Risk of Prosthetic Joint Infection Increases Following Early Aseptic Revision Surgery of Total Hip and Knee Arthroplasty

BackgroundIt is important to identify risk factors for periprosthetic joint infection (PJI) following total joint arthroplasty in order to mitigate the substantial social and economic burden. The objective of this study is to evaluate early aseptic revision surgery as a potential risk factor for PJI following total hip (THA) and total knee arthroplasty (TKA).MethodsPatients who underwent primary THA or TKA with early aseptic revision were identified in 2 national insurance databases. Control groups of patients who did not undergo revision were identified and matched 10:1 to study patients. Rates of PJI at 1 and 2 years postoperatively following revision surgery were calculated and compared to controls using a logistic regression analysis.ResultsIn total, 328 Medicare and 222 Humana patients undergoing aseptic revision THA within 1 year of index THA were found to have significantly increased risk of PJI at 1 year (5.49% vs 0.91%, odds ratio [OR] 5.61, P < .001 for Medicare; 7.21% vs 0.68%, OR 11.34, P < .001 for Humana) and 2 years (5.79% vs 1.10%, OR 4.79, P < .001 for Medicare; 8.11% vs 1.04%, OR 9.05, P < .001 for Humana). Similarly for TKA, 190 Medicare and 226 Humana patients who underwent aseptic revision TKA within 1 year were found to have significantly higher rates of PJI at 1 year (6.48% vs 1.16%, OR 7.69, P < .001 for Medicare; 6.19% vs 1.28%, OR 4.89, P < .001 for Humana) and 2 years (8.42% vs 1.58%, OR 6.57, P < .001 for Medicare; 7.08% vs 1.50%, OR 4.50, P < .001 for Humana).ConclusionEarly aseptic revision surgery following THA and TKA is associated with significantly increased risks of subsequent PJI within 2 years.     

10-Year Cumulative Incidence and Indications for Revision Total Knee Arthroplasty Among Patients Who Have Sickle Cell Disease

BackgroundLiterature regarding total knee arthroplasty (TKA) outcomes in sickle cell disease (SCD) is limited. Moreover, 10-year survivorship of SCD implants is unknown. This study aimed to observe 10-year cumulative incidence and indications for revision TKA in patients who did and did not have SCD.MethodsPatients who underwent primary TKA were identified using a large national database. The SCD patients were matched by age, sex, and a comorbidity index to a control cohort in a 1:4 ratio. The 10-year cumulative incidence rates were determined using Kaplan–Meier survival analyses. Multivariable analyses were conducted using Cox proportional hazard modeling. Chi-squared analyses were conducted to compare indications for revision between cohorts. In total, 1,010 SCD patients were identified, 100,000 patients included in the unmatched control, and 4,020 patients included in the matched control.ResultsCompared to the unmatched control cohort, SCD patients exhibited higher 10-year all-cause revision (HR: 1.86; P < .001) with higher proportions of revisions for periprosthetic joint infection (PJI) (P < .001), aseptic loosening (P < .001), and hematoma (P < .001). Compared to the matched control, SCD patients had higher 10-year all-cause revision (Hazard Ratio (HR): 1.39; P = .034) with a higher proportion of revisions for PJI (P = .044), aseptic loosening (P = .003), and hematoma (P = .019).ConclusionIndependent of other comorbidities, SCD patients are more likely to undergo revisions for PJI, aseptic loosening, and hematoma compared to patients who do not have SCD. Due to the high-risk of these complications, perioperative and postoperative surgical optimization should be enforced in SCD patients.     

Manipulation Following Primary Total Knee Arthroplasty is Associated With Increased Rates of Infection and Revision

BackgroundStiffness following total knee arthroplasty (TKA) is a disabling complication and manipulation under anesthesia (MUA) is often performed as an early intervention. Few studies have focused on the revision risk, infection risk, demographics, and clinical outcomes in Medicare patients undergoing MUA following primary TKA.MethodsWe reviewed 142,440 patients who had primary TKA from a national database and identified 3,652 patients (2.6%) who underwent MUA. Patient demographics and comorbid conditions were evaluated to identify risk factors. Incidence of revision and periprosthetic joint infection (PJI) at 1-, 2-, and 5-year time points in a cohort of MUA patients was compared to patients who did not undergo MUA. Multivariate Cox regressions were used for statistical analyses.ResultsThe incidence of MUA was higher in Black versus White individuals (4.1 versus 2.5%, P < .001). Revision risk was significantly greater in the MUA group at 1-, 2-, and 5-year time points with a hazard ratio (HR) of, 3.81, 3.90, and 3.22 respectively, P < .001. One- and 2-year revision risk was significantly greater when MUA occurred at 6 to 12 months post-TKA when compared to <3 months, P < .05. Risk of PJI was significantly greater in the MUA group with a HR of 2.2, 2.2, and 2.1 at 1, 2, and 5 years, respectively P < .001.ConclusionThe incidence of MUA was 2.6%. There was an increased incidence of revision surgery and PJI in patients undergoing MUA. Patients at increased risk for stiffness following TKA should be closely monitored and treated with early intervention to minimize risk of poor outcomes.     

High Mortality After Total Knee Arthroplasty Periprosthetic Joint Infection is Related to Preoperative Morbidity and the Disease Process but Not Treatment

BackgroundPeriprosthetic joint infection (PJI) mortality rate is approximately 20%. The etiology for high mortality remains unknown. The objective of this study was to determine whether mortality was associated with preoperative morbidity (frailty), sequalae of treatment, or the PJI disease process itself.MethodsA multicenter observational study was completed comparing 184 patients treated with septic revision total knee arthroplasty (TKA) to a control group of 38 patients treated with aseptic revision TKA. Primary outcomes included time and the cause of death. Secondary outcomes included preoperative comorbidities and Charlson Comorbidity Index (CCMI) measured preoperatively and at various postoperative timepoints.ResultsThe septic revision TKA cohort experienced earlier mortality compared to the aseptic cohort, with a higher mortality rate at 90 days, 1, 2, and 3 years after index revision surgery (P = .01). There was no significant difference for any single cause of death (P > .05 for each). The mean preoperative CCMI was higher (P = .005) in the septic revision TKA cohort. Both septic and aseptic cohorts experienced a significant increase in CCMI from the preoperative to 3 years postoperative (P < .0001 and P = .002) and time of death (P < .0001 both) timepoints. The septic revision TKA cohort had a higher CCMI 3 years postoperatively (P = .001) and at time of death (P = .046), but not one year postoperatively (P = .119).ConclusionCompared to mortality from aseptic revision surgery, septic revision TKA is associated with earlier mortality, but there is no single specific etiology. As quantified by changes in CCMI, PJI mortality was associated with both frailty and the PJI disease process, but not treatment.     

Surgical Helmet Systems Are Associated With a Lower Rate of Prosthetic Joint Infection After Total Knee Arthroplasty: Combined Results From the New Zealand Joint Registry and Surgical Site Infection Improvement Programme

BackgroundThis study aimed to identify the risk factors, in particular the use of surgical helmet systems (SHSs), for prosthetic joint infection (PJI) after total knee arthroplasty (TKA). Data recorded by the New Zealand Surgical Site Infection Improvement Programme (SSIIP) and the New Zealand Joint Registry (NZJR) were combined and analyzed.MethodsPrimary TKA procedures performed between July 2013 and June 2018 that were recorded by both the SSIIP and NZJR were analyzed. Two primary outcomes were measured: (1) PJI within 90 days as recorded by the SSIIP and (2) revision TKA for deep infection within 6 months as recorded by the NZJR. Univariate and multivariate analyses were performed to identify risk factors for both outcomes with results considered significant at P < .05.ResultsA total of 19,322 primary TKAs were recorded by both databases in which 97 patients had a PJI within 90 days as recorded by the SSIIP (0.50%), and 90 patients had a revision TKA for deep infection within 6 months (0.47%) as recorded by the NZJR. An SHS was associated with a lower rate of PJI (adjusted odds ratio [OR] = 0.50, P = .008) and revision for deep infection (adjusted OR = 0.55, P = .022) than conventional gowning. Male sex (adjusted OR = 2.6, P < .001) and an American Society of Anesthesiologists score >2 were patient risk factors for infection (OR = 2.63, P < .001 for PJI and OR = 1.75, P = .017 for revision for deep infection).ConclusionUsing contemporary data from the SSIIP and NZJR, the use of the SHS was associated with a lower rate of PJI after primary TKA than conventional surgical gowning. Male sex and a higher American Society of Anesthesiologists score continue to be risk factors for infection.     

Aseptic Reoperations Within 1 Year of Primary Total Knee Arthroplasty Markedly Increase the Risk of Later Periprosthetic Joint Infection

BackgroundDespite the high rate of success of primary total knee arthroplasty (TKA), some patients are candidates for early aseptic reoperation. The goal of this study is to evaluate the risk of subsequent periprosthetic joint infection (PJI) in patients treated with an aseptic reoperation within 1 year of primary TKA.MethodsA retrospective review of our total joint registry compared 249 primary TKAs requiring an aseptic reoperation within 1 year following index arthroplasty to a control group of 17,867 TKAs not requiring reoperation within 1 year. Patients were divided into groups based on time from index TKA: (1) 90 days or less (114 TKAs) and (2) 91 to 365 days (135 TKAs). Mean age was 68 years with 57% female. Mean follow-up was 7 years.ResultsAt 2 years postoperatively, patients undergoing an aseptic reoperation within 90 days subsequently had a 9% PJI rate, while patients undergoing an aseptic reoperation between 91 and 365 days subsequently had a 3% PJI rate. The control group had a 0.4% PJI rate. Compared to the control group, patients undergoing an aseptic reoperation within 90 days had an elevated risk of PJI (hazard ratio, 9; P < .0001), as did patients who had a reoperation between 91 and 365 days (hazard ratio, 4; P < .0001).ConclusionAseptic reoperation within 1 year of primary TKA was associated with a notably increased risk of subsequent PJI.     

Utilization of Debridement,Antibiotics, and Implant Retention for Infection After Total Joint Arthroplasty Over a Decade in the United States

BackgroundReported clinical outcomes have varied for debridement, antibiotics, and implant retention (DAIR) and little is known regarding trends in utilization. We sought to evaluate the rate of DAIR utilization for total knee arthroplasty (TKA) and total hip arthroplasty (THA) periprosthetic joint infection (PJI) over a decade and clinical factors associated with these trends.MethodsA retrospective study of primary TKAs and THAs was performed using Medicare data from 2005 to 2014 using the PearlDiver database platform. Current Procedural Technology and International Classification of Diseases Ninth Edition codes identified patients who underwent a surgical revision for PJI, whether revision was a DAIR, as well as associated clinical factors including timing from index arthroplasty.ResultsThe proportion of revision TKAs and THAs performed using DAIR was 27% and 12% across all years, respectively. This proportion varied by year for TKAs and THAs with a linear trend toward increasing relative use of DAIR estimated at 1.4% and 0.9% per year (P < .001; P < .001). DAIR for TKA and THA performed within 90 days increased at a faster rate, 3.4% and 2.1% per year (P < .001; P < .001). Trends over time in TKA DAIRs showed an association with Elixhauser Comorbidity Index (ECI), 0-5 group increasing at 2.0% per year (P = .03) and patients >85 years (P = .04).ConclusionThe proportion of revision arthroplasty cases for PJI managed with DAIR has been increasing over time in the United States, with the most substantial increase seen <90 days from index arthroplasty. Age, gender, and ECI had a minimal association with this trend, except in the TKA population >85 years and in those with a very low ECI score.     

Serum Fibrinogen Test Performs Well for the Diagnosis of Periprosthetic Joint Infection

BackgroundSerum fibrinogen (FIB) is an acute-phase glycoprotein in the infection response that may stop excessive bleeding. The purposes of this study are to determine the value of FIB that can be used to differentiate between periprosthetic joint infection (PJI) and aseptic loosening of the prosthesis, and to determine the clinical significance of FIB for analyzing infection outcomes after first-stage surgery.MethodsThis retrospective study included 90 patients undergoing total knee arthroplasty or total hip arthroplasty revision from January 2015 to August 2019. PJI was confirmed in 53 patients (group A), and the other 37 patients were diagnosed with aseptic loosening of the prosthesis (group B). Only 21 patients in group A documented the results for serum FIB, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) after spacer insertion, so the postoperative serological marker levels of the these patients were also assessed.ResultsThe FIB, CRP, and ESR levels were significantly higher in group A than in group B (P < .001). The area under the receiver operating characteristic curve was highest for FIB at 0.928. Analyses of FIB levels revealed a sensitivity of 79.25% and a specificity of 94.59%. FIB levels were significantly lower in patients with PJI after spacer insertion (P < .001).ConclusionFIB is an adequate test to aid in diagnosing PJI, and it is not inferior to CRP and ESR in distinguishing between PJI and aseptic loosening of the prosthesis. It is an especially useful tool in assessing infection outcomes after first-stage surgery.     

Ceramic Bearings Are Associated With a Significantly Reduced Revision Rate in Primary Hip Arthroplasty: An Analysis From the National Joint Registry for England,Wales, Northern Ireland,and the Isle of Man

BackgroundProsthetic joint infection (PJI) is a devastating complication. Studies have suggested reduction in PJI with the use of ceramic bearings.MethodsAdult patients who underwent total hip arthroplasty (THA) using an uncemented acetabular component with ceramic-on-ceramic (CoC), ceramic-on-polyethylene (CoP), or metal-on-polyethylene (MoP) bearing surfaces between 2002 and 2016 were extracted from the National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man. A competing risk regression model to investigate predictors of each revision outcome was used. Time-to-event was determined by duration of implantation since primary surgery with competing risks being death or revision. The results were adjusted for age, gender, American Association of Anaesthesiologists grade, body mass index, surgical indication, intraoperative complications, and implant data.ResultsIn total, 456,457 THAs (228,786 MoP, 128,403 CoC, and 99,268 CoP) were identified. Multivariable modeling showed that the risk of revision for PJI was significantly lower with CoC (risk ratio 0.748, P < .001) and CoP (risk ratio 0.775, P < .001) compared to MoP. Significant reduction in risk of aseptic and all-cause revision was also seen. The significant protective effect of ceramic bearing was predominantly seen 2 years after implantation. Aseptic revision beyond 2 years reduced by 18.1% and 24.8% for CoC and CoP (P < .001), respectively. All-cause revision rate beyond 2 years reduced by 21.6% for CoC and 27.1% for CoP (P < .001)ConclusionThis study demonstrates an association between the use of ceramic as part of the bearing, with lower rates of revision for all causes, revision for infection, and revision for aseptic causes, supporting ceramic bearings in THA.     

Diagnostic and Invasive Colonoscopy Are Not Risk Factors for Revision Surgery Due to Periprosthetic Joint Infection

BackgroundColonoscopy is routinely performed for colorectal cancer screening in patients who have a preexisting unicompartmental knee arthroplasty (UKA), total knee arthroplasty (TKA), or total hip arthroplasty (THA) prostheses. However, colonoscopy is theorized to provoke transient bacteremia, providing a potential nidus for periprosthetic joint infection. This study aimed to investigate the risk of aseptic and septic revision surgery in patients who underwent diagnostic colonoscopy or invasive colonoscopy within one year following UKA, TKA, or THA.MethodsA retrospective cohort analysis was performed using a national database. Patients were identified using Current Procedural Terminology. In total, 52,891 patients underwent UKA, 1,049,218 underwent TKA, and 526,296 underwent THA. Data were analyzed with univariate analysis preceding multivariable logistic regressions to investigate outcomes of interest at 2 and 3 years from the index procedure.ResultsDiagnostic colonoscopy resulted in no increase in odds of all-cause or septic revision surgery for any prostheses. At both time points, invasive colonoscopy resulted in lower odds of all-cause revision (P < .05) for patients with UKA, decreased odds of septic revision (P < .001) for patients with TKA, and decreased odds of both all-cause and septic revision (P < .05) for patients with THA.ConclusionOur results show that diagnostic colonoscopy was not a significant risk factor for revision following UKA, TKA, or THA. Paradoxically, invasive colonoscopy was protective against revision, even with very minimal use of antibiotic prophylaxis observed. This study addresses the theory that colonoscopy procedures may threaten an existing joint prosthesis via transient bacteremia and shows no increase in revision outcomes following colonoscopy.Level of EvidenceLevel III.     

Risk of Periprosthetic Joint Infection in Patients With Total Knee Arthroplasty Undergoing Colonoscopy: A Nationwide Propensity Score Matched Study

BackgroundThe post-colonoscopy periprosthetic joint infection (PJI) risk in patients with total prosthetic knee joints has limited research. The present study investigated the PJI risk and determined the risk factors for post-colonoscopy PJI in total knee arthroplasty (TKA) recipients. The hypothesis was that colonoscopy is associated with an increased PJI risk in patients with total prosthetic knee joints. This study can potentially help guide the decision making for prophylactic antibiotic use for colonoscopy.MethodsThis nationwide matched cohort study used claims data from the Health Insurance Review and Assessment Service database and enrolled patients who underwent unilateral TKA between 2008 and 2016. The history of diagnostic colonoscopy was investigated at least 1 year postoperatively. The propensity score was matched between colonoscopy and non-colonoscopy cohorts, and the post-colonoscopy PJI risk was compared. The PJI risk following invasive colonoscopic procedures, including biopsy, polypectomy, and mucosal or submucosal resection, was investigated, and the risk factors for post-colonoscopy PJI were determined.ResultsIn total, 45,612 and 211,841 patients were matched in the colonoscopy and control cohorts, respectively. The colonoscopy cohort had greater 9-month and 1-year PJI risks from the index colonoscopy date than the matched controls (9 months: hazard ratio [HR] 1.836, P = .006; 1 year: HR 1.822, P = .031). Invasive colonoscopic procedures did not increase the PJI risk at any time point post-colonoscopy. The only significant risk factor for PJI was post-traumatic arthritis (adjusted HR 4.034, P = .023).ConclusionColonoscopy was associated with an increased PJI risk in TKA recipients, regardless of concomitant invasive colonoscopic procedures.Level of evidenceIII, Prognostic.     

Is Intraoperative Dexamethasone Utilization Associated With Increased Rates of Periprosthetic Joint Infection Following Total Joint Arthroplasty?

BackgroundIntraoperative dexamethasone can reduce postoperative pain and nausea following total knee (TKA) and total hip arthroplasty (THA). To the best of our knowledge, no study to date has been adequately powered to detect the risk of periprosthetic joint infection (PJI) from early dexamethasone exposure. This study aimed to assess PJI rates and complications in patients undergoing primary elective TKA and THA who received intraoperative dexamethasone.MethodsA national database was used to identify adults undergoing primary elective TKA and THA between 2015 and 2020. Patients who received intraoperative dexamethasone and those who did not were identified. The primary endpoint was 90-day risk of infectious complications. Secondary end points included thromboembolic, pulmonary, renal, and wound complications. Multivariate analyses were performed to assess the risk of all endpoints between cohorts. Between 2015 and 2020, 1,322,025 patients underwent primary elective TJA, of which 857,496 (64.1%) underwent TKA and 474,707 (35.9%) underwent TKA.ResultsIn patients who underwent TKA, dexamethasone was associated with lower risk of PJI (adjusted odds ratio: 0.87, 95% CI: 0.82-0.93, P < .001) as well as other secondary endpoints such as pulmonary embolism, deep vein thrombosis, and acute kidney injury. In patients who underwent THA, dexamethasone was associated with a lower risk of PJI (adjusted odds ratio: 0.80, 95% CI: 0.73-0.86, P < .001) as well as other secondary endpoints such as pulmonary embolism, deep vein thrombosis, acute kidney injury, and pneumonia.ConclusionIntraoperative dexamethasone was not associated with increased risk of infectious complications. The data presented here provide evidence in support of intraoperative dexamethasone utilization during primary TKA or THA.     

Does Prednisone Dose Affect Rates of Periprosthetic Joint Infection Following Primary Total Hip and Total Knee Arthroplasty?

BackgroundPrednisone use is associated with higher rates of periprosthetic joint infection (PJI) following total joint arthroplasty (TJA). However, the relationship between prednisone dosage and infection risk is ill-defined. Therefore, this study aimed to assess the relationship between prednisone dosage and rates of PJI following TJA.MethodsA national database was queried for all elective total hip (THA) and total knee arthroplasty (TKA) patients between 2015 and 2020. Patients who received oral prednisone following TJA were matched in a 1:2 ratio based on age and sex to patients who did not. Univariate and multivariate regression analyses were performed to assess the 90-day risk of infectious complications based on prednisone dosage as follows: 0 to 5, 6 to 10, 11 to 20, 21 to 30, and >30 milligrams. Overall, 1,322,043 patients underwent elective TJA (35.9% THA, 64.1% TKA). Of these, 14,585 (1.1%) received prednisone and were matched to 29,170 patients who did not.ResultsAfter controlling for confounders, TKA patients taking prednisone were at increased risk for sepsis (adjusted odds ratio [aOR] 2.76, P < .001), PJI (aOR 2.67, P < .001), and surgical site infection (aOR: 2.56, P = .035). THA patients taking prednisone were at increased risk for sepsis (aOR: 3.21, P < .001) and PJI (aOR: 1.73, P = .001). No dose-dependent relationship between prednisone and infectious complications was identified when TJA was assessed in aggregate.ConclusionPatients receiving prednisone following TJA were at increased risk of PJI and sepsis. A dose-dependent relationship between prednisone and infectious complications was not identified. Arthroplasty surgeons should be aware of these risks and counsel TJA patients who receive prednisone therapy.     

Increased Revisions in Conversion Total Knee Arthroplasty After Periarticular Open Reduction Internal Fixation Compared With Primary Total Knee Arthroplasty: A Matched Cohort Analysis

BackgroundPrior studies on conversion total knee arthroplasty (cTKA) have reported increased technical challenges and risk of complications compared with primary knee arthroplasty. The purpose of this study was to compare two-year postoperative complication/revision rates between patients undergoing cTKA after prior periarticular open reduction and internal fixation (ORIF) and those undergoing primary TKA.MethodsPatients who underwent cTKA after prior periarticular ORIF of the ipsilateral knee were identified in a national all-payer claims database from 2010 to 2018. This ORIF-cTKA cohort was propensity matched to participants undergoing primary TKA based on age, gender, Charlson comorbidity index, and obesity status. Univariate analysis was performed to analyze differences in two-year complication and revision rates.ResultsAfter propensity matching, 823 patients were included in the ORIF-cTKA cohort and 1640 patients in the primary TKA cohort. No differences in demographics or comorbidities existed between cohorts. Relative to the primary TKA cohort, the ORIF-cTKA cohort had significantly higher incidences of all-cause revision (5.47% vs 2.47%, P = .001), periprosthetic joint infection (PJI; 4.74% vs 1.34%, P < .001), and intraoperative or postoperative periprosthetic fracture (1.58% vs 0.55%, P = .01) at two years postoperatively. There was also a nonsignificant trend toward increased rates of aseptic loosening (1.82% vs 0.91%, P = .052) in the ORIF-cTKA.ConclusionRelative to primary TKA, cTKA after periarticular ORIF is associated with significantly increased rates of all-cause revision, PJI, and periprosthetic fracture at two years postoperatively. Surgeons should counsel these patients about the increased risks of these postoperative complications and consider treating them as high risk for PJI in the perioperative period.     

Surgical Treatment of Chronic Periprosthetic Joint Infection: Fate of Spacer Exchanges

BackgroundPatients with periprosthetic joint infection (PJI) undergoing 2-stage exchange arthroplasty may undergo an interim spacer exchange for a variety of reasons including mechanical failure of spacer or persistence of infection. The objective of this study is to understand the risk factors and outcomes of patients who undergo spacer exchange during the course of a planned 2-stage exchange arthroplasty.MethodsOur institutional database was used to identify 533 patients who underwent a 2-stage exchange arthroplasty for PJI, including 90 patients with a spacer exchange, from 2000 to 2017. A retrospective review was performed to extract relevant clinical information. Treatment outcomes included (1) progression to reimplantation and (2) treatment success as defined by a Delphi-based criterion. Both univariate and multivariate Cox regression models were performed to investigate whether spacer exchange was associated with failure. Additionally, a propensity score analysis was performed based on a 1:2 match.ResultsA spacer exchange was required in 16.9%. Patients who underwent spacer exchanges had a higher body mass index (P < .001), rheumatoid arthritis (P = .018), and were more likely to have PJI caused by resistant (0.048) and polymicrobial organisms (P = .007). Patients undergoing a spacer exchange demonstrated lower survivorship and an increased risk of failure in the multivariate and propensity score matched analysis compared to patients who did not require a spacer exchange.DiscussionDespite an additional load of local antibiotics and repeat debridement, patients who underwent a spacer exchange demonstrated poor outcomes, including failure to undergo reimplantation and twice the failure rate. The findings of this study may need to be borne in mind when managing patients who require spacer exchange.     

Are Patient-Reported Drug Allergies Associated With Prosthetic Joint Infections and Functional Outcomes Following Total Hip and Knee Arthroplasty?

BackgroundThe purpose of this study is to determine if the number and types of patient-reported drug allergies are associated with prosthetic joint infection (PJI) and functional outcomes following total joint arthroplasty (TJA).MethodsThis is a retrospective review of all patients who underwent a primary, elective total hip (THA) or knee arthroplasty (TKA) over a 10-year period at a single academic institution. Demographic, clinical information, and number and type of patient-reported drug allergy was collected. Univariate and multivariate logistic regressions were performed to identify risk factors for PJI and risk of PJI based on number of allergies. Univariate analysis was also performed to identify if the number of patient-reported allergies affected functional outcome scores.ResultsOf 31,109 patients analyzed, there were 941 (3%) revisions for infection (491 knees and 450 hips). At least one allergy was reported by 16,435 (52.8%) patients, with a mean of 1.2 ± 1.9. Those who underwent revision for infection had a significantly higher number of reported allergies (1.68 ± 1.9 vs 1.23 ± 1.9, P < .0005, 95% confidence interval ?0.58 to 0.33). On univariate regression the number of allergies independently predicted revision TJA for infection (P < .0001) as did age, gender, body mass index, and smoking status. On multivariate regression for each additional patient-reported allergy, risk of PJI increased by 1.11 times (95% confidence interval 1.07-1.14, P < .0001). Number of patient-reported allergies did not predict 3-month or 1-year functional outcome scores.ConclusionPatients with a higher number of reported allergies may be at increased risk of PJI following TJA.Level of EvidencePrognostic Level II.     

Dilute Betadine Lavage Reduces the Risk of Acute Postoperative Periprosthetic Joint Infection in Aseptic Revision Total Knee and Hip Arthroplasty: A Randomized Controlled Trial

BackgroundThe purpose of this randomized, controlled trial is to determine whether dilute betadine lavage compared to normal saline lavage reduces the rate of acute postoperative periprosthetic joint infection (PJI) in aseptic revision total knee (TKA) and hip arthroplasty (THA).MethodsA total of 478 patients undergoing aseptic revision TKA and THA were randomized to receive a 3-minute dilute betadine lavage (0.35%) or normal saline lavage before surgical wound closure. Fifteen patients were excluded following randomization (3.1%) and six were lost to follow-up (1.3%), leaving 457 patients available for study. Of them, 234 patients (153 knees, 81 hips) received normal saline lavage and 223 (144 knees, 79 hips) received dilute betadine lavage. The primary outcome was PJI within 90 days of surgery with a secondary assessment of 90-day wound complications. A priori power analysis determined that 285 patients per group were needed to detect a reduction in the rate of PJI from 5% to 1% with 80% power and alpha of 0.05.ResultsThere were eight infections in the saline group and 1 in the betadine group (3.4% vs 0.4%, P = .038). There was no difference in wound complications between groups (1.3% vs 0%, P = .248). There were no differences in any baseline demographics or type of revision procedure between groups, suggesting appropriate randomization.ConclusionDilute betadine lavage before surgical wound closure in aseptic revision TKA and THA appears to be a simple, safe, and effective measure to reduce the risk of acute postoperative PJI.Level of EvidenceLevel I.     

A Novel Biomarker to Screen for Malnutrition: Albumin/Fibrinogen Ratio Predicts Septic Failure and Acute Infection in Patients Who Underwent Revision Total Joint Arthroplasty

BackgroundThis study aimed to investigate the efficacy of the albumin/fibrinogen ratio (AFR) in the assessment of malnutrition and to compare its ability to predict early postoperative periprosthetic joint infection (PJI) in patients with aseptic revisions.MethodsFour hundred sixty-six patients undergoing revision total hip or knee arthroplasty between February 2017 and December 2019 were recruited in this retrospective study. We compared the differences in nutritional parameters between patients undergoing revision for septic and aseptic reasons. We used multivariate logistic regression and assessed the association between nutritional parameters and risk of PJI. 207 patients with aseptic revision were then evaluated for the incidence of acute postoperative infection within 90 days. The predictive ability of nutritional markers was assessed by receiver operating characteristic curves.ResultsIn the multivariate logistic regression analysis, low albumin level (adjusted OR 1.56, 95% CI 1.16-2.08, P = .003), low prognostic nutritional index (PNI) (adjusted OR 1.57, 95% CI 1.01-2.43, P < .043), and low AFR (adjusted OR 2.54, 95% CI 1.92-3.36, P < .001) were independently associated with revision surgery for septic reasons. In accordance with the receiver operating characteristic analysis, the AFR exhibited a greater area under the curve value (0.721) than did the prognostic nutritional index and albumin. An elevated AFR (≥11.7) was significantly associated with old age, joint type, high Charlson comorbidity index, high American Society of Anesthesiologist, and diabetes (P < .05).ConclusionOur findings demonstrated AFR may be an effective biomarker to assess nutrition status and predict acute PJIs after revision TJA.     

How to Develop a Fair Revision Arthroplasty Bundle? Using Perioperative Complications and Readmissions to Investigate

BackgroundThe next frontier for value-based health care in total joint arthroplasty is revision surgery. Although the disparity in health care utilization between revision procedures compared with primary total hip and total knee arthroplasty (THA/TKA) procedures is recognized, no agreement regarding the risk adjustment necessary to make revision bundles fair to both payors and providers exists. The purpose of this study is to use the risk of perioperative complications and readmissions of patients undergoing revision THA/TKA to establish the foundations of a fair revision arthroplasty bundle.MethodsWe retrospectively evaluated a consecutive series of 484 aseptic THA/TKA revisions performed at our institution over a 12-month period and compared complications, length of stay, reoperations, and 90-day readmissions to a group of 802 consecutive patients undergoing primary THA/TKA.Results169 (34.9%) patients experienced major complications after revision THA/TKA compared with 176 (21.9%) patients undergoing primary THA/TKA (P < .001), (OR 1.91 CI 1.49-2.45, P < .001). Patients undergoing revision TKA were 3.64 times more likely to require hospitalization greater than 3 days (OR 2.59-5.12, CI 95%, P < .001), whereas patients undergoing revision THA were 4.46 times more likely to require hospitalization greater than 3 days (OR 2.89-6.87, CI 95%, P < .001). Revision patients were 3X more likely to have a 90-day readmission and 4X more likely to have a reoperation.ConclusionFor a revision bundle to be fair and widely adopted, either significant financial incentive must be instituted or the latitude given to exclude outliers from the final reconciliation. This must be adjusted to not disincentivize institutions from providing care for failed hip and knee arthroplasties.