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

Labelling patients as allergic to beta-lactam antibiotics is associated with periprosthetic joint infection up to five years following knee arthroplasty

Aims

Periprosthetic joint infections (PJIs) represent a significant complication of total knee arthroplasty (TKAs). However, the influence of drug or beta-lactam (BL) antibiotic allergy labelling of patients on PJI remains largely unknown. In this study, we examine the association between patients labelled with a BL allergy and the occurrence of PJI among patients undergoing TKA. We also assess the prevalence of incorrect patient labelling and explore the feasibility of a multidisciplinary drug allergy testing initiative to detect mislabelling.

Methods

Longitudinal data from all patients who underwent TKA between January 1993 and December 2021 were analyzed. We investigated the association between different risk factors and PJI, with particular focus on patients labelled as having an antibiotic drug allergy. The outcomes of patients with and without a labelled BL allergy were compared. Additionally, patients labelled as having a BL allergy and who had undergone or were scheduled for TKA were prospectively investigated by formal allergy assessment.

Results

Out of 4,730 TKAs, the overall incidence of PJI was 1.0% (47/4,730). Patients labelled as having a BL allergy had a higher incidence of PJI within the first five years post-TKA compared to those without (3.0% (5/165) vs 0.7% (34/4,565); p = 0.001). The presence of a BL allergy label was identified as an independent risk factor for PJI (hazard ratio 4.86 (95% CI 2.05 to 11.53); p < 0.001). Following negative drug provocation testing, the majority of patients (95% (21/22)) evaluated with BL allergy labels were successfully delabelled.

Conclusion

In this longitudinal study, patients labelled as having a BL allergy were associated with having increased risk of PJI following TKA, particularly within the first five years. Given the high rate of patients being mislabelled, we recommend that patients labelled as having a BL allergy should be prioritized for formal allergy assessment and evaluation. Further studies on the impact of preoperative antibiotic allergy delabelling initiatives should be encouraged.

The effect of allergies on outcomes following shoulder arthroplasty: A national database analysis of 154,478 patients

Background

The objective of this study is to investigate the effect of allergies on complications following total shoulder arthroplasty (TSA).

Materials and Methods

All data were collected by using the PearlDiver national database to identify patients who had undergone TSA (anatomic or reverse) between 1 January 2010 and 31 October 2021. Patients were stratified into two groups: allergies and no allergies. Comparisons were made regarding complications and revision surgeries. Complications were compared at 30 and 90 days. Revisions were compared at 1, 5 and 10 years postoperatively.

Results

This study identified 28,182 patients with allergies and 126,296 patients without allergies. Patients with allergies were more likely to require revision surgery at all time points analyzed (p < 0.001). Patients with allergies were more likely to have sepsis within 30 (OR 1.53 [1.30-1.80], p < 0.001) and 90 days (1.71 [1.51-1.94], p < 0.001) postoperatively. Patients with allergies were more likely to experience a wound complication within 30 (1.89 [1.58-2.26], p < 0.001) and 90 days (1.81 [1.58-2.08], p < 0.001). The allergy group experienced higher rates of prosthetic joint infections (PJI) (2.14 [1.81-2.54], p < 0.001) and implant complications at 90 days (1.52 [1.42-1.62], p < 0.001).

Discussion

Patients with allergies were more likely to require revision surgery, experience wound complications, sepsis and PJI following TSA.

The impact of allergies on patient-reported outcomes after total hip and knee arthroplasty: a systematic review and meta-analysis

INTRODUCTION

Metal hypersensitivity has been associated with persistent symptoms after total hip arthroplasty (THA) and total knee arthroplasty (TKA), despite successful joint replacement. Allergies frequently co-occur and have been linked to psychiatric disturbances such as anxiety. There is a knowledge gap regarding the effect of allergies, including metal hypersensitivity, on patient-reported outcome measures (PROMs) after THA and TKA. This study aimed to evaluate the influence of allergies including metal hypersensitivity on PROMs in patients undergoing THA and TKA.

MATERIAL AND METHODS

A systematic search PROSPERO (CRD42023475972) was conducted using PubMed, EMBASE, Scopus, and Cochrane databases. Studies that compared allergic and non-allergic adults undergoing primary THA or TKA and reported PROMs were included. Methodological quality was assessed using the MINORS criteria. The mean differences (MD) and standardized mean differences (SMD) with 95% confidence intervals (CI) were calculated. Eight studies, involving 33,808 patients, were included.

RESULTS

For functional outcomes assessed using SF-12, SF-36, KOOS JR, and HOOS JR, allergic patients demonstrated significantly worse scores (SMD - 0.23, 95% CI -0.36 to -0.09). The WOMAC functional scale also demonstrated poorer results in allergic patients (MD 2.49, 95% CI 0.64 4.35). For pain assessed using the WOMAC pain scale, allergic patients reported significantly greater pain (MD 1.04, 95% CI 0.46 1.62). Changes in mental status assessed using the SF-12 and SF-36 did not show significant differences between the groups (MD -0.46, 95% CI -1.40 to 0.47). In subgroup analysis, patients in the THA subgroup showed significantly worse outcomes (MD -7.20, 95% CI -12.97 - -1.43).

CONCLUSION

This meta-analysis found that patients with allergies, including metal hypersensitivity, generally had worse functional outcomes after THA and TKA than patients without allergies. Further research is required to confirm these findings. Preoperative allergy screening can identify individuals at risk of treatment optimization.

Immune Hypersensitivity Is Associated With Higher Graft Failure Rate After Osteochondral Allograft Transplantation of the Knee

Purpose

To analyze the effects of 1 or more patient-reported allergies on clinical outcomes, in particular graft failure rate, and patient-reported outcomes (PROs) following osteochondral allograft transplantation (OCA) of the knee.

Methods

Retrospective review of patients who underwent knee OCA from August 2010 to May 2021 with a minimum of 2-year follow-up. Patients were initially divided into 2 cohorts: those with at least 1 allergy and those without any allergies. Clinical outcomes assessed included graft failure, reoperation rates, deep vein thrombosis/pulmonary embolism, and manipulation under anesthesia/lysis of adhesions (MUA/LOA). PROs assessed, including the visual analog scale (VAS) for pain and satisfaction, the Knee injury and Osteoarthritis Outcome Score (KOOS), and return to sport rates, were compared.

Results

In total, 285 patients were included with a mean clinical follow-up of 4.8 ± 2.0 years. The allergy cohort had a significantly higher rate of graft failure (P = .008). In a regression analysis controlling for confounding variables, graft failure remained significantly associated with the presence of medication allergies (odds ratio [OR], 3.631; 95% CI, 1.139-11.577; P = .029). Furthermore, an increasing number of allergies were associated with an increased rate of graft failure (OR, 1.644; 95% CI, 1.074-2.515; P = .022). There was no difference in rate of reoperation, complications, infection, and MUA/LOA. Of the 100 patients who completed PROs, there was no difference in VAS satisfaction, pain, and any of the KOOS outcome scores or return to sport.

Conclusions

The presence of 1 or more patient-reported allergies was shown to be significantly associated with OCA graft failure. Furthermore, an increasing number of patient-reported allergies were associated with a higher rate of graft failure. However, there were no significant differences in VAS satisfaction or pain, KOOS symptom, quality of life, pain, or return to sport in patients with at least 1 patient-reported allergy and those without allergies.

Level of Evidence

Level III, retrospective cohort study.

Patient-reported allergies are associated with increased rate of postoperative stiffness after arthroscopic rotator cuff repair

BACKGROUND

Several risk factors have been identified for the development of postoperative shoulder stiffness, and there has been increasing interest in orthopedic literature regarding patient-reported allergy (PRA) as an identifiable risk factor for adverse outcomes. The purpose of this study is to determine whether PRAs are associated with subsequent rates of diagnosis of adhesive capsulitis (AC) or return to the operating room for postoperative shoulder stiffness within 2 years after arthroscopic rotator cuff repair (ARCR).

METHODS

Current Procedural Terminology surgical billing codes were used to retrospectively identify patients who underwent ARCR at a single urban academic institution from January 2012 to December 2020 with minimum 2-year follow-up. Lysis of adhesions (LOA), manipulation under anesthesia (MUA), and AC of the shoulder were further queried within 2 years postoperatively for the ipsilateral shoulder. Patients were excluded if they had undergone ipsilateral MUA/LOA or received a diagnosis of AC before the index procedure. Demographic characteristics and medical comorbidities (hypertension, diabetes, hyperlipidemia, and hypothyroidism) were extracted from electronic medical records. Baseline characteristics were compared between patients with and without PRAs. Multivariate logistic regression analyses were performed to determine the association of the presence of PRAs overall, as well as the presence of 1, 2, or 3 or more PRAs, with subsequent MUA/LOA or diagnosis of AC within 2 years postoperatively.

RESULTS

Of 7057 patients identified in the study period, 6583 were eligible for the final analysis. The mean age was 56.6 ± 11.7 years, and the mean body mass index was 29.1 ± 5.6. Overall, 19.3% of patients (n = 1271) reported at least 1 allergy, and 7.1% (n = 469) had >1 PRA. A total of 44 patients (0.7%) underwent subsequent ipsilateral MUA/LOA within 2 years postoperatively, whereas 93 patients (1.4%) received a diagnosis of ipsilateral AC in the same time frame. PRAs were significantly associated with subsequent diagnosis of AC (odds ratio [OR]: 2.39; 95% confidence interval [CI]: 1.45-3.92; P < .001), but not MUA/LOA (OR: 1.97, 95% CI: 1.26-3.61; P = .133). Patients with 2 PRAs had greater odds of being diagnosed with AC than patients with 1 PRA (OR: 2.74; 95% CI: 1.14-5.99; P = .012). Although this association was nonsignificant for MUA/LOA, patients with 2 PRAs (OR: 2.67; 95% CI: 0.96-8.80; P = .059) demonstrated a similar statistical trend.

CONCLUSION

PRAs are associated with increased odds of receiving a diagnosis of AC within 2 years after ARCR but were not found to be associated with return to the operating room for postoperative stiffness.

Impact of Patient-Reported Allergies on Post-operative Complications and Healthcare Utilization Following Carpal Tunnel Release

INTRODUCTION

Open carpal tunnel release (O-CTR) is associated with high patient satisfaction and low complication rates. Risk factors for complications are well-established. Recent studies have found that patient-reported allergies (PRAs) and psychiatric comorbidities may be associated with increased complication rates. The impact of these factors after elective hand surgery has not been evaluated. This study sought to identify whether PRAs and psychiatric comorbidities are associated with complications after O-CTR and to evaluate their association with prolonged follow-up and the need for post-operative occupational therapy (OT).

METHODS

Patient demographics, PRAs, Patient Health Questionnaire-2 score, Charlson Comorbidity Index, Carpal Tunnel Symptoms-6 score, postoperative complications, OT utilization, and time to final follow-up were recorded for patients who underwent elective O-CTR between 2014 and 2022. Multivariable binomial logistic regression analysis was used to determine pre-operative variables associated with increased risk for complication.

RESULTS

About 250 patients met the inclusion criteria. Fifty-one (20.4%) patients developed minor complications, including scar tenderness (N=34, 13.6%), superficial wound dehiscence (N=9, 3.6%), and superficial infection (N=8, 3.2%). There were no major complications. Independent risk factors for complications included PRAs (OR 1.80, p<0.01) and PHQ-2 score (OR 1.39, p=0.04). Five or more PRAs and PHQ-2 score ≥3 are significant independent risk factors for increased post-operative complications. Increased PRAs and PHQ-2 scores were associated with longer follow-up (p=0.01 and p<0.01, respectively) but not increased OT utilization.

CONCLUSION

An increased number of PRAs and higher PHQ-2 scores are significant, independent risk factors for minor complications following O-CTR. Risk adjustment and peri-operative counseling should incorporate and account for these variables.

Increasing patient-reported allergies are not associated with pain, functional outcomes, or satisfaction following medial patellofemoral ligament reconstruction: a retrospective comparative cohort study

Background

Patient-reported allergies (PRAs) are often stigmatized as a potential nonmodifiable risk factor for increased pain and worse functional outcomes following surgery. However, there is a dearth of literature directly assessing the impact of PRAs on outcomes in sport surgeries such as medial patellofemoral ligament reconstruction (MPFLR). The purpose of our study was to determine whether PRAs were associated with worse outcomes following MPFLR.

Methods

We conducted a retrospective review of patients who underwent MPFLR at our institution from 2011 to 2019. Patients were included if they had at least 12 months of follow-up. PRAs were obtained from preoperative medical assessments and categorized by drug class. Demographic and perioperative data were obtained from electronic medical records. Postoperative outcomes were measured using a telephone survey and included recurrent instability, Visual analog scale (VAS) for pain, VAS for sports, Kujala score, MPFL-Return to Sport after Injury (MPFL-RSI) score, and overall satisfaction score. Multiple linear regression was used to determine association between PRAs and outcome measures, and p-values less than 0.05 were considered significant.

Results

The cohort included 141 MPFLR. Most patients were female (98, 70%) with an average age of 25 years (range 12–56 years). Average follow-up time was 47 months. Forty-seven patients (33%) reported at least one PRA. There were no significant differences in postoperative pain, functional outcomes, satisfaction, or return to sport between patients with or without PRAs (all p > 0.05). Absence of antibiotic PRAs was predictive of higher VAS (p < 0.007), but there were no other differences. There were no significant differences in outcomes between patients without PRAs, PRAs without a concomitant psychiatric disorder, or PRAs with a concomitant psychiatric disorder (all p > 0.05).

Conclusions

In conclusion, PRAs with or without concomitant psychiatric diagnoses are not associated with worse postoperative pain, functional outcomes, or satisfaction following MPFLR with allograft, dispelling common misconceptions that increased number of allergies or psychiatric diagnoses lead to inferior surgical outcomes. Presence of antibiotic allergies was associated with lower VAS postoperative pain score. Future research should investigate the relationship between PRAs and other surgeries in the field of sports medicine.

Risk Factors for Periprosthetic Joint Infection after Primary Total Knee Arthroplasty

Periprosthetic joint infection (PJI) is a major adverse event of primary total knee arthroplasty (TKA) from the patient's perspective, and it is also costly for health care systems. In 2010, the reported incidence of PJI in the first 2 years after TKA was 1.55%, with an incidence of 0.46% between the second and tenth year. In 2022, it has been published that 1.41% of individuals require revision TKA for PJI. The following risk factors have been related to an increased risk of PJI: male sex, younger age, type II diabetes, obesity class II, hypertension, hypoalbuminemia, preoperative nutritional status as indicated by prognostic nutritional index (PNI) and body mass index, rheumatoid arthritis, post-traumatic osteoarthritis, intra-articular injections prior to TKA, previous multi-ligament knee surgery, previous steroid therapy, current tobacco use, procedure type (bilateral), length of stay over 35 days, patellar resurfacing, prolonged operative time, use of blood transfusions, higher glucose variability in the postoperative phase, and discharge to convalescent care. Other reported independent risk factors for PJI (in diminishing order of importance) are congestive heart failure, chronic pulmonary illness, preoperative anemia, depression, renal illness, pulmonary circulation disorders, psychoses, metastatic tumor, peripheral vascular illness, and valvular illness. Preoperative intravenous tranexamic acid has been reported to diminish the risk of delayed PJI. Knowing the risk factors for PJI after TKA, especially those that are avoidable or controllable, is critical to minimizing (ideally preventing) this complication. These risk factors are outlined in this article.