Top

Clinical Orthopaedics and Related Research®

Published in:

01-11-2017 | Clinical Research

Increased Mortality After Prosthetic Joint Infection in Primary THA

Authors: Per Hviid Gundtoft, MD, PhD, Alma Becic Pedersen, MD, PhD, DMSc, Claus Varnum, MD, PhD, Søren Overgaard, MD, DMSc

Published in: Clinical Orthopaedics and Related Research® | Issue 11/2017

Abstract

Background

Revision for prosthetic joint infection (PJI) has a major effect on patients’ health but it remains unclear if early PJI after primary THA is associated with a high mortality.

Questions/Purposes

(1) Do patients with a revision for PJI within 1 year of primary THA have increased mortality compared with patients who do not undergo revision for any reason within 1 year of primary THA? (2) Do patients who undergo a revision for PJI within 1 year of primary THA have an increased mortality risk compared with patients who undergo an aseptic revision? (3) Are there particular bacteria among patients with PJI that are associated with an increased risk of death?

Methods

This population-based cohort study was based on the longitudinally maintained Danish Hip Arthroplasty Register on primary THA performed in Denmark from 2005 to 2014. Data from the Danish Hip Arthroplasty Register were linked to microbiology databases, the National Register of Patients, and the Civil Registration System to obtain data on microbiology, comorbidity, and vital status on all patients. Because reporting to the register is compulsory for all public and private hospitals in Denmark, the completeness of registration is 98% for primary THA and 92% for revisions (2016 annual report). The mortality risk for the patients who underwent revision for PJI within 1 year from implantation of primary THA was compared with (1) the mortality risk for patients who did not undergo revision for any reason within 1 year of primary THA; and (2) the mortality risk for patients who underwent an aseptic revision. A total of 68,504 primary THAs in 59,954 patients were identified, of those 445 primary THAs underwent revision for PJI, 1350 primary THAs underwent revision for other causes and the remaining 66,709 primary THAs did not undergo revision. Patients were followed from implantation of primary THA until death or 1 year of followup, or, in case of a revision, 1 year from the date of revision.

Results

Within 1 year of primary THA, 8% (95% CI, 6%–11%) of patients who underwent revision for PJI died. The adjusted relative mortality risk for patients with revision for PJI was 2.18 (95% CI, 1.54–3.08) compared with the patients who did not undergo revision for any cause (p < 0.001). The adjusted relative mortality risk for patients with revisions for PJI compared with patients with aseptic revision was 1.87 (95% CI, 1.11–3.15; p = 0.019). Patients with enterococci-infected THA had a 3.10 (95% CI, 1.66–5.81) higher mortality risk than patients infected with other bacteria (p < 0.001).

Conclusions

Revision for PJI within 1 year after primary THA induces an increased mortality risk during the first year after the revision surgery. This study should incentivize further studies on prevention of PJI and on risk to patients with the perspective to reduce mortality in patients who have had THA in general and for patients with PJI specifically.

Level of Evidence

Level III, therapeutic study.

Andersen PK, Klein JP, Rosthøj S. Generalised linear models for correlated pseudo-observations, with applications to multi-state models. Biometrika. 2003;90:15–27.CrossRef

Bank S, Soby KM, Kristensen LH, Voldstedlund M, Prag J. A validation of the Danish microbiology database (MiBa) and incidence rate of Actinotignum schaalii (Actinobaculum schaalii) bacteraemia in Denmark. Clin Microbiol Infect. 2015;21:1097.e1–4.

Charnley J. Postoperative infection after total hip replacement with special reference to air contamination in the operating room. Clin Orthop Relat Res. 1972;87:167–87.

Choi HR, Beecher B, Bedair H. Mortality after septic versus aseptic revision total hip arthroplasty: a matched-cohort study. J Arthroplasty. 2013;28(8 suppl):56–58.CrossRefPubMed

Danish Hip Arthroplasty Register: Annual Report 2016 Available at: https://www.sundhed.dk/content/cms/98/4698_dhr-%C3%A5rsrapport-2016.pdf. 2016. Accessed August 1, 2016.

Gundtoft PH, Overgaard S, Schonheyder HC, Moller JK, Kjaersgaard-Andersen P, Pedersen AB. The “true” incidence of surgically treated deep prosthetic joint infection after 32,896 primary total hip arthroplasties: a prospective cohort study. Acta Orthop. 2015;86:326–334.CrossRefPubMedPubMedCentral

Gundtoft PH, Pedersen AB, Schonheyder HC, Overgaard S. Validation of the diagnosis ‘prosthetic joint infection’ in the Danish Hip Arthroplasty Register. Bone Joint J. 2016;98:320–325.CrossRefPubMed

Jamsen E, Huotari K, Huhtala H, Nevalainen J, Konttinen YT. Low rate of infected knee replacements in a nationwide series: is it an underestimate? Acta Orthop. 2009;80:205–212.CrossRefPubMedPubMedCentral

Kurtz SM, Lau E, Schmier J, Ong KL, Zhao K, Parvizi J. Infection burden for hip and knee arthroplasty in the United States. J Arthroplasty. 2008;23:984–991.CrossRefPubMed

10.

Lindberg-Larsen M, Jorgensen CC, Bagger J, Schroder HM, Kehlet H. Revision of infected knee arthroplasties in Denmark. Acta Orthop. 2016;87:333–338.CrossRefPubMedPubMedCentral

11.

Lindgren JV, Gordon M, Wretenberg P, Karrholm J, Garellick G. Validation of reoperations due to infection in the Swedish Hip Arthroplasty Register. BMC Musculoskelet Disord. 2014;15:384.CrossRefPubMedPubMedCentral

12.

Lindgren V, Gordon M, Wretenberg P, Karrholm J, Garellick G. Deep infection after total hip replacement: a method for national incidence surveillance. Infect Control Hosp Epidemiol. 2014;35:1491–1496.CrossRefPubMed

13.

Lora-Tamayo J, Euba G, Ribera A, Murillo O, Pedrero S, Garcia-Somoza D, Pujol M, Cabo X, Ariza J. Infected hip hemiarthroplasties and total hip arthroplasties: Differential findings and prognosis. J Infect. 2013;67:536–544.CrossRefPubMed

14.

Lutro O, Langvatn H, Dale H, Schrama JC, Hallan G, Espehaug B, Sjursen H, Engesaeter LB. Increasing resistance of coagulase-negative staphylococci in total hip arthroplasty infections: 278 THA-revisions due to infection reported to the Norwegian Arthroplasty Register from 1993 to 2007. Adv Orthop. 2014;2014:580359.CrossRefPubMedPubMedCentral

15.

Pedersen A, Johnsen S, Overgaard S, Soballe K, Sorensen HT, Lucht U. Registration in the danish hip arthroplasty registry: completeness of total hip arthroplasties and positive predictive value of registered diagnosis and postoperative complications. Acta Orthop Scand. 2004;75:434–441.CrossRefPubMed

16.

Quan H, Sundararajan V, Halfon P, Fong A, Burnand B, Luthi JC, Saunders LD, Beck CA, Feasby TE, Ghali WA. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care. 2005;43:1130–1139.CrossRefPubMed

17.

Ranstam J, Karrholm J, Pulkkinen P, Makela K, Espehaug B, Pedersen AB, Mehnert F, Furnes O. Statistical analysis of arthroplasty data: II. Guidelines. Acta Orthop. 2011;82:258–267.CrossRefPubMed

18.

Rasouli MR, Tripathi MS, Kenyon R, Wetters N, Della Valle CJ, Parvizi J. Low rate of infection control in enterococcal periprosthetic joint infections. Clin Orthop Relat Res. 2012;470:2708–2716.CrossRefPubMedPubMedCentral

19.

Schairer WW, Sing DC, Vail TP, Bozic KJ. Causes and frequency of unplanned hospital readmission after total hip arthroplasty. Clin Orthop Relat Res. 2014;472:464–470.CrossRefPubMed

20.

Schmidt M, Pedersen L, Sorensen HT. The Danish Civil Registration System as a tool in epidemiology. Eur J Epidemiol. 2014;29:541–549.CrossRefPubMed

21.

Thygesen SK, Christiansen CF, Christensen S, Lash TL, Sorensen HT. The predictive value of ICD-10 diagnostic coding used to assess Charlson comorbidity index conditions in the population-based Danish National Registry of Patients. BMC Med Res Methodol. 2011;11:83.CrossRefPubMedPubMedCentral

22.

Trampuz A, Zimmerli W. Diagnosis and treatment of implant-associated septic arthritis and osteomyelitis. Curr Infect Dis Rep. 2008;10:394–403.CrossRefPubMed

23.

Vanhegan IS, Malik AK, Jayakumar P, Ul Islam S, Haddad FS. A financial analysis of revision hip arthroplasty: the economic burden in relation to the national tariff. J Bone Joint Surg Br. 2012;94:619–623.CrossRefPubMed

24.

Webb JE, Schleck CD, Larson DR, Lewallen DG, Trousdale RT. Mortality of elderly patients after two-stage reimplantation for total joint infection: a case-control study. J Arthroplasty. 2014;29:2206–2210.CrossRefPubMed

25.

Zhou Z, Rahme E, Abrahamowicz M, Pilote L. Survival bias associated with time-to-treatment initiation in drug effectiveness evaluation: a comparison of methods. Am J Epidemiol. 2005;162:1016–1023.CrossRefPubMed

26.

Zhu HX, Cai XZ. CORR Insights((R)): Addition of vancomycin to cefazolin prophylaxis is associated with acute kidney injury after primary joint arthroplasty. Clin Orthop Relat Res. 2015;473:2204–2206.CrossRefPubMedPubMedCentral

27.

Zmistowski B, Karam JA, Durinka JB, Casper DS, Parvizi J. Periprosthetic joint infection increases the risk of one-year mortality. J Bone Joint Surg Am. 2013;95:2177–2184.CrossRefPubMed

Title: Increased Mortality After Prosthetic Joint Infection in Primary THA
Authors: Per Hviid Gundtoft, MD, PhD
Alma Becic Pedersen, MD, PhD, DMSc
Claus Varnum, MD, PhD
Søren Overgaard, MD, DMSc
Publication date: 01-11-2017
Publisher: Springer US
Published in: Clinical Orthopaedics and Related Research® / Issue 11/2017
Print ISSN: 0009-921X
Electronic ISSN: 1528-1132
DOI: https://doi.org/10.1007/s11999-017-5289-6

At a glance: The STEP trials

Springer Medicine

Increased Mortality After Prosthetic Joint Infection in Primary THA

Abstract

Background

Questions/Purposes

Methods

Results

Conclusions

Level of Evidence

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Questions/Purposes

Methods

Results

Conclusions

Level of Evidence

Please log in to get access to this content

Other articles of this Issue 11/2017

CORR Insights®: What Are the Risk Factors and Complications Associated With Intraoperative and Postoperative Fractures in Total Wrist Arthroplasty?

How Long Does Antimycobacterial Antibiotic-loaded Bone Cement Have In Vitro Activity for Musculoskeletal Tuberculosis?

Erratum to: What Demographic and Clinical Characteristics Correlate With Expectations With Trapeziometacarpal Arthritis?

Are Barbed Sutures Associated With 90-day Reoperation Rates After Primary TKA?

What Should Define Preoperative Anemia in Primary THA?

Reply to the Letter to the Editor: False-positive Cultures After Native Knee Aspiration: True or False