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).

Increased Postoperative Glucose Variability Is Associated With Adverse Outcome Following Two-Stage Exchange Arthroplasty for Periprosthetic Joint Infection

BackgroundGlucose variability in the postoperative period has been associated with increased rates of periprosthetic joint infection (PJI) following primary arthroplasty. It is unknown how postoperative glucose control affects outcome of surgical treatment of PJI patients. We hypothesized that postoperative glucose variability adversely affects the outcome of 2-stage exchange arthroplasty.MethodsWe retrospectively reviewed records of 665 patients with PJI of the knee and hip who underwent 2-stage exchange arthroplasty from 2000 to 2017. Of them, 341 PJIs with a minimum follow-up of 1 year, and either a minimum of 2 glucose values per day or greater than 3 overall during the reimplantation were included. Glucose variability was assessed by calculating the coefficient of variation. Adverse outcomes included treatment failure according to the Delphi consensuses criteria, reinfection, reoperation, and mortality. A subgroup analysis was performed based on patients with or without diabetes.ResultsGlucose variability following reimplantation was associated with higher treatment failure, reinfection, and reoperation. Adjusted analysis indicated that for every standard deviation (15%) increase in the coefficient of variation, the risks of treatment failure, reinfection, and reoperation increased by 27%, 31%, and 26%. Although stratifying patients with (n = 81) or without diabetes (n = 260), these associations remained robust in nondiabetic patients, but not in diabetic patients.ConclusionHigher glucose variability is associated with increased risks of treatment failure, reinfection, and reoperation after 2-stage exchange arthroplasty in PJI patients. Compared to diabetic patients, nondiabetic patients have a higher association between glucose variability and poor outcomes. Reducing adverse outcomes may be achieved with close monitoring and strict postoperative glucose control.     

Hepatitis C Antiviral Treatment Decreases All-Cause Complications After Total Joint Arthroplasty Regardless of the Presence of Fibrosis

BackgroundPatients with hepatitis C virus (HCV) have an increased risk of complications after total joint arthroplasty (TJA). There is a limited but growing body of evidence on the benefit of preoperative antiviral treatment to reduce complications after TJA. What has not been well established is the effect of preoperative antiviral treatment among those with advanced disease as indicated by hepatic fibrosis.MethodsIn total, 270 patients at 2 urban medical centers were reviewed for patient demographics, comorbidities, HCV treatment, hepatic fibrosis status, surgical information, and postoperative complications. Patients were divided into 2 groups based on their antiviral treatment status prior to TJA: Treated (n = 129) and Untreated (n = 141). Pearson’s chi-squared test, Student’s t-test, and multivariate logistic regressions were used to analyze complications between groups.ResultsPatients in the Treated group had significantly fewer all-type complications (4.7% vs 14.9%, P = .007), infections (2.3% vs 12.1%, P = .002), and reoperations (0.8% vs 9.9%, P = .001) compared to the Untreated group. After controlling for hepatic fibrosis, we found that Treated patients still had significantly lower odds of experiencing all-type complications (odds ratio [OR] 0.30, 95% confidence interval [CI] 0.10-0.88; P = .028), infection (OR 0.19, 95% CI 0.04-0.87; P = .033), and reoperation (OR 0.11, 95% CI 0.01-0.90; P = .039) following TJA.ConclusionHCV antiviral treatment reduces postoperative complications after primary TJA, even among those who have progressed to hepatic fibrosis. Surgeons can use this information in shared decision making prior to TJA to counsel patients about the benefits of preoperative antiviral treatment even in the presence of hepatic fibrosis.     

Cumulative Intraarticular Injections Are Not a Risk Factor for Periprosthetic Joint Infection Following total Knee Arthroplasty

BackgroundWhile injections within 90 days prior to total knee arthroplasty (TKA) are associated with an increased risk of periprosthetic joint infection (PJI), there is a paucity of literature regarding the impact of cumulative injections on PJI risk. This study was conducted to assess the association between cumulative corticosteroid and hyaluronic acid (HA) injections and PJI risk following TKA.MethodsThis retrospective study using an injection database included patients undergoing TKA with a minimum 1-year follow-up from 2015 to 2020. Patients with injections within 90 days prior to surgery were excluded. The sum of corticosteroid and HA injections within five years prior to TKA was recorded. The primary outcome was PJI within 90 days following TKA. Area under the curve (AUC) values were calculated for a cumulative number of injections.Results648 knees with no injections and 672 knees with injections prior to TKA were included, among whom 243 received corticosteroids, 151 received HA, and 278 received both. No significant differences in early PJI rates existed between patients who received injections (0.60%) or not (0.93%) (P = .541). No significant differences existed in early PJI rates between patients injected with corticosteroids (0.82%), HA (0.66%), or both (0.36%) (P = .832). No cutoff number of injections was predictive for PJI.DiscussionA cumulative amount of steroid or HA injections, if given more than 90 days prior to TKA, does not appear to increase the risk of PJI within 90 days postoperatively. Multiple intraarticular corticosteroid injections and HA injections may be safely administered before TKA, without increased risk for early PJI.     

Tobacco Use and Risk of Wound Complications and Periprosthetic Joint Infection: A Systematic Review and Meta-Analysis of Primary Total Joint Arthroplasty Procedures

Background

The purpose of this study was to perform a systematic review and meta-analysis to quantitatively assess the association between tobacco use and the risk of any wound complication and periprosthetic joint infection (PJI) after primary total hip and total knee arthroplasty procedures.

A Missed Opportunity: The Impact of Hepatitis C Treatment Prior to Total Knee Arthroplasty on Postoperative Complications

BackgroundHepatitis C (HCV) is undertreated and increasing in prevalence. Its influence on outcomes following total knee arthroplasty (TKA) remains unclear. The purpose of this study is to examine the impact of HCV and prearthroplasty antiviral treatment on postoperative complications following TKA.MethodsA retrospective matched cohort study was conducted using an administrative claims database to compare postoperative complication rates following TKA for (1) patients with vs without HCV and (2) among patients with HCV, patients with antiviral treatment before TKA vs no treatment. In total, 6971 patients with HCV were matched 1:4 with 27,884 controls without HCV, and 708 HCV patients with antiviral treatment before TKA were matched 1:2 with 1416 HCV patients without treatment. Rates of joint complications at 1 and 2 years postoperatively were compared via multivariable logistic regression.ResultsThe HCV cohort exhibited significantly higher risk of prosthetic joint infection (PJI) than controls at both 1 (4.1 vs 2.1%; odds ratio [OR] 1.58) and 2 years (5.0% vs 2.7%; OR 1.55) postoperatively. Rates of revision TKA were also significantly higher for HCV patients at 1 (2.8% vs 1.8%; OR 1.40) and 2 years (4.1% vs 2.9%; OR 1.30). HCV patients with prearthroplasty antiviral treatment exhibited significantly lower risk of PJI at 1 (2.1% vs 4.1%; OR 0.50) and 2 years (2.7% vs 5.1%, OR 0.51) compared to patients without treatment.ConclusionPatients with HCV have significantly increased risk of PJI and revision arthroplasty following TKA. Antiviral treatment before TKA significantly decreases the risk of PJI postoperatively.Level of EvidenceLevel III.     

Risk of Periprosthetic Joint Infection in Patients With Multiple Arthroplasties

Background

Risk of subsequent periprosthetic joint infection (PJI) in a second prosthetic joint following initial PJI has been shown to be 19%-20%. We sought to identify (1) the risk of developing a second PJI for our patients with multiple prosthetic joints and (2) the effect of bacteremia on development of a subsequent PJI.

Hepatitis C Is Associated With Higher Short-Term Complication Rates After Initial Aseptic and Septic Revision Total Hip Arthroplasty: A Matched Cohort Study

BackgroundIt is unclear if hepatitis C virus (HCV) negatively impacts outcomes of revision total hip arthroplasty (rTHA). The purpose of this study is to trend recent rTHA utilization in patients who have HCV and compare postoperative complication rates versus a matched cohort.MethodsAll patients who underwent rTHA were retrospectively identified in a national database. Patients who had HCV (n = 1,746) were matched 1:3 with a matching group (n = 5,238) for age, gender, and several comorbidities. Cochran-Armitage tests were used to analyze trends in the annual proportion of rTHA performed in patients who had HCV from 2010 to 2019. Rates of 90-day medical and prosthesis-related complications within 2 years postoperatively were compared with multivariable logistic regressions.ResultsThe annual proportion of rTHA performed in patients who had HCV significantly increased from 2010 to 2019 (P < .001). Patients who had HCV exhibited significantly higher rates of acute kidney injuries (7.6% versus 4.4%; odds ratio [OR] 1.50), transfusions (20.6% versus 14.6%; OR 1.38), and re-revisions for prosthetic joint infection (10.9% versus 6.5%; OR 1.73). In subgroup analyses, rates of re-revision for prosthetic joint infection after initial aseptic rTHA (7.1% versus 3.8%; OR 1.82) and periprosthetic fracture after initial septic rTHA (4.5% versus 1.6%; OR 2.77) were significantly higher in the HCV cohort.ConclusionSimilar to primary THA, patients who have HCV exhibit significantly increased complication rates after rTHA. With growing utilization in recent years, these data suggest that this population will comprise an increasingly larger proportion of rTHA procedures performed in the coming years.     

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.

Specific Infectious Organisms Associated With Poor Outcomes in Treatment for Hip Periprosthetic Infection

Background

Periprosthetic hip infection treatment remains a significant challenge for orthopedics. Some studies have suggested that methicillin resistance and gram-negative organism type are associated with increased treatment failure. The aim of this research is to determine if specific organisms were associated with poor outcomes in treatment for hip periprosthetic infection.

Preoperative Opioid Use Is Associated With Higher Revision Rates in Total Joint Arthroplasty: A Systematic Review

BackgroundAlthough preoperative opioid use has been associated with poor postoperative patient-reported outcome measures and delayed return to work in patients undergoing total joint arthroplasty, direct surgery-related complications in patients on chronic opioids are still not clear. Thus, we sought to perform a systematic review of the literature to evaluate the influence of preoperative opioid use on postoperative complications and revision following primary total joint arthroplasty.MethodsFollowing the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, we queried PubMed, EMBASE, the Cochrane Library, and the ISI Web of Science for studies investigating the influence of preoperative opioid use on postoperative complications following total hip arthroplasty and total knee arthroplasty up to May 2020.ResultsAfter applying exclusion criteria, 10 studies were included in the analysis which represented 87,165 opioid users (OU) and 5,214,010 nonopioid users (NOU). The overall revision rate in the OU group was 4.79% (3846 of 80,303 patients) compared to 1.21% in the NOU group (43,719 of 3,613,211 patients). There was a higher risk of aseptic loosening (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.11-1.53, P = .002), periprosthetic fractures (OR 1.89, 95% CI 1.53-2.34, P < .00001), and dislocations (OR 1.26, 95% CI 1.14-1.39, P < .00001) in the OU group compared to the NOU group. Overall, 5 of 6 studies reporting on periprosthetic joint infection (PJI) rates showed statistically significant correlation between preoperative opioid use and higher PJI rates.ConclusionThere is strong evidence that preoperative opioid use is associated with a higher overall revision rate for aseptic loosening, periprosthetic fractures, and dislocation, and an increased risk for PJI.Level of EvidenceLevel III, systematic review.     

Preoperative Malnutrition Negatively Correlates With Postoperative Wound Complications and Infection After Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

Background

Malnutrition continues to be prevalent in the general population. A variety of studies have correlated poor nutritional status with reduced perioperative outcomes. However, the correlation between serologic malnutrition and arthroplasty outcomes has not been systematically evaluated. The purpose of this study was to determine if serologic malnutrition has a correlation with postoperative wound infection, as well as other complications, after total joint arthroplasty.

Postoperative Infection Risk in Total Joint Arthroplasty After Perioperative IV Corticosteroid Administration: A Systematic Review and Meta-Analysis of Comparative Studies

BackgroundPerioperative corticosteroid administration is associated with reduced postoperative nausea, pain, and enhanced recovery after surgery. However, potential complications including wound and periprosthetic joint infections remain a concern for surgeons after total joint arthroplasty (TJA).MethodsA systematic review of the search databases PubMed, Google Scholar, and EMBASE was made in January 2021 to identify comparative studies evaluating infection risk after perioperative corticosteroid administration in TJA. PRISMA guidelines were used for this review. Meta-analysis was used to assess infection risk in accordance with joint and corticosteroid dosing regimen used.Results201 studies were returned after initial search strategy, with 29 included for review after application of inclusion and exclusion criteria. Studies were categorized as using low- or high-dose corticosteroid with single or repeat dosing regimens. Single low-dose corticosteroid administration was not associated with an increased risk of infection (P = .4; CI = 0.00-0.00). Single high-dose corticosteroid was not associated with an increased infection risk (P = .3; CI = 0.00-0.01) nor did repeat low-dose regimens result in increased risk of infection (P = .8; CI = ?0.02-0.02). Studies assessing repeat high-dosing regimens reported no increased infection, with small numbers of participants included. No significant risk difference in infection risk was noted in hip (P = .59; CI = ?0.03-0.02) or knee (P = .2; CI = 0.00-0.01) arthroplasty. Heterogeneity in patient profiles included in studies to date was noted.ConclusionUse of perioperative corticosteroid in TJA does not appear to be associated with increased risk of postoperative infection in patients with limited comorbidities. Further research is warranted to evaluate postoperative complications after TJA in these at-risk patient populations.     

Inadequate Glycemic Control Is Associated With Increased Surgical Site Infection in Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

Background

The association between inadequate glycemic control and surgical site infection (SSI) following total joint arthroplasty (TJA) remains unclear. The aim of this study is to assess the relationship between perioperative glycemic control and the risk for SSI, mainly periprosthetic joint infection.

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.

Positive Blood Cultures in Periprosthetic Joint Infection Decrease Rate of Treatment Success

Background

Blood cultures are often obtained at the time of periprosthetic joint infection (PJI) diagnosis yet they are not considered part of the diagnostic criteria and the effects of a positive result on surgical outcome are unknown. The purposes of this study are to characterize the use of blood cultures when diagnosing PJI and to determine the association of positive blood cultures with PJI treatment success.

Treatment of Periprosthetic Knee Infection With Concurrent Rotational Muscle Flap Coverage Is Associated With High Failure Rates

Background

Soft-tissue deficiency is a potentially devastating complication of the infected total knee arthroplasty (TKA). Rotational muscle flaps are commonly used to address these defects. However, reported success rates vary widely.

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.     

Worse Outcomes Are Associated With Proximal Femoral Replacement Following Periprosthetic Joint Infection

BackgroundProximal femoral replacements (PFRs) are often used in the setting of severe bone loss. As osteolysis has become less common, PFR may be used to address other causes of bone loss such as infection or periprosthetic fracture. The aim of this study is to investigate the clinical outcomes of PFR for non-neoplastic conditions.MethodsA retrospective review of 46 patients undergoing PFR at a single institution was performed. The electronic records were reviewed to extract relevant information including the reason for use of PFR, surgical variables, follow-up, and complications. Survivorship curves were generated and differences in survivorship were evaluated using the log-rank test. Radiographic evaluation was also performed.ResultsUsing revision as an endpoint, the Kaplan-Meier analysis of the entire cohort demonstrated a survival rate of 74% at 1 year and 67% at 5 years. Patients with a preoperative diagnosis of periprosthetic joint infection demonstrated the lowest survivorship with a failure rate of 47%. Furthermore, a high dislocation rate at 17.4% (n = 8) was observed. The use of dual-mobility articulation was effective in reducing dislocation.ConclusionPFR is a valuable reconstructive option for patients with massive proximal femoral bone loss. This study demonstrates that patients with periprosthetic joint infection who undergo PFR reconstruction are at very high risk of subsequent failure, most commonly from reinfection and instability. The use of a dual-mobility articulation in association with PFR appears to help mitigate risk of subsequent dislocation.     

Prevalence of Hepatitis C Virus Infection in the Veteran Population Undergoing Total Joint Arthroplasty: An Update

BackgroundIn 2012, we reported on the prevalence of hepatitis C virus (HCV) infection in Veterans Affairs (VA) patients undergoing total joint arthroplasty (TJA) at our center. In this patient population, 8.4% were antibody positive and 4.5% were viremic with HCV. In 2014, the first all-oral direct-acting antiviral treatment for hepatitis C became available. The Department of Veterans Affairs then underwent an aggressive program to eradicate hepatitis C from the veteran population. The purpose of this report is to provide updated information on the prevalence of HCV viremia among patients undergoing primary TJA at the same center.MethodsA retrospective review was performed of all patients undergoing primary TJA at a single VA medical center in 2019. Anti-HCV antibody and HCV viremia prevalence were calculated. Comparisons were made to data from a previously reported cohort of patients who had undergone TJA at the same center from 2007 to 2009.ResultsThirty-three (11.6%) of 285 patients screened preoperatively were positive for the hepatitis C antibody. Only one of the 33 anti-HCV–positive patients was viremic at the time of screening for an overall viremic prevalence of 0.4%. We found no statistically significant difference in the birth year, or anti-HCV antibody–positive rate from the prior cohort, but the prevalence of HCV viremia decreased significantly.ConclusionBecause direct-acting antiviral HCV treatment has become available, HCV viremia among VA patients undergoing TJA has been reduced from 4.5% to 0.4%. Surgeons are still advised to minimize the risk of sharps injury.