Top

Clinical Orthopaedics and Related Research®

Published in:

01-10-2013 | Symposium: 2012 Musculoskeletal Infection Society

Medical Comorbidities Are Independent Preoperative Risk Factors for Surgical Infection After Total Joint Arthroplasty

Authors: Joshua S. Everhart, BS, Eric Altneu, MS, Jason H. Calhoun, MD

Published in: Clinical Orthopaedics and Related Research® | Issue 10/2013

Abstract

Background

Surgical site infection (SSI) after total joint arthroplasty (TJA) is a major cause of morbidity. Multiple patient comorbidities have been identified as SSI risk factors including obesity, tobacco use, diabetes, immunosuppression, malnutrition, and coagulopathy. However, the independent effect of multiple individual patient factors on risk of subsequent periprosthetic infection is unclear.

Questions/purposes

The purposes of this study are (1) to collect data on several preestablished infection risk factors in addition to SSI-related data on a large TJA cohort; and (2) to use multivariate modeling on previously established patient risk factors to determine independent preoperative predictors of SSI.

Methods

We reviewed records of patients undergoing TJA from January 1, 2010, to July 30, 2012. Confirmation of SSI followed published guidelines for superficial, deep, and periprosthetic. A total of 29 culture-positive SSIs (1.5% total) and 1846 controls were identified. The prevalence of known patient-specific infection risk factors was determined for both infected cases and healthy control subjects followed by multiple regression analysis to determine independent risk.

Results

Isolated organisms consisted of methicillin-resistant Staphylococcus aureus (MRSA; 34.5%) followed by gram-negative rods (31.0%). After adjusting for anatomic site, independent risk factors for infection include: revision surgery (odds ratio [OR], 2.28; confidence interval [CI], 1.26–3.98), super obesity (body mass index > 50 kg/m²; OR, 5.28; CI, 1.38–17.1), diabetes mellitus (OR, 1.83; CI, 1.02–3.27), tobacco abuse (OR, 2.96; CI, 1.65–5.11), MRSA colonization or infection (OR, 4.17; CI, 1.63–9.66), and current or prior bone cancer (OR, 3.86; CI, 1.21–12.79).

Conclusions

Multiple patient comorbidities independently contribute to infection risk after TJA. Preoperative TJA infection risk stratification may be feasible and should be investigated further.

Level of Evidence

Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Andrew JG, Palan J, Kurup HV, Gibson P, Murray DW, Beard DJ. Obesity in total hip replacement. J Bone Joint Surg Am. 2008;90:424–429.

Batsis JA, Naessens JM, Keegan MT, Huddleston PM, Wagie AE, Huddleston JM. Body mass index and the impact on hospital resource use in patients undergoing total knee arthroplasty. J Arthroplasty. 2010;25:1250–1257.e1251.

Berbari EF, Hanssen AD, Duffy MC, Steckelberg JM, Ilstrup DM, Harmsen WS, Osmon DR. Risk factors for prosthetic joint infection: case-control study. Clin Infect Dis. 1998;27:1247–1254.PubMedCrossRef

Centers for Disease Control. Surgical Site Infection. Available at: http://www.cdc.gov/HAI/ssi/ssi.html. Accessed August 1, 2012.

Cui Q, Mihalko WM, Shields JS, Ries M, Saleh KJ. Antibiotic-impregnated cement spacers for the treatment of infection associated with total hip or knee arthroplasty. J Bone Joint Surg Am. 2007;89:871–882.PubMedCrossRef

Dowsey MM, Choong PF. Obesity is a major risk factor for prosthetic infection after primary hip arthroplasty. Clin Orthop Relat Res. 2008;466:153–158.PubMedCrossRef

Dowsey MM, Choong PF. Obese diabetic patients are at substantial risk for deep infection after primary TKA. Clin Orthop Relat Res. 2009;467:1577–1581.PubMedCrossRef

Elia M. Obesity in the elderly. Obesity. 2001;9:244S–248S.CrossRef

Fulkerson E, Valle CJ, Wise B, Walsh M, Preston C, Di Cesare PE. Antibiotic susceptibility of bacteria infecting total joint arthroplasty sites. J Bone Joint Surg Am. 2006;88:1231–1237.PubMedCrossRef

10.

Hardes J, von Eiff C, Streitbuerger A, Balke M, Budny T, Henrichs MP, Hauschild G, Ahrens H. Reduction of periprosthetic infection with silver-coated megaprostheses in patients with bone sarcoma. J Surg Oncol. 2010;101:389–395.PubMed

11.

Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol. 1992;13:606–608.PubMedCrossRef

12.

Iorio R, Williams KM, Marcantonio AJ, Specht LM, Tilzey JF, Healy WL. Diabetes mellitus, hemoglobin A1C, and the incidence of total joint arthroplasty infection. J Arthroplasty. 2012;27:726–729.e721.

13.

Jamsen E, Nevalainen P, Kalliovalkama J, Moilanen T. Preoperative hyperglycemia predicts infected total knee replacement. Eur J Int Med. 2010;21:196–201.CrossRef

14.

Kim DH, Spencer M, Davidson SM, Li L, Shaw JD, Gulczynski D, Hunter DJ, Martha JF, Miley GB, Parazin SJ, Dejoie P, Richmond JC. Institutional prescreening for detection and eradication of methicillin-resistant Staphylococcus aureus in patients undergoing elective orthopaedic surgery. J Bone Joint Surg Am. 2010;92:1820–1826.PubMedCrossRef

15.

Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol. 1999;20:725–730.PubMedCrossRef

16.

Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89:780–785.PubMedCrossRef

17.

Lai K, Bohm ER, Burnell C, Hedden DR. Presence of medical comorbidities in patients with infected primary hip or knee arthroplasties. J Arthroplasty. 2007;22:651–656.PubMedCrossRef

18.

Levent T, Vandevelde D, Delobelle JM, Labourdette P, Letendard J, Lesage P, Lecocq P, Dufour M. Infection risk prevention following total knee arthroplasty. Orthop Traumatol Surg Res. 2010;96:49–56.PubMedCrossRef

19.

Lindstrom D, Sadr Azodi O, Wladis A, Tonnesen H, Linder S, Nasell H, Ponzer S, Adami J. Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial. Ann Surg. 2008;248:739–745.PubMedCrossRef

20.

Lubbeke A, Stern R, Garavaglia G, Zurcher L, Hoffmeyer P. Differences in outcomes of obese women and men undergoing primary total hip arthroplasty. Arthritis Rheum. 2007;57:327–334.PubMedCrossRef

21.

Malinzak RA, Ritter MA, Berend ME, Meding JB, Olberding EM, Davis KE. Morbidly obese, diabetic, younger, and unilateral joint arthroplasty patients have elevated total joint arthroplasty infection rates. J Arthroplasty. 2009;24:84–88.PubMedCrossRef

22.

Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Am J Infect Control. 1999;27:97–134.PubMedCrossRef

23.

Namba RS, Paxton L, Fithian DC, Stone ML. Obesity and perioperative morbidity in total hip and total knee arthroplasty patients. J Arthroplasty. 2005;20:46–50.PubMedCrossRef

24.

Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity in the United States, 2009–2010. NCHS Data Brief. 2012;82:1–8.PubMed

25.

Parvizi J, Matar WY, Saleh KJ, Schmalzried TP, Mihalko WM. Decolonization of drug-resistant organisms before total joint arthroplasty. Instr Course Lect. 2010;59:131–137.PubMed

26.

Parvizi J, Zmistowski B, Berbari EF, Bauer TW, Springer BD, Della Valle CJ, Garvin KL, Mont MA, Wongworawat MD, Zalavras CG. New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res. 2011;469:2992–2994.PubMedCrossRef

27.

Paxton EW, Inacio MC, Kiley ML. The Kaiser Permanente implant registries: effect on patient safety, quality improvement, cost effectiveness, and research opportunities. Perm J. 2012;16:36–44.PubMedCrossRef

28.

Peersman G, Laskin R, Davis J, Peterson M. Infection in total knee replacement: a retrospective review of 6489 total knee replacements. Clin Orthop Relat Res. 2001;392:15–23.PubMedCrossRef

29.

Pulido L, Ghanem E, Joshi A, Purtill JJ, Parvizi J. Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res. 2008;466:1710–1715.PubMedCrossRef

30.

Rizvi AA, Chillag SA, Chillag KJ. Perioperative management of diabetes and hyperglycemia in patients undergoing orthopaedic surgery. J Am Acad Orthop Surg. 2010;18:426–435.PubMed

31.

Samson AJ, Mercer GE, Campbell DG. Total knee replacement in the morbidly obese: a literature review. ANZ J Surg. 2010;80:595–599.PubMedCrossRef

32.

Sharma D, Douglas J, Coulter C, Weinrauch P, Crawford R. Microbiology of infected arthroplasty: implications for empiric peri-operative antibiotics. J Orthop Surg. 2008;16:339–342.

33.

Shih LY, Cheng CY, Chang CH, Hsu KY, Hsu RW, Shih HN. Total knee arthroplasty in patients with liver cirrhosis. J Bone Joint Surg Am. 2004;86:335–341.PubMed

34.

Winiarsky R, Barth P, Lotke P. Total knee arthroplasty in morbidly obese patients. J Bone Joint Surg Am. 1998;80:1770–1774.PubMed

Title: Medical Comorbidities Are Independent Preoperative Risk Factors for Surgical Infection After Total Joint Arthroplasty
Authors: Joshua S. Everhart, BS
Eric Altneu, MS
Jason H. Calhoun, MD
Publication date: 01-10-2013
Publisher: Springer US
Published in: Clinical Orthopaedics and Related Research® / Issue 10/2013
Print ISSN: 0009-921X
Electronic ISSN: 1528-1132
DOI: https://doi.org/10.1007/s11999-013-2923-9

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Medical Comorbidities Are Independent Preoperative Risk Factors for Surgical Infection After Total Joint Arthroplasty

Abstract

Background

Questions/purposes

Methods

Results

Conclusions

Level of Evidence

Keynote webinar | Spotlight on medication adherence

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 10/2013

Editorial: Our Enthusiasm for “Related Research”

Voriconazole Is Cytotoxic at Locally Delivered Concentrations: A Pilot Study

No Infection Reduction Using Chlorhexidine Wipes in Total Joint Arthroplasty

Outcome of One-stage Cementless Exchange for Acute Postoperative Periprosthetic Hip Infection

Can Certain Benign Lesions of the Proximal Femur Be Treated Without Surgery?

CORR Insights®: Outcome of One-stage Cementless Exchange for Acute Postoperative Periprosthetic Hip Infection