Risk factors for prosthetic joint infections following total hip arthroplasty based on 33,337 hips in the Finnish Arthroplasty Register from 2014 to 2018

Low-Volume Surgeons Operating at High-Volume Hospitals Have Low Rates of Periprosthetic Joint Infection After Hip and Knee Arthroplasty

BACKGROUND

The relationship between surgeon and hospital case volumes and postoperative risk following total hip arthroplasty and total knee arthroplasty (THA and TKA) has been described independently. This study aimed to assess the risk of periprosthetic joint infection (PJI) following primary TKA and THA to determine if lower volume surgeons operating at higher volume centers would have lower rates of complications compared to lower volume surgeons operating at lower volume hospitals.

METHODS

A health care database was used to retrospectively identify all primary and elective total joint arthroplasties from October 2015 to December 2021. Using restricted cubic splines, high-volume hospitals were defined using Markov chain Monte Carlo simulation, which identified a volume beyond which PJI rates no longer decreased significantly with increasing hospital volume. A similar methodology was used to identify low-volume surgeons operating in high- and low-volume hospitals. There were 605,254 patients who underwent total joint arthroplasty (THA: 37.71%; TKA: 62.29%) by low-volume surgeons (< 57 THAs and < 68 TKAs) identified and divided into high- and low-volume hospital cohorts. High-volume hospitals were defined as > 508 THA and > 812 TKAs per year, and low-volume hospitals were defined as < 145 THAs and < 243 TKAs per year. Multivariable models accounting for potential confounding covariates were created to determine the odds of PJI between cohorts.

RESULTS

After taking confounding variables into account, low-volume surgeons at high-volume hospitals had lower rates of PJI relative to their counterparts at low-volume hospitals (THA 0.67 versus 0.80%, adjusted odds ratio = 0.69 [95% confidence interval = 0.54 to 0.88], P = 0.002; TKA 0.51 versus 0.69%, adjusted odds ratio = 0.73, [95% confidence interval = 0.61 to 0.87], P = 0.007).

CONCLUSIONS

Increasing institutional case volume may mitigate the increased risk of PJI associated with low annual surgeon case volume.

The Application of artificial intelligence in periprosthetic joint infection

Periprosthetic joint infection (PJI) represents one of the most devastating complications following total joint arthroplasty, often necessitating additional surgeries and antimicrobial therapy, and potentially leading to disability. This significantly increases the burden on both patients and the healthcare system. Given the considerable suffering caused by PJI, its prevention and treatment have long been focal points of concern. However, challenges remain in accurately assessing individual risk, preventing the infection, improving diagnostic methods, and enhancing treatment outcomes. The development and application of artificial intelligence (AI) technologies have introduced new, more efficient possibilities for the management of many diseases. In this article, we review the applications of AI in the prevention, diagnosis, and treatment of PJI, and explore how AI methodologies might achieve individualized risk prediction, improve diagnostic algorithms through biomarkers and pathology, and enhance the efficacy of antimicrobial and surgical treatments. We hope that through multimodal AI applications, intelligent management of PJI can be realized in the future.

Risk factors for surgical site infection after hip replacement: A systematic review and meta-analysis

BACKGROUND

We conducted a meta-analysis to determine the risk of infection following hip replacement and identified risk factors for surgical site infection.

METHODS

We systematically searched the PubMed/Medline, Embase and Cochrane Library databases, as well as the reference lists of previous systematic reviews and meta-analyses. The pooled odds ratio (OR) was estimated using a random effects model for each investigated factor. The evidence of observational studies was classified as high quality (class I), moderate quality (class II or III) or low quality (class IV) based on the GRADE system.

RESULTS

A total of 25,383 potential articles met the inclusion criteria in the database search. After reviewing the titles, abstracts, and full texts, 27 articles were included in the final analysis, encompassing 699,473 patients who underwent hip arthroplasty. High-quality evidence shows that BMI (≥30 kg/m2) (OR 2.16; 95% CI 1.72-2.70), male sex (OR 1.39; 95% CI 1.26-1.53), operation time (≥120 min) (OR 1.72; 95% CI 1.39-2.14), ASA class ≥3 (OR 2.05; 95% CI 1.49-2.83), diabetes (OR 1.33; 95% CI 1.23-1.43), and heart disease (OR 1.99; 95% CI 1.48-2.68) are associated with a greater risk of infection. The meta-analysis revealed that age and renal disease were not associated with infection.

CONCLUSION

This meta-analysis identified significant risk factors for infection after hip replacement surgery, including BMI, male sex, operation time, heart disease, diabetes, and ASA class.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and Level IV studies.

TRIAL REGISTRATION NUMBER

The review protocol was registered in PROSPERO. Unique Identifying Number (UIN) is "CRD42024535902".Hyperlink to the specific registration (must be publicly accessible and will be checked): "https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=535902".

Predicting periprosthetic joint infection in primary total knee arthroplasty: a machine learning model integrating preoperative and perioperative risk factors

BACKGROUND

Periprosthetic joint infection leads to significant morbidity and mortality after total knee arthroplasty. Preoperative and perioperative risk prediction and assessment tools are lacking in Asia. This study developed the first machine learning model for individualized prediction of periprosthetic joint infection following primary total knee arthroplasty in this demographic.

METHODS

A retrospective analysis was conducted on 3,483 primary total knee arthroplasty (81 with periprosthetic joint infection) from 1998 to 2021 in a Chinese tertiary and quaternary referral academic center. We gathered 60 features, encompassing patient demographics, operation-related variables, laboratory findings, and comorbidities. Six of them were selected after univariate and multivariate analysis. Five machine learning models were trained with stratified 10-fold cross-validation and assessed by discrimination and calibration analysis to determine the optimal predictive model.

RESULTS

The balanced random forest model demonstrated the best predictive capability with average metrics of 0.963 for the area under the receiver operating characteristic curve, 0.920 for balanced accuracy, 0.938 for sensitivity, and 0.902 for specificity. The significant risk factors identified were long operative time (OR, 9.07; p = 0.018), male gender (OR, 3.11; p < 0.001), ASA > 2 (OR, 1.68; p = 0.028), history of anemia (OR, 2.17; p = 0.023), and history of septic arthritis (OR, 4.35; p = 0.030). Spinal anesthesia emerged as a protective factor (OR, 0.55; p = 0.022).

CONCLUSION

Our study presented the first machine learning model in Asia to predict periprosthetic joint infection following primary total knee arthroplasty. We enhanced the model's usability by providing global and local interpretations. This tool provides preoperative and perioperative risk assessment for periprosthetic joint infection and opens the potential for better individualized optimization before total knee arthroplasty.

Choice of Bearings Influences the Implant Survival of Total Hip Arthroplasty in Patients Who Have Osteoarthritis Aged 55 Years or Older: Results of 158,044 Patients From the Nordic Arthroplasty Register Association From 2005 to 2017

BACKGROUND

The aim of our study was to compare implant survival rates of different total hip arthroplasty (THA) bearings in the Nordic Arthroplasty Register Association.

METHODS

All conventional primary THAs performed between 2005 and 2017 in patients aged more than 55 years who had primary osteoarthritis were studied. Metal-on-highly cross-linked polyethylene (MoXLP), ceramic-on-highly cross-linked polyethylene (CoXLP), ceramic-on-ceramic (CoC), and metal-on-metal (MoM) bearings were included. The outcome was a revision. Kaplan-Meier (KM) estimates were calculated at 5 and 10 years. The risk for revision was analyzed using a flexible parametric survival model adjusted for nation, age, sex, femoral head size, and femoral fixation.

RESULTS

A total of 158,044 THAs were included. The 5-year KM estimates were 95.9% (95% confidence interval [CI] 95.8 to 96.1) in MoXLP, 95.8% (95% CI 95.6 to 96.1) in CoXLP, 96.7% (95% CI 96.4 to 97.0) in CoC, and 93.9% (95% CI 93.5 to 94.4) in MoM. The 10-years KM estimates were 94.2% (94.0 to 94.5) in MoXLP, 94.3% (93.9 to 94.8) in CoXLP, 95.4% (95.0 to 95.9) in CoC, and 85.5% (84.9 to 86.2) in MoM. Compared with MoXLP, the adjusted risk for revision was lower in CoC (hazard ratio [HR] 0.6, CI 0.5 to 0.6), similar in CoXLP (HR 1.0, CI 0.9 to 1.0), and higher in MoM (HR 1.3, CI 1.2 to 1.4).

CONCLUSIONS

We found that MoXLP, CoXLP, and CoC bearings evinced comparably high implant survival rates up to 10 years, and they can all be regarded as safe options in this patient group. The MoM bearings were associated with clearly lower survivorship. The CoC bearings had the highest implant survival and a lower adjusted risk for revision compared with highly cross-linked polyethylene bearings.

Prognosis after one- and two-stage revision surgery for periprosthetic joint infection: A systematic review and meta-analysis

OBJECTIVE

Revision surgeries for periprosthetic joint infections (PJIs) in arthroplasty can follow either one- or two-stage treatment protocols. Previous studies have reported similar reinfection rates and reductions in complication rates for both treatment options. However, the literature on the selection of one protocol is still controversial. Thus, our aim was to compare the outcomes, including reinfections, complications, reoperations, and mortality, associated with one- and two-stage revision surgeries for PJI via a systematic review and meta-analysis of comparative studies.

METHODS

Comparative studies were identified through searches in PubMed, EMBASE, the Web of Science, and the Cochrane Library as of November 2023. RevMan version 5.3 was used for the analyses. The included studies directly compared one-stage revisions with two-stage revisions for PJI. The primary outcomes included reinfection, complications, reoperation, and mortality.

RESULTS

Sixteen cohort studies (fifteen retrospective and one prospective) were included in the systematic review. All studies comprising 2039 patients were included in the meta-analysis. Fourteen studies reported reinfection patient risk postrevision; when pooled via random effects models, 10.02% of patients in the one-stage group and 14.75% of patients in the two-stage group were reinfected, indicating low heterogeneity (risk ratio = 0.69; 95% CI = 0.50 - 0.94, I2 = 0%). A pooled analysis of ten studies reported complications between the two groups. Compared with the two-stage group, the one-stage group was associated with significantly fewer complications (risk ratio = 0.76; 95% CI = 0.63 - 0.91, I2 = 27%). The meta-analysis revealed no significant difference in reoperation events between the 1st-stage and 2nd-stage groups in nine studies (risk ratio = 0.77; 95% CI = 0.59 - 1.01, I2 = 20%) or in mortality in ten studies (risk ratio = 0.93; 95% CI = 0.49 - 1.78, I2 = 0%).

CONCLUSIONS

Among the available observational studies, the meta-analysis revealed a lower incidence of reinfection and complications in the one-stage group than in the two-stage group, but there were no significant differences in reoperation events or mortalities.

Association between IV and topical tranexamic acid use and periprosthetic joint infections in hip and knee arthroplasty: a retrospective study

BACKGROUND

Anemia and blood transfusions are recognized as risk factors for periprosthetic joint infections (PJI). Tranexamic acid (TXA) is established in reducing perioperative blood loss and transfusion requirements. Our study investigates the impact of perioperative TXA administration on the incidence of PJI in patients undergoing total joint arthroplasty (TJA) and evaluates the association of intravenous (IV) and topical applications with PJI occurrence.

METHODS

A retrospective review was performed on 8042 patients who underwent primary total hip arthroplasty (THA) and knee arthroplasty (TKA) from January 2009 to December 2020, with a minimum one-year follow-up at our institution. We compared patients who received TXA (n = 3664, with 2345 receiving it IV and 1319 topically) to those who did not (n = 4378). 0.5-1.25 g of IV TXA was administered before skin incision, and 1.5-3 g of topical TXA was injected intra-articularly or into the drainage tube during surgery. The primary outcome was PJI development within one year, defined by the 2013 International Consensus Meeting criteria. Secondary outcomes included blood transfusion, hospital length of stay (LOS), venous thromboembolism (VTE), and 90-day readmission. We employed multivariate logistic regression and propensity score weighting to adjust for potential confounders and conducted subgroup analyses to assess PJI odds in TKA and THA patients treated with IV and topical TXA.

RESULTS

The TXA group demonstrated a lower PJI occurrence (1.1% vs. 2.1%, p < 0.001), less blood transfusion (14.4% vs. 22.7%, p < 0.001) and shorter LOS (5.6 ± 1.6 vs. 6.5 ± 2.5, p < 0.001) compared to those without TXA. There was no difference between the two groups with regards to VTE and 90-day readmission. Perioperative TXA administration demonstrated lower PJI in multivariate analysis (OR 0.54, 95% CI 0.36-0.80, p = 0.002), and in propensity score weighting (OR 0.53, 95% CI 0.36-0.80, p = 0.002). In the subgroup analysis, both IV and topical administration of TXA resulted in decreased PJI (IV group: OR 0.53, 95% CI, 0.33-0.84, p = 0.007, topical group: OR 0.51, 95% CI, 0.29-0.89, p = 0.018), especially in primary TKA (IV TXA, OR 0.49, 95% CI, 0.29-0.83, p = 0.008; Topical TXA, OR, 0.56, 95% CI, 0.32-0.98, p = 0.042).

CONCLUSION

Perioperative TXA administration in primary hip and knee arthroplasty is significantly associated with a reduced PJI occurrence. Both IV and topical TXA routes showed similar association with reduced PJI occurrence, with a notable correlation observed in primary TKA.

Prediction of Early Adverse Events After THA: A Comparison of Different Machine-Learning Strategies Based on 262,356 Observations From the Nordic Arthroplasty Register Association (NARA) Dataset

OBJECTIVE

Preoperative risk prediction models can support shared decision-making before total hip arthroplasties (THAs). Here, we compare different machine-learning (ML) approaches to predict the six-month risk of adverse events following primary THA to obtain accurate yet simple-to-use risk prediction models.

METHODS

We extracted data on primary THAs (N = 262,356) between 2010 and 2018 from the Nordic Arthroplasty Register Association dataset. We benchmarked a variety of ML algorithms in terms of the area under the receiver operating characteristic curve (AUROC) for predicting the risk of revision caused by periprosthetic joint infection (PJI), dislocation or periprosthetic fracture (PPF), and death. All models were internally validated against a randomly selected test cohort (one-third of the data) that was not used for training the models.

RESULTS

The incidences of revisions because of PJI, dislocation, and PPF were 0.8%, 0.4%, and 0.3%, respectively, and the incidence of death was 1.2%. Overall, Lasso regression with stable iterative variable selection (SIVS) produced models using only four to five input variables but with AUROC comparable to more complex models using all 32 variables available. The SIVS-based Lasso models based on age, sex, preoperative diagnosis, bearing couple, fixation, and surgical approach predicted the risk of revisions caused by PJI, dislocations, and PPF, as well as death, with AUROCs of 0.61, 0.67, 0.76, and 0.86, respectively.

CONCLUSION

Our study demonstrates that satisfactory predictive potential for adverse events following THA can be reached with parsimonious modeling strategies. The SIVS-based Lasso models may serve as simple-to-use tools for clinical risk assessment in the future.

Association between dental procedures and periprosthetic joint infection: A case-crossover study

BACKGROUND

Although the risk of dental procedures as a cause of bacteremia has been recognized, evidence regarding the association between dental procedures and late periprosthetic joint infection (LPJI) is scarce. We sought to determine whether dental procedures are associated with an increased risk of LPJI.

METHODS

The study was conducted under a case-crossover design using a large claims database in Japan. We identified adult patients who had undergone dental procedures and were hospitalized for LPJI between April 2014 and September 2021. Exposure to dental procedures was assessed during a case period of 1-4 weeks, with two control periods of 9-12 weeks and 17-20 weeks, preceding LPJI hospital admission. Conditional logistic regression models were used to calculate the odds ratios (ORs) and 95% confidence intervals (CIs) of LPJI associated with dental procedures in the case period compared with the two control periods.

RESULTS

In total, 241 patients with LPJI were included in the case-crossover study. At least one dental procedure was performed in 46 patients (19.1%) in the hazard period and in 75 patients (31.1%) in the control periods. The OR for LPJI with dental procedures was 0.96 (95% CI, 0.61-1.53; p = 0.88). Findings were robust in several sensitivity analyses, including stratification by whether the dental procedure included antibiotic prophylaxis.

CONCLUSIONS

This study suggests that dental procedures are not associated with increased risk of LPJI, and will raise questions about the recommendation for antibiotic prophylaxis before dental procedures.

Mouldable Collagen-Tricalciumphosphate Is a Safe Carrier for Local Antibiotics-Short-Term Results in Revision Hip Arthroplasty

BACKGROUND

Improving local antibiotic delivery is a promising approach to improve infection control and potentially shorten systemic treatment in periprosthetic joint infection (PJI). This study investigates the use of an antibiotic-loaded, mouldable collagen-tricalciumphosphate composite in treatment of hip PJI.

METHODS

124 application cases in 79 patients were included from a referral centre; systemic adverse infects, local complications, and infection control were analysed.

RESULTS

In most cases, either vancomycin or meropenem were used. Pathogens were previously known in 82 (66%) cases with polymicrobial infection in 20 (25%) patients. There were no cases of hypercalcaemia. Acute kidney injure was present in 14 (11%) cases. Chronic kidney failure persisted in two cases. During a mean follow-up of 12 (SD 9.3; range 3-35) months, implant survival was achieved in 73 (92%) patients; revision due to PJI was performed in 19 cases.

CONCLUSION

Mouldable collagen-tricalciumphosphate composite bone substitute as a local antibiotic carrier in revision hip arthroplasty appears to be a valid option for local antibiotic delivery without systemic complications. Implant survival of 92% supports the hypothesis that local antibiotic therapy is an important component in the treatment of PJI.

Compensation Claims After Hip Fracture Surgery in Norway 2008-2018

Background

Surgical complications contribute to the significant mortality following hip fractures in the elderly. The purpose of this study was to increase our knowledge of surgical complications by evaluating compensation claims following hip fracture surgery in Norway. Further, we investigated whether the size and location of performing institutions would influence surgical complications.

Methods

We collected data from the Norwegian System of Patient Injury Compensation (NPE) and the Norwegian Hip Fracture Register (NHFR) from 2008 to 2018. We classified institutions into 4 categories based on annual procedure volume and geographical location.

Results

90,601 hip fractures were registered in NHFR. NPE received 616 (.7%) claims. Of these, 221 (36%) were accepted, which accounts for .2% of all hip fractures. Men had nearly a doubled risk of ending with a compensation claim compared to women (OR: 1.8, CI, 1.4-2.4, P < .001). Hospital-acquired infection was the most frequent reason for accepted claims (27%). However, claims were rejected if patients had underlying conditions predisposing to infection. Institutions treating fewer than 152 hip fractures (first quartile) annually, had a statistically significant increased risk (OR: 1.9, CI, 1.3-2.8, P = .005) for accepted claims compared to higher volume facilities.

Discussion

The fewer registered claims in our study could be due to the relatively high early mortality and frailty in this patient group, which may decrease the likelihood of filing a complaint. Men could have undetected underlying predisposing conditions that lead to increased risk of complications. Hospital-acquired infection may be the most significant complication following hip fracture surgery in Norway. Lastly, the number of procedures performed annually in an institution influences compensation claims.

Conclusions

Our findings indicate that hospital acquired infections need greater focus following hip fracture surgery, especially in men. Lower volume hospitals may be a risk factor.

Transverse posterior wall acetabular fracture pattern is associated with increased risk of periprosthetic joint infection after conversion total hip arthroplasty

INTRODUCTION

Acetabular fracture subtypes are associated with varying rates of subsequent conversion total hip arthroplasty (THA) after open reduction internal fixation (ORIF) with transverse posterior wall (TPW) patterns having a higher risk for early conversion. Conversion THA is fraught with complications including increased rates of revision and periprosthetic joint infections (PJI). We aimed to determine if TPW pattern is associated with higher rates of readmissions and complications including PJI after conversion compared to other subtypes.

METHODS

We retrospectively reviewed 1,938 acetabular fractures treated with ORIF at our institution from 2005 to 2019, of which 170 underwent conversion that met inclusion criteria, including 80 TPW fracture pattern. Conversion THA outcomes were compared by initial fracture pattern. There was no difference between the TPW and other fracture patterns in age, BMI, comorbidities, surgical variables, length of stay, ICU stay, discharge disposition, or hospital acquired complications related to their initial ORIF procedure. Multivariable analysis was performed to identify independent risk factors for PJI at both 90-days and 1-year after conversion.

RESULTS

TPW fracture had higher risk of PJI after conversion THA at 1-year (16.3% vs 5.6%, p = 0.027). Multivariable analysis revealed TPW independently carried increased risk of 90-day (OR 4.89; 95% CI 1.16-20.52; p = 0.03) and 1-year PJI (OR 6.51; 95% CI 1.56-27.16; p = 0.01) compared to the other acetabular fracture patterns. There was no difference between the fracture cohorts in 90-day or 1-year mechanical complications including dislocation, periprosthetic fracture and revision THA for aseptic etiologies, or 90-day all-cause readmission after the conversion procedure.

CONCLUSION

Although conversion THA after acetabular ORIF carry high rates of PJI overall, TPW fractures are associated with increased risk for PJI after conversion compared to other fracture patterns at 1-year follow-up. Novel management/treatment of these patients either at the time of ORIF and/or conversion THA procedure are needed to reduce PJI rates.

LEVEL OF EVIDENCE

Therapeutic Level III (retrospective study of consecutive patients undergoing an intervention with analyses of outcomes).

The Role of Single Positive Cultures in Presumed Aseptic Total Hip and Knee Revision Surgery-A Systematic Review of the Literature

(1) Background: Prior to revision hip (THA) or knee arthroplasty (TKA), periprosthetic low-grade infection (PJI) should be ruled out. Despite advances in preoperative diagnosis, unsuspected positive cultures (UPCs) may occur in initially planned aseptic revisions. Particularly, single UPCs pose a diagnostic and therapeutic dilemma, as their impact on outcome is unclear and recommendations are heterogeneous. This review investigates the frequency of single UPCs and their impact on implant survivorship. (2) Methods: In July 2022, a comprehensive literature search was performed using PubMed and Cochrane Library search. In total, 197 articles were screened. Seven retrospective studies with a total of 5821 cases were able to be included in this review. (3) Results: Based on the cases included, UPCs were found in 794/5821 cases (14%). In 530/794 cases (67%), the majority of the UPCs were single positive. The most commonly isolated pathogens were coagulase negative Staphylococci and Cutibacterium acnes. Five of seven studies reported no influence on revision- or infection-free survival following a single positive culture. In two studies, single UPCs following THA revision were correlated with subsequent re-revision for PJI. (4) Conclusions: Single UPCs of a non-virulent pathogen following presumed aseptic TKA revision may be interpreted as contaminants. A single UPC following THA revision may be a risk factor for subsequent PJI. The role of systemic antibiotic treatment remains unclear, but it should be considered if other risk factors for PJI are present.

Risk factors for revision due to prosthetic joint infection following total knee arthroplasty based on 62,087 knees in the Finnish Arthroplasty Register from 2014 to 2020

BACKGROUND AND PURPOSE

Periprosthetic joint infection (PJI) is the commonest reason for revision after total knee arthroplasty (TKA). We assessed the risk factors for revision due to PJI following TKA based on the Finnish Arthroplasty Register (FAR).

PATIENTS AND METHODS

We analyzed 62,087 primary condylar TKAs registered between June 2014 and February 2020 with revision for PJI as the endpoint. Cox proportional hazards regression was used to estimate hazard ratios (HR) with 95% confidence intervals (CI) for the first PJI revision using 25 potential patient- and surgical-related risk factors as covariates.

RESULTS

484 knees were revised for the first time during the first postoperative year because of PJI. The HRs for revision due to PJI in unadjusted analysis were 0.5 (0.4-0.6) for female sex, 0.7 (0.6-1.0) for BMI 25-29, and 1.6 (1.1-2.5) for BMI > 40 compared with BMI < 25, 4.0 (1.3-12) for preoperative fracture diagnosis compared with osteoarthritis, and 0.7 (0.5-0.9) for use of an antimicrobial incise drape. In adjusted analysis the HRs were 2.2 (1.4-3.5) for ASA class III-IV compared with class I, 1.7 (1.4-2.1) for intraoperative bleeding ≥ 100 mL, 1.4 (1.2-1.8) for use of a drain, 0.7 (0.5-1.0) for short duration of operation of 45-59 minutes, and 1.7 (1.3-2.3) for long operation duration > 120 min compared with 60-89 minutes, and 1.3 (1.0-1.8) for use of general anesthesia.

CONCLUSION

We found increased risk for revision due to PJI when no incise drape was used. The use of drainage also increased the risk. Specializing in performing TKA reduces operative time and thereby also the PJI rate.

Total Hip and Knee Arthroplasty Surgery in the Morbidly Obese Patient: A Critical Analysis Review

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Obesity, defined as body mass index (BMI) ≥30, is a serious public health concern associated with an increased incidence of stroke, diabetes, mental illness, and cardiovascular disease resulting in numerous preventable deaths yearly.

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From 1999 through 2018, the age-adjusted prevalence of morbid obesity (BMI ≥40) in US adults aged 20 years and older has risen steadily from 4.7% to 9.2%, with other estimates showing that most of the patients undergoing hip and knee replacement by 2029 will be obese (BMI ≥30) or morbidly obese (BMI ≥40).

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In patients undergoing total joint arthroplasty (TJA), morbid obesity (BMI ≥40) is associated with an increased risk of perioperative complications, including prosthetic joint infection and mechanical failure necessitating aseptic revision.

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The current literature on the role that bariatric weight loss surgery before TJA has on improving surgical outcomes is split and referral to a bariatric surgeon should be a shared-decision between patient and surgeon on a case-by-case basis.

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Despite the increased risk profile of TJA in the morbidly obese cohort, these patients consistently show improvement in pain and physical function postoperatively that should be considered when deciding for or against surgery.

The Impact of a Dedicated Multidisciplinary Team Approach for Prosthetic Joint Infections of the Lower Limb

Introduction

Prosthetic joint infections (PJI) of the hip and knee have significant morbidity and mortality, and present with varying local, host and microbiological factors. Given the broad presentation and complexity of PJI’s, we developed a dedicated multidisciplinary team (MDT) to manage this complex patient cohort, and report on our early outcomes.

Methods

This was a retrospective observational study of all patients diagnosed with a prosthetic joint infection of the hip or knee (n = 71) at our institution during a 4.5-year period. Patients treated after development of the MDT (post-MDT) (n = 44), were compared to a control group prior establishment of the MDT (pre-MDT) (n = 27).

Results

85.2% of individuals in the pre-MDT, and 85.7% of individuals in the post-MDT group were considered cured at a minimum 2 years post-operatively according to the Delphi-based definition. The total number of admissions to hospital (2.44 vs. 1.84) and total number of antibiotics used (3.37 vs. 2.75) decreased in the post-MDT group; however, differences were not considered statistically significant.

Discussion

Implementation of a dedicated MDT in the management of individuals with PJI’s of the lower limb at our hospital has allowed early and effective collaboration between healthcare personnel, with early promising results. Given the broad nature of PJI, future studies are ongoing to determine modifiable risk factors to reduce the incidence and improve outcomes of individuals with PJI’s where systems can then be implemented into already established MDTs to achieve the best clinical outcome for our patients.

Effects of total hip arthroplasty and hemiarthroplasty on hip function in patients with traumatic femoral neck fracture

OBJECTIVE

Traumatic femoral neck fracture is a common disease that can be treated by hip arthroplasty, which is divided into hemiarthroplasty (HA) and total hip arthroplasty (THA). The difference between HA and THA are incompletely understood. The objective of this study was to investigate the effect of hip arthroplasty on hip function in patients with traumatic femoral neck fracture.

METHODS

A total of 132 patients with traumatic femoral neck fracture admitted to our hospital from January 2019 to January 2021 were selected and divided into control group (HA group) and study group (THA group) with 66 cases in each group by random number table method. The duration of operation, intraoperative blood loss, postoperative drainage and length of hospital stay were compared between the two groups. The degree of pain before operation, 3 days after operation and 7 days after operation were observed, the hip joint function before operation, 6 months after operation and 12 months after operation was analyzed, and the occurrence of short-term and long-term complications was compared between the two groups.

RESULT

Compared with the HA group, the operative time, intraoperative blood loss, postoperative drainage and hospital stay were higher in the THA group. The degree of pain in THA group was higher than that in HA group on 3 and 7 days after operation; At 6 and 12 months after surgery, the scores of pain, range of motion, joint function and deformity in the THA group were higher than those in the HA group with statistically significant. Compared with HA group, IGF-1 and Leptin in THA group were increased significantly, while inflammatory cytokines TNF-α was decreased in THA group. The total incidence of short-term and long-term complications was lower in THA group.

CONCLUSION

Total hip arthroplasty can effectively restore hip joint function in patients with traumatic femoral neck fracture, with low incidence of short-term and long-term complications, high safety, and worthy of clinical application.

Patient-related factors associated with superficial surgical site infection and progression to a periprosthetic joint infection after elective primary total joint arthroplasty: a single-centre, retrospective study in Sweden

OBJECTIVES

Superficial surgical site infection (SSSI) may increase the risk of serious complications such as periprosthetic joint infection (PJI). This study aims to identify patient-related risk factors associated with SSSI and investigate their correlation with the progression of PJI.

DESIGN

In this retrospective study, 1191 elective hip and knee prostheses were included. Patients were interviewed 3-5 months after surgery to answer questions about the postoperative period. Patient records were reviewed to determine whether there had been any documentation of wound-healing difficulties or whether antibiotics were prescribed to treat an infection related to arthroplasty surgery.

SETTING

Uppsala University Hospital, patients treated between November 2008 and December 2012.

PARTICIPANTS

The study population comprised 433 knees and 758 hips.

OUTCOME MEASURES

We studied patient-related risk factors (joint, age, sex, the American Society of Anesthesiologists (ASA) classification, body mass index (BMI), smoking, diabetes and rheumatic disease) to determine whether they were associated with (1) SSSI and (2) the progress from SSSI to PJI.

RESULTS

84 (7%) patients of the total cohort developed SSSI. This infection progressed to a PJI in 24 (29%) of the patients. Factors with increased adjusted risk ratios (aRRs) for SSSIs were knee surgery (1.7; 95% CI: 1.1 to 2.7), age≥65 years (1.7; 95% CI: 1.1 to 2.8), BMI≥30 (1.9; 95% CI: 1.0 to 3.4) and ASA classification≥3 (1.7; 95% CI: 1.0 to 2.9). ASA classification≥3 was the only factor showing a significant progression from SSSI to PJI (aRR=3.3; 95% CI: 1.0 to 10.3).

CONCLUSIONS

The risk of progressing from an SSSI to a PJI is high. Older patients, patients with obesity, and those with a high ASA classification considered for elective total knee arthroplasty seem to have an increased risk of developing SSSI. Patients with a high ASA classification seem to have an increased risk of progressing from SSSI to PJI.

Pharmacological thromboprophylaxis as a risk factor for early periprosthetic joint infection following primary total joint arthroplasty

Venous thromboembolism (VTE) prophylaxis has been suggested for patients who underwent total join arthroplasty (TJA). However, the morbidity of surgical site complications (SSC) and periprosthetic joint infection (PJI) has not been well evaluated. We aimed to evaluate the impact of VTE prophylaxis on the risk of early postoperative SSC and PJI in a Taiwanese population. We retrospectively reviewed 7511 patients who underwent primary TJA performed by a single surgeon from 2010 through 2019. We evaluated the rates of SSC and PJI in the early postoperative period (30-day, 90-day) as well as 1-year reoperations. Multivariate regression analysis was used to identify possible risk factors associated with SSC and PJI, including age, sex, WHO classification of weight status, smoking, diabetes mellitus (DM), rheumatoid arthritis(RA), Charlson comorbidity index (CCI), history of VTE, presence of varicose veins, total knee or hip arthroplasty procedure, unilateral or bilateral procedure, or receiving VTE prophylaxis or blood transfusion. The overall 90-day rates of SSC and PJI were 1.1% (N = 80) and 0.2% (N = 16). VTE prophylaxis was a risk factor for 90-day readmission for SSC (aOR: 1.753, 95% CI 1.081-2.842), 90-day readmission for PJI (aOR: 3.267, 95% CI 1.026-10.402) and all 90-day PJI events (aOR: 3.222, 95% CI 1.200-8.656). Other risk factors included DM, underweight, obesity, bilateral TJA procedure, younger age, male sex and RA. Pharmacological thromboprophylaxis appears to be a modifiable risk factor for SSC and PJI in the early postoperative period. The increased infection risk should be carefully weighed in patients who received pharmacological VTE prophylaxis.