Advertisement

Risk factors for periprosthetic joint infection after total knee arthroplasty

  • Juan F. BlancoEmail author
  • Agustín Díaz
  • Francisco R. Melchor
  • Carmen da Casa
  • David Pescador
Knee Arthroplasty
  • 1 Downloads

Abstract

Introduction

Periprosthetic joint infection (PJI) is the most serious and feared complication in total knee arthroplasty (TKA) and can have catastrophic consequences. The number of total knee arthroplasties is increasing, so infections could also be greater in the future. The aim of this study is to identify the most relevant risk factors associated with infection after a total knee arthroplasty.

Methods

This is a case–control study of patients who underwent total knee arthroplasty at the University Hospital of Salamanca. We included 66 TKA PJI patients and 66 control TKA patients. Demographic and clinical variables were collected. A descriptive and inferential analysis was performed by logistic regression and attributable risk fraction assessed.

Results

Prolonged operative time (> 90′) and tourniquet time (> 60′) were the most relevant risk factors described (OR 40.77, AFE 0.97, p > 0.001 and OR 37.14, AFE 0.97, p < 0.001, respectively). The use of non-antibiotic-laded cement (OR 3.62), obesity (BMI > 30, OR 8.86), diabetes (OR 2.33), high ASA grade (III–IV, OR 15.30), and blood transfusion requirement (OR 4.60) were also statistically significant risk factors for TKA PJI.

Conclusions

Our study provides evidence concerning that operative time, tourniquet time, cement type, diabetes, obesity, ASA grade, and blood transfusion requirement as independently associated risk factors for TKA PJI. Modifiable risk factors were specifically relevant, so we should be able to reduce the infection rate.

Keywords

Periprosthetic joint infection Total knee arthroplasty Risk factor 

Abbreviations

BMI

Body mass index

ESR

Erythrocyte sedimentation rate

PJI

Periprosthetic joint infection

PMN

Polymorphonuclear

CRP

C-reactive protein

TKA

Total knee arthroplasty

UHS

University Hospital of Salamanca

Notes

Acknowledgements

Authors would like to specially thank Dr. Agustín Soler (Department of Orthopedic Surgery, Lister Hospital, United Kingdom) for English language support.

Compliance with ethical standards

Conflict of interest

Juan F Blanco, Agustin Díaz, Francisco R Melchor, Carmen da Casa and David Pescador declare that they have no conflict of interest.

Availability of data

All data are available from the corresponding author upon reasonable request.

Ethical approval

All procedures were in accordance with the ethical standards of the University Hospital of Salamanca Clinical Research Committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

References

  1. 1.
    Ritter MA, Farris A (2010) Outcome of infected total joint replacement. Orthopedics.  https://doi.org/10.3928/01477447-20100129-09 CrossRefPubMedGoogle Scholar
  2. 2.
    Lum ZC, Natsuhara KM, Shelton TJ et al (2018) Mortality during total knee periprosthetic joint infection. J Arthroplasty 33:3783–3788.  https://doi.org/10.1016/j.arth.2018.08.021 CrossRefPubMedGoogle Scholar
  3. 3.
    Poultsides LA, Ma Y, Della Valle AG et al (2013) In-hospital surgical site infections after primary hip and knee arthroplasty—incidence and risk factors. J Arthroplasty 28:385–389.  https://doi.org/10.1016/j.arth.2012.06.027 CrossRefPubMedGoogle Scholar
  4. 4.
    Gathen M, Wimmer MD, Ploeger MM et al (2018) Comparison of two-stage revision arthroplasty and intramedullary arthrodesis in patients with failed infected knee arthroplasty. Arch Orthop Trauma Surg 138:1443–1452.  https://doi.org/10.1007/s00402-018-3007-9 CrossRefPubMedGoogle Scholar
  5. 5.
    Kurtz S, Ong K, Lau E et al (2007) Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Jt Surg 89:780.  https://doi.org/10.2106/JBJS.F.00222 CrossRefGoogle Scholar
  6. 6.
    Jaén F, Sanz-Gallardo M, Arrazola M et al (2012) Multicentre study of infection incidence in knee prosthesis. Rev Esp Cir Ortop Traumatol 56:38–45.  https://doi.org/10.1016/j.recot.2011.08.001 CrossRefPubMedGoogle Scholar
  7. 7.
    Wu C, Qu X, Liu F et al (2014) Risk factors for periprosthetic joint infection after total hip arthroplasty and total knee arthroplasty in Chinese patients. PLoS ONE 9:e95300.  https://doi.org/10.1371/journal.pone.0095300 CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Malinzak RA, Ritter MA, Berend ME et al (2009) Morbidly obese, diabetic, younger, and unilateral joint arthroplasty patients have elevated total joint arthroplasty infection rates. J Arthroplasty 24:84–88.  https://doi.org/10.1016/j.arth.2009.05.016 CrossRefPubMedGoogle Scholar
  9. 9.
    Everhart JS, Altneu E, Calhoun JH (2013) Medical comorbidities are independent preoperative risk factors for surgical infection after total joint arthroplasty. Clin Orthop Relat Res 471:3112–3119.  https://doi.org/10.1007/s11999-013-2923-9 CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Bozic KJ, Lau E, Kurtz S et al (2012) Patient-related risk factors for postoperative mortality and periprosthetic joint infection in medicare patients undergoing TKA. Clin Orthop Relat Res 470:130–137.  https://doi.org/10.1007/s11999-011-2043-3 CrossRefPubMedGoogle Scholar
  11. 11.
    Namba RS, Inacio MC, Paxton EW (2013) Risk factors associated with deep surgical site infections after primary total knee arthroplasty. J Bone Jt Surg Am 95:775–782.  https://doi.org/10.2106/JBJS.L.00211 CrossRefGoogle Scholar
  12. 12.
    Wu C-T, Chen I-L, Wang J-W et al (2016) Surgical site infection after total knee arthroplasty: risk factors in patients with timely administration of systemic prophylactic antibiotics. J Arthroplasty 31:1568–1573.  https://doi.org/10.1016/j.arth.2016.01.017 CrossRefPubMedGoogle Scholar
  13. 13.
    Wang H, Qiu G-X, Lin J et al (2015) Antibiotic bone cement cannot reduce deep infection after primary total knee arthroplasty. Orthopedics 38:e462–e466.  https://doi.org/10.3928/01477447-20150603-52 CrossRefPubMedGoogle Scholar
  14. 14.
    Naranje S, Lendway L, Mehle S, Gioe TJ (2015) Does operative time affect infection rate in primary total knee arthroplasty? Clin Orthop Relat Res 473:64–69.  https://doi.org/10.1007/s11999-014-3628-4 CrossRefPubMedGoogle Scholar
  15. 15.
    Yi S, Tan J, Chen C et al (2014) The use of pneumatic tourniquet in total knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg 134:1469–1476.  https://doi.org/10.1007/s00402-014-2056-y CrossRefPubMedGoogle Scholar
  16. 16.
    Parvizi J, Zmistowski B, Berbari EF et al (2011) New definition for periprosthetic joint infection: from the workgroup of the musculoskeletal infection society. Clin Orthop Relat Res 469:2992–2994.  https://doi.org/10.1007/s11999-011-2102-9 CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Nilsdotter A-K, Toksvig-Larsen S, Roos EM (2009) A 5 year prospective study of patient-relevant outcomes after total knee replacement. Osteoarthr Cartil 17:601–606.  https://doi.org/10.1016/j.joca.2008.11.007 CrossRefPubMedGoogle Scholar
  18. 18.
    Koh CK, Zeng I, Ravi S et al (2017) Periprosthetic joint infection is the main cause of failure for modern knee arthroplasty: an analysis of 11,134 knees. Clin Orthop Relat Res 475:2194–2201.  https://doi.org/10.1007/s11999-017-5396-4 CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Daines BK, Dennis DA, Amann S (2015) Infection prevention in total knee arthroplasty. J Am Acad Orthop Surg 23:356–364.  https://doi.org/10.5435/JAAOS-D-12-00170 CrossRefPubMedGoogle Scholar
  20. 20.
    López-Contreras J, Limón E, Matas L et al (2012) Epidemiology of surgical site infections after total hip and knee joint replacement during 2007–2009: a report from the VINCat Program. Enferm Infecc Microbiol Clin 30(Suppl 3):26–32.  https://doi.org/10.1016/S0213-005X(12)70093-9 CrossRefPubMedGoogle Scholar
  21. 21.
    Springer BD, Cahue S, Etkin CD et al (2017) Infection burden in total hip and knee arthroplasties: an international registry-based perspective. Arthroplast Today 3:137–140.  https://doi.org/10.1016/j.artd.2017.05.003 CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Meehan JP, Danielsen B, Kim SH et al (2014) Younger age is associated with a higher risk of early periprosthetic joint infection and aseptic mechanical failure after total knee arthroplasty. J Bone Jt Surg Am 96:529–535.  https://doi.org/10.2106/JBJS.M.00545 CrossRefGoogle Scholar
  23. 23.
    Rodríguez-Baño J, del Toro MD, Lupión C et al (2008) Arthroplasty-related infection: incidence, risk factors, clinical features, and outcome. Enferm Infecc Microbiol Clin 26:614–620CrossRefGoogle Scholar
  24. 24.
    Zhu M, Ravi S, Frampton C et al (2016) New Zealand Joint Registry data underestimates the rate of prosthetic joint infection. Acta Orthop 87:346–350.  https://doi.org/10.3109/17453674.2016.1171639 CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Rhee C, Lethbridge L, Richardson G, Dunbar M (2018) Risk factors for infection, revision, death, blood transfusion and longer hospital stay 3 months and 1 year after primary total hip or knee arthroplasty. Can J Surg 61:165–176.  https://doi.org/10.1503/cjs.007117 CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Tayton ER, Frampton C, Hooper GJ, Young SW (2016) The impact of patient and surgical factors on the rate of infection after primary total knee arthroplasty: an analysis of 64,566 joints from the New Zealand Joint Registry. Bone Jt J 98-B:334–340.  https://doi.org/10.1302/0301-620X.98B3.36775 CrossRefGoogle Scholar
  27. 27.
    Poultsides LA, Triantafyllopoulos GK, Sakellariou VI et al (2018) Infection risk assessment in patients undergoing primary total knee arthroplasty. Int Orthop 42:87–94.  https://doi.org/10.1007/s00264-017-3675-z CrossRefPubMedGoogle Scholar
  28. 28.
    Teo BJX, Yeo W, Chong HC, Tan AHC (2018) Surgical site infection after primary total knee arthroplasty is associated with a longer duration of surgery. J Orthop Surg 26:1–7.  https://doi.org/10.1177/2309499018785647 CrossRefGoogle Scholar
  29. 29.
    Crowe B, Payne A, Evangelista PJ et al (2015) Risk factors for infection following total knee arthroplasty: a series of 3836 cases from one institution. J Arthroplasty 30:2275–2278.  https://doi.org/10.1016/j.arth.2015.06.058 CrossRefPubMedGoogle Scholar
  30. 30.
    Jung P, Morris AJ, Roberts SA et al (2017) BMI is a key risk factor for early periprosthetic joint infection following total hip and knee arthroplasty. N Z Med J 130:24–34PubMedGoogle Scholar
  31. 31.
    Lee QJ, Mak WP, Wong YC (2015) Risk factors for periprosthetic joint infection in total knee arthroplasty. J Orthop Surg 23:282–286.  https://doi.org/10.1177/230949901502300303 CrossRefGoogle Scholar
  32. 32.
    Jämsen E, Nevalainen P, Eskelinen A et al (2012) Obesity, diabetes, and preoperative hyperglycemia as predictors of periprosthetic joint infection: a single-center analysis of 7181 primary hip and knee replacements for osteoarthritis. J Bone Jt Surg Am 94:e101.  https://doi.org/10.2106/JBJS.J.01935 CrossRefGoogle Scholar
  33. 33.
    Dowsey MM, Choong PFM (2009) Obese diabetic patients are at substantial risk for deep infection after primary TKA. Clin Orthop Relat Res 467:1577–1581.  https://doi.org/10.1007/s11999-008-0551-6 CrossRefPubMedGoogle Scholar
  34. 34.
    Jämsen E, Nevalainen P, Kalliovalkama J, Moilanen T (2010) Preoperative hyperglycemia predicts infected total knee replacement. Eur J Intern Med 21:196–201.  https://doi.org/10.1016/j.ejim.2010.02.006 CrossRefPubMedGoogle Scholar
  35. 35.
    Windisch C, Brodt S, Roehner E, Matziolis G (2017) C-reactive protein course during the first 5 days after total knee arthroplasty cannot predict early prosthetic joint infection. Arch Orthop Trauma Surg 137:1115–1119.  https://doi.org/10.1007/s00402-017-2709-8 CrossRefPubMedGoogle Scholar
  36. 36.
    Bohm E, Zhu N, Gu J et al (2014) Does adding antibiotics to cement reduce the need for early revision in total knee arthroplasty? Clin Orthop Relat Res 472:162–168.  https://doi.org/10.1007/s11999-013-3186-1 CrossRefPubMedGoogle Scholar
  37. 37.
    Hinarejos P, Guirro P, Leal J et al (2013) The use of erythromycin and colistin-loaded cement in total knee arthroplasty does not reduce the incidence of infection: a prospective randomized study in 3000 knees. J Bone Jt Surg Am 95:769–774.  https://doi.org/10.2106/JBJS.L.00901 CrossRefGoogle Scholar
  38. 38.
    Kim JL, Park J-H, Han S-B et al (2017) Allogeneic blood transfusion is a significant risk factor for surgical-site infection following total hip and knee arthroplasty: a meta-analysis. J Arthroplasty 32:320–325.  https://doi.org/10.1016/j.arth.2016.08.026 CrossRefPubMedGoogle Scholar
  39. 39.
    Everhart JS, Sojka JH, Mayerson JL et al (2018) Perioperative allogeneic red blood-cell transfusion associated with surgical site infection after total hip and knee arthroplasty. J Bone Jt Surg 100:288–294.  https://doi.org/10.2106/JBJS.17.00237 CrossRefGoogle Scholar
  40. 40.
    Dong Z, Han L, Song Y et al (2019) Hemostatic techniques to reduce blood transfusion after primary TKA: a meta—analysis and systematic review. Arch Orthop Trauma Surg.  https://doi.org/10.1007/s00402-019-03271-y CrossRefPubMedGoogle Scholar
  41. 41.
    Kurtz SM, Ong KL, Lau E et al (2010) Prosthetic joint infection risk after TKA in the medicare population. Clin Orthop Relat Res 468:52–56.  https://doi.org/10.1007/s11999-009-1013-5 CrossRefPubMedGoogle Scholar
  42. 42.
    Peersman G, Laskin R, Davis J et al (2006) Prolonged operative time correlates with increased infection rate after total knee arthroplasty. HSS J 2:70–72.  https://doi.org/10.1007/s11420-005-0130-2 CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Lau RL, Perruccio AV, Gandhi R, Mahomed NN (2012) The role of surgeon volume on patient outcome in total knee arthroplasty: a systematic review of the literature. BMC Musculoskelet Disord 13:250.  https://doi.org/10.1186/1471-2474-13-250 CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Trauma and Orthopedic SurgeryUniversity Hospital of SalamancaSalamancaSpain
  2. 2.Instituto de Investigación Biomédica de Salamanca (IBSAL)SalamancaSpain
  3. 3.Department of AnesthesiaUniversity Hospital of SalamancaSalamancaSpain

Personalised recommendations