Do Extended Oral Postoperative Antibiotics Prevent Early Periprosthetic Joint Infection in Morbidly Obese Patients Undergoing Primary Total Joint Arthroplasty?

Duration of cefazolin prophylaxis did not impact infection risk in a murine model of joint arthroplasty

To minimize periprosthetic joint infection (PJI) risk, some clinicians prescribe extended antibiotic prophylaxis (EAP) following total joint arthroplasty (TJA). Given the limited evidence supporting EAP, we sought to evaluate impact of prophylactic antibiotic duration on PJI risk in a murine TJA model. A titanium prosthesis was implanted into the proximal tibia of 89 mice and inoculated with 102 colony forming units (cfu) of Staphylococcus aureus Xen36. Control mice (n = 20) did not receive antibiotics. Treated mice received either 24 h (n = 35) or 4 days (n = 34) of cefazolin prophylaxis. Cultures were obtained from the prostheses, tibia, femur, and knee tissues 3 weeks after surgery. All mice in the control group developed PJI. Both prophylaxis regimens reduced the rate of PJI relative to the control, with only 2/35 mice in the 24-h cohort (p < 0.0001) and 1/34 in 4-day cohort developing PJI (p < 0.0001). CFU counts from the prostheses, bone and knee tissues were reduced for the 24-h and 4-day prophylaxis cohorts relative to the control (p < 0.0001 for both). There was no difference in rates of PJI or CFU counts between the two prophylaxis cohorts (p = 0.58). Prophylactic cefazolin profoundly reduced rates of PJI in a murine model of TJA in which all control animals developed PJI. Extending cefazolin prophylaxis duration from 24 h to 4 days did not result in improved PJI rates or decreased bacterial loads in infected cases. While these results strongly support use of antibiotic prophylaxis for TJA, EAP did not appear to add benefit in the described mouse model.

Not so Fast: Extended Oral Antibiotic Prophylaxis Does Not Reduce 90-Day Infection Rate Following Joint Arthroplasty

BACKGROUND

Periprosthetic joint infection (PJI) is a devastating complication following both total hip (THA) and knee (TKA) arthroplasty. Extended oral antibiotic (EOA) prophylaxis has been reported to reduce PJI following TJA in high-risk patients. The purpose of this study was to determine if EOA reduces PJI in all-comers and high-risk THA and TKA populations.

METHODS

This is a retrospective cohort study, including 4,576 patients undergoing primary THA or TKA at a single institution from 2018 to 2022. Beginning in 2020, EOA prophylaxis was administered for 10 days following THA or TKA at our institution. Patients were separated into 2 cohorts (1,769 EOA, 2,807 no EOA) based on whether they received postoperative EOA. The 90-day and 1-year outcomes, with a focus on PJI, were then compared between groups. A subgroup analysis of high-risk patients was also performed.

RESULTS

There was no difference in 90-day PJI rates between cohorts (EOA 1 versus no EOA 0.8%; P = .6). The difference in the rate of PJI remained insignificant at 1 year (EOA 1 versus no EOA 1%; P = .9). Similarly, our subgroup analysis of high-risk patients demonstrated no difference in postoperative PJI between EOA (n = 254) and no EOA (n = 396) (0.8 versus 2.3%, respectively; P = .2). Reassuringly, we also found no differences in the incidence of Clostridium difficile infection (EOA 0.1 versus no EOA 0.1%; P > .9) or in antibiotic resistance among those who developed PJI within 90 days (EOA 59 versus no EOA 83%; P = .2).

CONCLUSIONS

With the numbers available for analysis, EOA prophylaxis was not associated with PJI risk reduction following primary TJA when universally deployed. Furthermore, among high-risk patients, there was no statistically significant difference. While we did not identify increased antibiotic resistance or Clostridium difficile infection, we cannot recommend wide-spread adoption of EOA prophylaxis, and clarification regarding the role of EOA, even in high-risk patients, is needed.

How are Oral Antibiotics Being Used in Total Joint Arthroplasty? A Review of the Literature

While the role and benefit of perioperative intravenous (IV) antibiotics in patients undergoing total joint arthroplasty (TJA) is well-established, oral antibiotic use in TJA remains a controversial topic with wide variations in practice patterns. With this review, we aimed to better educate the orthopedic surgeon on when and how oral antibiotics may be used most effectively in TJA patients, and to identify gaps in the literature that could be clarified with targeted research. Extended oral antibiotic prophylaxis (EOAP) use in high-risk primary, aseptic revision, and exchange TJA for infection may be useful in decreasing periprosthetic joint infection (PJI) rates. When prescribing oral antibiotics either as EOAP or for draining wounds, patient factors, type of surgery, and type of infectious organisms should be considered in order to optimally prevent and treat PJI. It is important to maintain antibiotic stewardship by administering the proper duration, dose, and type of antibiotics and by consulting infectious disease when necessary.

Extended Prophylactic Antibiotics for Primary and Aseptic Revision Total Joint Arthroplasty: A Meta-Analysis

BACKGROUND

There is growing interest in extended antibiotic prophylaxis (EAP) following total joint arthroplasty (TJA); however, the benefit of EAP remains controversial. For this investigation, both oral and intravenous antibiotic protocols were included in the EAP group.

METHODS

The Cochrane Database of Systematic Reviews, Cochrane Register of Controlled Trials, PubMed, MEDLINE, Web of Science, Ovid Embase, Elton B. Stephens CO, and Cumulative Index to Nursing and Allied Health Literature were queried for literature comparing outcomes of primary and aseptic revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients who were treated with either ≤24 hours of postoperative antibiotic prophylaxis (standard of care [SoC]) or >24 hours of EAP. The primary outcome was periprosthetic joint infection (PJI). A pooled relative-risk random-effects Mantel-Haenszel model was implemented to compare cohorts.

RESULTS

There were 18 studies with a total of 19,153 patients included. There was considerable variation in antibiotic prophylaxis protocols with first-generation cephalosporins being the most commonly implemented antibiotic for both groups. Patients treated with EAP were 35% less likely to develop PJI relative to the SoC (P = .0004). When examining primary TJA, patients treated with EAP were 39% and 40% less likely to develop a PJI for TJA (P = .0008) and THA (P = .02), respectively. There was no significant difference for primary TKA (P = .17). When examining aseptic revision TJA, EAP led to a 36% and 47% reduction in the probability of a PJI for aseptic revision TJA (P = .007) and aseptic revision TKA (P = .008), respectively; there was no observed benefit for aseptic revision THA (P = .36).

CONCLUSIONS

This meta-analysis demonstrated that patients treated with EAP were less likely to develop a PJI relative to those treated with the SoC for all TJA, primary TJA, primary THA, aseptic revision TJA, and aseptic revision TKA. There was no significant difference observed between EAP and SoC for primary TKA or aseptic revision THA.

Trends in Extended Oral Antibiotic Prophylaxis Utilization Following Primary and Revision Total Hip Arthroplasty From 2010 to 2022

BACKGROUND

In patients considered high-risk for infection, extended oral antibiotic (EOA) prophylaxis has been demonstrated to reduce rates of prosthetic joint infection following total hip arthroplasty (THA). Although national guidelines regarding their use have not yet been created, the increase in literature surrounding EOA prophylaxis suggests a potential change in practice patterns. The purpose of this study was to investigate the trends in utilization of EOA prophylaxis following THA from 2010 to 2022 and identify prescription patterns.

METHODS

A total of 646,059 primary THA and 51,879 aseptic revision THA patients were included in this study. Patients who underwent primary or aseptic revision THA between 2010 and 2022 were identified in a national administrative claims database. Rates and duration of EOA prescriptions were calculated. A secondary analysis examined rates of utilization across demographics, including patients considered high risk for infection.

RESULTS

From 2010 to 2022, utilization of EOA increased by 366% and 298% following primary and revision THA, respectively. Of patients prescribed postoperative antibiotics, 30% and 59% were prescribed antibiotics for more than 7 days following primary and revision THA, respectively. Rates of utilization were similar between high-risk individuals and the general population.

CONCLUSIONS

Rates of utilization of EOA prophylaxis after THA have increased significantly since 2010. As current trends demonstrate a wide variation in prescription patterns, including in length of antibiotic duration and in patient population prescribed, guidelines surrounding the use of EOA prophylaxis after THA are necessary to promote antibiotic stewardship while preventing rates of periprosthetic joint infection.

The Use of Oral Antibiotics After Total Joint Arthroplasty: A Critical Analysis Review

» There is conflicting and insufficient evidence that extended oral antibiotic (EOA) therapy prevents infection in high-risk patients undergoing primary total joint arthroplasty (TJA), limiting recommendation for or against the practice.» In the case of aseptic revision TJA, the evidence is also conflicting and limited by underlying confounders, preventing recommendation for use of EOA.» There is fair evidence that use of EOA after debridement antibiotic therapy and implant retention of the prosthesis prolongs infection-free survival, but randomized controlled trials are needed. On the other hand, there is strong evidence that patients undergoing 2-stage revision should receive a period of suppressive oral antibiotics after the second stage.» The optimal duration of EOA in primary TJA, aseptic revision, and debridement antibiotic therapy and implant retention of the prosthesis is unknown. However, there is strong evidence that 3 months of EOA suppression may be appropriate after reimplantation as part of 2-stage exchange arthroplasty.» Complications secondary to EOA are reported to be between 0% and 13.7%, yet are inconsistently reported and poorly defined. The risks associated with antibiotic use, including development of antimicrobial resistance, must be weighed against a possible decrease in infection rate.

The Challenge of Emerging Resistant Gram-Positive Pathogens in Hip and Knee Periprosthetic Joint Infections

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An increase in resistant bacterial pathogens has occurred over the last 4 decades.

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Careful patient selection and improving or correcting risk factors for periprosthetic joint infection (PJI) before elective surgical treatment are strongly recommended.

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Appropriate microbiological methods, including those used to detect and grow Cutibacterium acnes, are recommended.

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Antimicrobial agents used in the prevention or management of infection should be selected appropriately and the duration of therapy should be carefully considered in order to mitigate the risk of developing bacterial resistance.

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Molecular methods including rapid polymerase chain reaction (PCR) diagnostics, 16S sequencing, and/or shotgun and/or targeted whole-genome sequencing are recommended in culture-negative cases of PJI.

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Expert consultation with an infectious diseases specialist (if available) is recommended to assist with the appropriate antimicrobial management and monitoring of patients with PJI.

Extended Oral Antibiotic Prophylaxis After Aseptic Total Hip or Knee Arthroplasty Revisions: A Preliminary Report

BACKGROUND

It is unknown whether extended oral antibiotic (EOA) prophylaxis reduces periprosthetic joint infection (PJI) rates after aseptic revision total hip (THA) and knee arthroplasty (TKA). The literature is scarce. Therefore, we sought to ascertain whether EOA prophylaxis decreases PJI rates after aseptic first-time revision THA and TKA when compared to standard prophylaxis.

METHODS

This is a retrospective review of 328 consecutive revisions (3 surgeons, single institution, from September 27, 2017 to December 31, 2019). Preoperative 2013 Musculoskeletal Infection Society (MSIS) criteria, radiographs, and medications were reviewed. Inclusion criteria included aseptic first-time revision THA and TKA. Exclusion criteria were positive intraoperative cultures and/or histology, PJI (2013 MSIS criteria), hemiarthroplasty/partial arthroplasty revision, revision using foreign material (ie, mesh), metastatic bone disease, and intravenous antibiotics >24 hours after surgery. A total of 178 revisions were included, and 2 groups were set apart based on antibiotic prophylactic regime. The following were the groups: (1) EOA prophylaxis (>24 hours, n = 93) and (2) standard prophylaxis (≤24 hours, n = 85). Demographics, joint types, lengths of stay, skin-to-skin operative times, revision types, transfusions, discharge dispositions, and PJIs (per 2013 MSIS criteria) after the first-time revision were compared between groups. There were no significant differences in demographics. However, skin-to-skin operative time was significantly higher in the EOA group (123 minutes versus 98 minutes, P = .01). Mean follow-up was 849 days (range, 15-1,671). Statistical significance was set at a P value lower than .05.

RESULTS

Postoperative PJI rates were not significantly different: 2.2% EOA prophylaxis versus 3.5% standard prophylaxis (P = .671).

CONCLUSION

No significant difference was found between PJI rates between both prophylactic regimens. A large multicenter study with a larger sample size is needed to support EOA after aseptic revisions.

LEVEL OF EVIDENCE

Level III.

Extended Oral Antibiotic Prophylaxis After Aseptic Revision Total Hip Arthroplasty: Does It Decrease Infection Risk?

BACKGROUND

Extended oral antibiotic prophylaxis (EOA) has been shown to reduce infection after high-risk primary total hip arthroplasties (THAs) and reimplantations. However, data are limited regarding EOA after aseptic revision THAs. This study evaluated the impact of EOA on infection-related outcomes after aseptic revision THAs.

METHODS

We retrospectively identified 1,107 aseptic revision THAs performed between 2014 and 2019. Patients who received EOA >24 hours perioperatively (n = 370) were compared to those who did not (n = 737) using an inverse probability of treatment weighting model. Their mean age was 65 years (range, 19-98 years), mean body mass index was 30 kg/m² (range, 16-72), and 54% were women. Outcomes included cumulative probabilities of any infection, periprosthetic joint infection (PJI), and re-revision or reoperation for infection. Mean follow-up was 4 years (range, 2-8 years).

RESULTS

The cumulative probability of any infection after aseptic revision THA was 2.3% at 90 days, 2.7% at 1 year, and 3.5% at 5 years. The cumulative probability of PJI was 1.7% at 90 days, 2.1% at 1 year, and 2.8% at 5 years. There was a trend toward an increased risk of any infection (hazards ratio [HR] = 2.6; P = .058), PJI (HR = 2.6; P = .085), and re-revision (HR = 6.5; P = .077) or reoperation (HR = 2.3; P = .095) for infection in patients who did not have EOA at the final clinical follow-up.

CONCLUSIONS

EOA after aseptic revision THA was not associated with a statistically significant decreased risk of any infection, PJI, or re-revision or reoperation for infection at all time points.

LEVEL OF EVIDENCE

Level III.

Rates of Antimicrobial Resistance With Extended Oral Antibiotic Prophylaxis After Total Joint Arthroplasty

Background

There is increased interest and utilization of extended oral antibiotic prophylaxis (EOAP) following primary and revision total hip arthroplasties (THAs) and total knee arthroplasties (TKAs). The purpose of this study was to look for potential associations between EOAP and differential rates of antimicrobial resistance or epidemiology of organisms causing periprosthetic joint infection (PJI) following primary and aseptic revision THAs/TKAs.

Methods

Patients who developed PJI following a primary or aseptic revision TKA/THA at a single institution from 2009 to 2020 were retrospectively identified. Patients who received at least 7 days of EOAP following the surgery were noted. Rates of antimicrobial resistance were compared between standard antibiotic prophylaxis and EOAP cohorts using the Fisher's exact test.

Results

One hundred twenty-eight cultures were obtained from 119 patients with PJI. Fourty-four cases (37%) developed PJI after EOAP. Staphylococcus aureus was the most frequently isolated organism (30% of all cultures; 78% were methicillin-sensitive). Rates of antimicrobial resistance were similar between standard antibiotic prophylaxis and EOAP cohorts in all but 2 instances: Increased resistance to erythromycin and trimethoprim-sulfamethoxazole was observed in coagulase-negative Staphylococci isolates in the EOAP cohort (89% vs 21%, P < .01; 44% vs 0%, P = .02). An increased frequency of gram-negative organisms was observed in the EOAP group (22% vs 8%, P = .03).

Conclusions

Rates of antimicrobial resistance were not significantly different between EOAP and standard antibiotic prophylaxis cohorts except in coagulase-negative Staphylococci. The increased frequency of gram-negative infections was present in the EOAP cohort. Larger, multicenter studies are needed to better understand the impact of EOAP on antimicrobial resistance and PJI epidemiology.

Level of Evidence

Level III; retrospective cohort study.

Antimicrobial Stewardship in Total Joint Arthroplasty: Outcomes of a Collaborative Program Implementation

INTRODUCTION

Antimicrobial stewardship has been cited as a crucial component of orthopaedic surgical care; however, limited high-quality data exist to guide antibiotic use across the total joint arthroplasty continuum. Antimicrobial stewardship program (ASP) implementation and evaluation is needed in this space.

METHODS

We pursued a prospective, sequential cohort study of an interprofessional ASP for total joint arthroplasty (TJA) formed in late 2017 at the study institution. Twelve total evidence-based recommendations for protocol change were issued, with 11 accepted and implemented across three project phases spanning March 2018 to December 2019. The primary study outcome was the rate of optimal preoperative intravenous antibiotic selection as assessed for Baseline versus Postintervention time periods. Secondary outcomes included individual antibiotic utilization rates. Descriptive statistics were pursued for institutional surgical site infection (SSI) and postoperative acute kidney injury (AKI) rates across the affected time frame. A cost-benefit analysis of the ASP was estimated from the institutional perspective.

RESULTS

The rate of optimal preoperative antibiotic selection increased from 64.9% in the Baseline Period (February 2018, n = 57) to 95.4% in the Postimplementation period (June 2018 to December 2019, n = 1,220) (P < 0.001). The rates of second-line preoperative antibiotics and total perioperative antibiotic exposures decreased. Total SSI and AKI rates in primary elective TJA seemed to decrease from calendar year 2018 to 2019 (deep SSI 1.00% to 0.22%, superficial SSI 0.66% to 0.00%, and AKI 1.97% to 1.03%). The institution realized an estimated $197,050 cost savings per 1000 TJA procedures.

DISCUSSION

A comprehensive ASP for TJA was associated with an increased use of optimal preoperative antibiotic selection, decreased total antibiotic exposures, and cost savings, without apparent detriment to SSI or AKI rates.

Cefadroxil-Induced Clostridium difficile Infection Following Total Knee Arthroplasty

Perioperative infection prophylaxis is a fundamental element of total knee arthroplasty (TKA). There has been a recent trend toward the use of extended postoperative oral antibiotics in high-risk patients. We describe a case report of a patient who underwent a primary TKA and subsequently developed Clostridium difficile colitis after an extended course of postoperative prophylactic oral cefadroxil. Following the C. difficile infection, the patient eventually developed bacteremia and a multidrug-resistant Escherichia coli prosthetic joint infection which required multiple debridements. Extended use of postoperative prophylactic oral cefadroxil may increase the risk of C. difficile-associated diarrhea. Additionally, our case suggests that C. difficile infection may subsequently increase the risk of bacteremia which could lead to prosthetic joint infection. More evidence is required to further define this risk.

Recrudescent infection after deep brain stimulator reimplantation

OBJECTIVE

The efficacy of deep brain stimulation (DBS) in treating the symptoms of movement disorders can be life changing for patients. Thus, the 5%-15% incidence of stimulator-related infection requiring removal of the device can be particularly disheartening. Although DBS system reimplantation is generally successful, this is not always the case. The literature is replete with publications describing the incidence of infection and the associated features. However, the literature is sparse in terms of information on the incidence of recurrent or recrudescent infection after system reimplantation. The goal of this paper was to evaluate factors leading to unsuccessful reimplantation of a DBS system following initial infection.

METHODS

Data were reviewed for all DBS procedures performed by one surgeon (K.L.H.) over 19 years including the infectious agent, location of infection, treatment regimen, and subsequent reimplantation of a DBS system and long-term outcome.

RESULTS

In this series of 558 patients who had undergone DBS surgery, 37 (6.6%) subsequently developed an infection. Infections with methicillin-sensitive Staphylococcus aureus, Enterobacter species, or coagulase-negative staphylococci were predominant. Four patients had cerebritis, one had meningitis, and the rest had soft tissue infections of the pocket or scalp. All had their entire DBS system explanted, followed by 4-6 weeks of intravenous antibiotics and surveillance for recrudescence for an additional period of at least 30 days. Twenty-five patients subsequently underwent DBS system reimplantation, and the procedure was successful in 22. Three of the 4 patients with cerebritis developed a subsequent wound infection after system reimplantation. None of the other 22 patients developed a recurrence. The odds ratio for developing a recurrent infection after cerebritis was 28.5 (95% CI 1.931-420.5, p = 0.007).

CONCLUSIONS

This study, the largest series of DBS system reimplantations following infection, demonstrated that most patients can have successful reimplantations without recurrent infection. However, patients who have had DBS-related cerebritis have a nearly 30-fold increased risk of developing reinfection after reimplantation. Alternative strategies for these patients are discussed.

The Cost-Effectiveness of Extended Oral Antibiotic Prophylaxis for Infection Prevention After Total Joint Arthroplasty in High-Risk Patients

BACKGROUND

Extended oral antibiotic prophylaxis may decrease rates of prosthetic joint infection (PJI) after total joint arthroplasty (TJA) in patients at high risk for infection. However, the cost-effectiveness of this practice is not clear. In this study, we used a break-even economic model to determine the cost-effectiveness of routine extended oral antibiotic prophylaxis for PJI prevention in high-risk TJA patients.

METHODS

Baseline PJI rates in high-risk patients, the cost of revision arthroplasty for PJI, and the costs of extended oral antibiotic prophylaxis regimens were obtained from the literature and institutional purchasing records. These variables were incorporated in a break-even economic model to calculate the absolute risk reduction (ARR) in infection rate necessary for extended oral antibiotic prophylaxis to be cost-effective. ARR was used to determine the number needed to treat (NNT).

RESULTS

Extended oral antibiotic prophylaxis with Cefadroxil in patients at high risk for PJI was cost-effective at an ARR in baseline infection rate of 0.187% (NNT = 535) and 0.151% (NNT = 662) for TKA and THA, respectively. Cost-effectiveness was preserved with varying costs of antibiotic regimens, PJI treatment costs, and infection rates.

CONCLUSION

The use of extended oral antibiotic prophylaxis may reduce PJI rates in patients at high risk for infection following TJA and appears to be cost-effective. However, the current evidence supporting this practice is limited in quality. The use of extended oral antibiotic prophylaxis should be weighed against the possible development of future antimicrobial resistance, which may change the value proposition.

Extended Postoperative Prophylactic Antibiotics for Primary and Aseptic Revision Total Joint Arthroplasty: A Systematic Review

INTRODUCTION

Limited literature is available about the effects of extended (>24 hours) antibiotic use after primary and aseptic revision total joint arthroplasty (TJA) on rates of periprosthetic joint infection (PJI). The purpose of this study was to systematically review the outcomes of extended prophylactic antibiotic use.

METHODS

A systematic search on PubMed and EMBASE databases was done in August 2021 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles that met inclusion criteria were screened by two separate authors. Basic patient demographics, route of delivery, type, dose, frequency of the antibiotic, rates of PJI, and length of stay were extracted.

RESULTS

A total of 11 articles published from 1979 to 2021 were included in the final analysis. Two studies evaluated aseptic revisions, seven evaluated primary TJA, and two studies evaluated both. Five studies were randomized controlled trials, one multicenter nonrandomized trial, and five retrospective cohort studies. All 11 studies used a cephalosporin or a penicillin antibiotic in both the control and cohort groups. Five studies used intravenous (IV) antibiotics, one study used oral (PO) antibiotics, and the other five studies used both IV and PO antibiotics. Length of stay was reported in three studies, all using IV antibiotics. All 11 studies evaluated rates of PJI, while four studies evaluated included rates of superficial surgical site infections. Four studies showed a statistically significant decrease in PJI when compared with a control group, while seven studies showed no statistically significant difference.

CONCLUSION

There is conflicting evidence regarding the benefit of extended (>24 hours) antibiotics, IV or PO, after TJA. As of now, current guidelines do not support the use of extended antibiotics; future prospective clinical trials are needed to help support these claims.

Projected Prevalence of Obesity in Primary Total Hip Arthroplasty: How Big Will the Problem Get?

BACKGROUND

Obesity is associated with higher rates of adverse outcomes following primary total hip arthroplasty (THA). The purpose of this study is to utilize 3 national databases to develop projections of obesity within the general population and primary THA patients in the United States through 2029.

METHODS

Data from the National Surgical Quality Improvement Program (NSQIP), the Behavior Risk Factor Surveillance System (BRFSS), and the National Health and Nutrition Examination Survey were queried for years 1999-2019. Current Procedural Terminology code 27130 was used to identify primary THA patients in NSQIP. Individuals were categorized according to body mass index (kg/m²) by year: normal weight (≤24.9); overweight (25.0-29.9); obese (30.0-39.9); and morbidly obese (≥40). Multinomial logistic regression was used to project categorical body mass index data for years 2020-2029.

RESULTS

A total of 8,222,013 individuals were included (7,986,414 BRFSS, 235,599 NSQIP THA). From 2011 to 2019, the prevalence of normal weight and overweight individuals declined in the general population (BRFSS) and in primary THA. Prevalence of obese/morbidly obese individuals increased in the general population from 31% to 36% and in primary THA from 42% to 49%. Projection models estimate that by 2029, 46% of the general population will be obese/morbidly obese and 55% of primary THA will be obese/morbidly obese.

CONCLUSION

By 2029, we estimate ≥55% of primary THA to be obese/morbidly obese. Increased resources dedicated to care pathways and research focused on improving outcomes in obese arthroplasty patients will be necessary as this population continues to grow.

LEVEL OF EVIDENCE

Level III, Retrospective Cohort Study.

Patients Who Undergo Early Aseptic Revision TKA Within 90 Days of Surgery Have a High Risk of Re-revision and Infection at 2 Years: A Large-database Study

BACKGROUND

Early aseptic revision within 90 days after primary TKA is a devastating complication. The causes, complications, and rerevision risks of aseptic revision TKA performed during this period are poorly described.

QUESTIONS/PURPOSES

(1) What is the likelihood of re-revision within 2 years after early aseptic TKA revision within 90 days compared with that of a control group of patients undergoing primary TKA? (2) What are the indications for early aseptic TKA revision within 90 days? (3) What are the differences in revision risk between different indications for early aseptic revision TKA?

METHODS

Patients who underwent unilateral aseptic revision TKA within 90 days of the index procedure were identified in a national insurance claims database (PearlDiver Technologies) using administrative codes. The exclusion criteria comprised revision for infection, history of bilateral TKA, and age younger than 18 years. The PearlDiver database was selected for its large and geographically diverse patient base and the availability of outpatient follow-up data that are unavailable in other databases focused on inpatient care. A total of 481 patients met criteria for early aseptic revision TKA, with 14% (67) loss to follow-up at 2 years. This final cohort of 414 patients was compared with a control group of patients who underwent primary TKA without revision within 90 days. For the control group, 137,661 patients underwent primary TKA without early revision, with 13% (18,138) loss to follow-up at 2 years. Among these patients, 414 controls were matched using a one-to-one propensity score method; no differences in age, gender, and Charlson comorbidity index score were observed between the groups. Indications for initial revision and 2-year re-revision were recorded. The Kaplan-Meier method was used to assess survival between the early revision and control groups.

RESULTS

Two-year survivorship free from additional revision surgery was lower in the early aseptic revision cohort compared with the control (78% [95% confidence interval 77% to 79%] versus 98% [95% CI 96% to 99%]; p < 0.001). Among early revisions, 10% (43 of 414) of the patients underwent re-revision for periprosthetic infection with an antibiotic spacer within 2 years. The reasons for early aseptic revision TKA were instability/dislocation (37% [153 of 414]), periprosthetic fracture (23% [96 of 414]), aseptic loosening (23% [95 of 414]), pain (11% [45 of 414]), and arthrofibrosis (6% [25 of 414]). Early revision for pain was associated with higher odds of re-revision than early revisions performed for other all other reasons (44% [20 of 45] versus 29% [100 of 344]; odds ratio 2.0 [95% CI 1.0 to 3.7]; p = 0.04).

CONCLUSION

Acute early aseptic revision TKA carries a high risk of re-revision at 2 years and a high risk of subsequent periprosthetic joint infection. Patients who undergo an early revision should be carefully counseled regarding the very high risk of repeat revision and discouraged from having early revision unless the indications are absolutely clear and compelling. Early aseptic revision for pain alone carries an unacceptably high risk of repeat revision and should not be performed. Adjunctive measures for infection prophylaxis should be strongly considered. Specific interventions to reduce surgical complications in this subset of patients have not been adequately studied; additional investigation of strategies to minimize the risk of reoperation or infection is warranted.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Impact of antibiotic prophylaxis courses on postoperative complications following total joint arthroplasty: Finding from Chinese population

WHAT IS KNOWN AND OBJECTIVE

Prolonged antibiotic prophylaxis after total joint arthroplasty (TJA) may not assist in minimizing postoperative complications, however, data based on the Chinese population have been limited. The purpose of this study is to investigate the effect of antibiotic prophylaxis on postoperative complications after TJA in Chinese patients.

METHODS

We retrospectively reviewed 990 patients undergoing elective primary TJA surgery from January 2016 to June 2019. Patients who received a short course (≤3 days) of antibiotic prophylaxis were compared with those who received a longer course (>3 days). Logistic regression analysis and subgroup analysis were performed to control for potential confounders. Beyond that, survival analysis was used to determine the cumulative incidence of postoperative complications.

RESULTS AND DISCUSSION

Follow-up to 12 months after surgery, the prevalence of system complications in the longer course group and the short course group were 5.1% and 3.9%, respectively (p = 0.451). Similarly, no statistical differences in incisional complications (1.5% vs. 1.8%, p > 0.999) and periprosthetic joint infection (PJI) (1.0% vs. 1.0%, p > 0.999) were observed between the two groups. After performing logistic regression analysis and survival analysis, no potential association was found between the course of antibiotic prophylaxis and postoperative complications. In addition, prolonged antibiotic prophylaxis conferred no benefit for high-risk obese patients.

WHAT IS NEW AND CONCLUSION

Extended antibiotic prophylaxis did not result in a statistically significant and clinically meaningful reduction in postoperative complications. Therefore, we recommended that the duration of antibiotic prophylaxis in TJA should be shortened to 3 days or less in the Chinese population.