed tomography scan of the abdomen/pelvis within two years of their TJA. Body composition data (ie, VFA, subcutaneous fat area, and skeletal muscle area) were calculated at the Lumbar-3 vertebral level via two fully automated and externally validated machine learning algorithms. A multivariable logistic model was created to determine the relationship between VFA and PJI, while accounting for other PJI risk factors. Of the 484 patients, 31 (6.4%) had a PJI complication.ResultsThe rate of PJI among patients with VFA in the top quartile (> 264.1 cm²) versus bottom quartile (< 82.6 cm²) was 5.6% versus 10.6% and 18.8% versus 2.7% in the total hip arthroplasty and total knee arthroplasty cohorts, respectively. In the multivariate model, total knee arthroplasty patients with a VFA in the top quartile had a 30.5 times greater risk of PJI than those in the bottom quartile of VFA (P = .0154).ConclusionVFA may have a strong association with PJI in TJA patients. Using a standardized imaging modality like computed tomography scans to calculate VFA can be a valuable tool for surgeons when assessing risk of PJI.     

Treatment for Chronic Hepatitis C Prior to Total Hip Arthroplasty Significantly Reduces Periprosthetic Joint Infection

Background

Patients with chronic hepatitis C (HCV) have had extremely high complication rates after total hip arthroplasty (THA). We sought to compare perioperative complication rates between untreated and treated HCV in THA patients and to compare these rates between patients treated with 2 different therapies (interferon vs direct antiviral agents).

Hospital Costs for Unsuccessful Two-Stage Revisions for Periprosthetic Joint Infection

BackgroundAlthough 2-stage exchange arthroplasty is the preferred surgical treatment for periprosthetic joint infection (PJI) in the United States, little is known about the risk of complications between stages, mortality, and the economic burden of unsuccessful 2-stage procedures.MethodsThe 2015-2019 Medicare 100% inpatient sample was used to identify 2-stage PJI revisions in total hip and knee arthroplasty patients using procedural codes. We used the Fine and Gray sub-distribution adaptation of the conventional Kaplan-Meier method to estimate the probability of completing the second stage of the 2-stage PJI infection treatment, accounting for death as a competing risk. Hospital costs were estimated from the hospital charges using “cost-to-charge” ratios from Centers for Medicare and Medicaid Services.ResultsA total of 5094 total hip arthroplasty and 13,062 total knee arthroplasty patients had an index revision for PJI during the study period. In the first 12 months following the first-stage explantation, the likelihood of completing a second-stage PJI revision was 43.1% (95% confidence interval [CI] 41.7-44.5) for hips and 47.9% (95% CI 47.0-48.8) for knees. Following explantation, 1-year patient survival rates for hip and knee patients were 87.4% (95% CI 85.8-88.9) and 91.4% (95% CI 90.6-92.2), respectively. The median additional cost for hospitalizations between stages was $23,582 and $20,965 per patient for hips and knees, respectively. Hospital volume, Northeast or Midwest region, and younger age were associated with reduced PJI costs (P < .05).ConclusionAlthough viewed as the most preferred, the 2-stage revision strategy for PJI had less than a 50% chance of successful completion within the first year, and was associated with high mortality rates and substantial costs for treatment failure.     

Management of Periprosthetic Joint Infection: The More We Learn,the Less We Know

BackgroundDespite the tremendous and long-standing success of total hip arthroplasty and total knee arthroplasty as treatments for end-stage arthritis, periprosthetic joint infection (PJI) remains a rare but feared complication of these procedures.MethodsThis review highlights some of the difficulties inherent to studying PJI. These include the difficulty in powering studies to capture this relatively uncommon complication, as well as the heterogeneity in clinical presentation and manifestations associated with the diagnosis and treatment of PJI.ConclusionWe suggest an algorithm for moving forward with new research in an attempt to answer the challenging questions facing the arthroplasty community regarding PJI.