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European Journal of Trauma and Emergency Surgery

Published in:

01-04-2019 | Original Article

Risk factors for early infection following hemiarthroplasty in elderly patients with a femoral neck fracture

Authors: Dirk Zajonz, Alexander Brand, Christian Lycke, Orkun Özkurtul, Jan Theopold, Ulrich J. A. Spiegl, Andreas Roth, Christoph Josten, Johannes K. M. Fakler

Published in: European Journal of Trauma and Emergency Surgery | Issue 2/2019

Abstract

Purpose

Periprosthetic joint infections (PJI) after hemiarthroplasty for geriatric femoral neck fractures are a devastating complication that results in serious morbidity and increased mortality. Identifying risk factors associated with early infection after HA for hip fractures may offer an opportunity to address and prevent this complication in many patients. The aim of this study was to evaluate preoperative risk factors for early PJI after HA in hip fracture patients.

Methods

From January 2010 to December 2015, 312 femoral neck fractures (AO/OTA 31-B) in 305 patients were included in this single-center, retrospective study. PJI was defined according to the Centers for Disease Control (CDC) definition of deep incisional surgical site infection. Early infection referred to a postoperative period of 4 weeks. Binary univariable and multivariable regression analysis with backward elimination was applied to identify predictors of PJI.

Results

Median age of all patients was 83.0 (IQR 76–89) years. We identified 16 (5.1%) early PJI which all required surgical revision. Median length of in-hospital stay (LOS) was 20.0 (IQR 10–36) days after PJI compared to 10.0 (8–15) days without deep wound infection. In-hospital mortality was 30.8 vs. 6.6%, respectively. Preoperative CRP levels (OR 1.009; 95% CI 1.002–1.018; p = 0.044), higher BMI (OR 1.092; 95% CI 1.002–1.189; p = 0.044) and prolonged surgery time (OR 1.013; 95% CI 1.000–1.025; p = 0.041) were independent risk factors for PJI. Excluding infection following major revision due to mechanical complications identified preoperative CRP levels (OR 1.012; 95% CI 1.003–1.021; p = 0.007) and chronic glucocorticoid therapy (OR 6.314; 95% CI 1.223–32.587; p = 0.028) as risk factors, a clear trend was seen for higher BMI (OR 1.114; 95% CI 1.000–1.242; p = 0.051). A cut-off value at CRP levels ≥ 14 mg/l demonstrated a sensitivity of 69% and a specificity of 70% with a fair accuracy (AUC 0.707).

Conclusion

Preoperative serum CRP levels, higher BMI and prolonged surgery time are independent predictors of early PJI. Excluding PJI secondary to major revision surgery revealed chronic glucocorticoid use as a risk factor apart from preoperative CRP levels.

Müller F, Galler M, Kottmann T, Zellner M, Bäuml C, Füchtmeier B. Analysis of 2000 surgically treated proximal femoral fractures: multiple variables influence mortality. Unfallchirurg. 2017. https://doi.org/10.1007/s00113-017-0386-2 (Epub ahead of print).CrossRefPubMed

Papadimitropoulos EA, Coyte PC, Josse RG, Greenwood CE. Current and projected rates of hip fracture in Canada. CMAJ. 1997;157:1357–63.PubMedPubMedCentral

Bhandari M, Devereaux PJ, Tornetta P 3rd, Swiontkowski MF, Berry DJ, Haidukewych G, Schemitsch EH, Hanson BP, Koval K, Dirschl D, Leece P, Keel M, Petrisor B, Heetveld M, Guyatt GH. Operative management of displaced femoral neck fractures in elderly patients. An international survey. J Bone Joint Surg Am. 2005;87:2122–30.CrossRefPubMed

Ossendorf C, Scheyerer MJ, Wanner GA, Simmen HP, Werner CM. Treatment of femoral neck fractures in elderly patients over 60 years of age—which is the ideal modality of primary joint replacement? Patient Saf Surg. 2010;4:16. https://doi.org/10.1186/1754-9493-4-16.CrossRefPubMedPubMedCentral

Fakler JKM, Grafe A, von Dercks N, Theopold J, Spiegl UJA, Josten C. Influence of internal fixation and cemented hemiarthroplasty on 1-year mortality in geriatric hip fracture patients. Int J Orthop. 2017;4:689–94.CrossRef

Guren E, Figved W, Frihagen F, Watne LO, Westberg M. Prosthetic joint infection-a devastating complication of hemiarthroplasty for hip fracture. Acta Orthop. 2017;88:383–9. https://doi.org/10.1080/17453674.2017.1301009.CrossRefPubMedPubMedCentral

Buchheit J, Uhring J, Sergent P, Puyraveau M, Leroy J, Garbuio P. Can preoperative CRP levels predict infections of bipolar hemiarthroplasty performed for femoral neck fracture? A retrospective, multicenter study. Eur J Orthop Surg Traumatol. 2015;25:117–21. https://doi.org/10.1007/s00590-014-1449-5.CrossRef

Cumming D, Parker MJ. Urinary catheterisation and deep wound infection after hip fracture surgery. Int Orthop. 2007;31:483–5.CrossRefPubMed

Ridgeway S, Wilson J, Charlet A, Kafatos G, Pearson A, Coello R. Infection of the surgical site after arthroplasty of the hip. J Bone Joint Surg Br. 2005;87(6):844–50.CrossRefPubMed

10.

de Jong L, Klem TMAL, Kuijper TM, Roukema GR. Factors affecting the rate of surgical site infection in patients after hemiarthroplasty of the hip following a fracture of the neck of the femur. Bone Joint J. 2017;99-B:1088–94. https://doi.org/10.1302/0301-620X.99B8.BJJ-2016-1119.R1.CrossRefPubMed

11.

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;23:984–91. https://doi.org/10.1016/j.arth.2007.10.017.CrossRef

12.

Cordero-Ampuero J, de Dios M. What are the risk factors for infection in hemiarthroplasties and total hip arthroplasties? Clin Orthop Relat Res. 2010;468:3268–77. https://doi.org/10.1007/s11999-010-1411-8.CrossRefPubMedPubMedCentral

13.

Dale H, Skråmm I, Løwer HL, Eriksen HM, Espehaug B, Furnes O, Skjeldestad FE, Havelin LI, Engesaeter LB. Infection after primary hip arthroplasty: a comparison of 3 Norwegian health registers. Acta Orthop. 2011;82:646–54. https://doi.org/10.3109/17453674.2011.636671.CrossRef

14.

Dripps RD. New classification of physical status. Anesthesiology. 1963;24:111.

15.

Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Centers for disease control and prevention (CDC) hospital infection control practices advisory committee. Am J Infect Control. 1999;27:97–132.CrossRef

16.

Tsukayama DT, Estrada R, Gustilo RB. Infection after total hip arthroplasty. A study of the treatment of one hundred and six infections. J Bone Joint Surg Am. 1996;78:512–23.CrossRefPubMed

17.

Sedlár M, Kudrnová Z, Erhart D, Trca S, Kvasnicka J, Krska Z, Mazoch J, Malíková I, Zeman M, Linhart A. Older age and type of surgery predict the early inflammatory response to hip trauma mediated by interleukin-6 (IL-6). Arch Gerontol Geriatr. 2010;51:e1–e6. https://doi.org/10.1016/j.archger.2009.06.006.CrossRefPubMed

18.

Pfitzner T, Krocker D, Perka C, Matziolis G. C-reactive protein. An independent risk factor for the development of infection after primary arthroplasty. Orthopade. 2008;37:1116–20. https://doi.org/10.1007/s00132-008-1342-1.CrossRefPubMed

19.

Fakler JK, Grafe A, Dinger J, Josten C, Aust G. Perioperative risk factors in patients with a femoral neck fracture - influence of 25-hydroxyvitamin D and C-reactive protein on postoperative medical complications and 1-year mortality. BMC Musculoskelet Disord. 2016;17:51. https://doi.org/10.1186/s12891-016-0906-1.CrossRefPubMedPubMedCentral

20.

Desborough JP. The stress response to trauma and surgery. Br J Anaesth. 2000;85:109–17.CrossRef

21.

Choi J, Joseph L, Pilote L. Obesity and C-reactive protein in various populations: a systematic review and meta-analysis. Obes Rev 2013;14:232–44. https://doi.org/10.1111/obr.12003.CrossRef

22.

Yoshikane H, Yamamoto T, Ozaki M, Matsuzaki M. Clinical significance of high-sensitivity C-reactive protein in lifestyle-related disease and metabolic syndrome. J Cardiol 2007;50:175–82.

23.

Smektala R, Hahn S, Schräder P, Bonnaire F, Schulze Raestrup U, Siebert H, Fischer B, Boy O. Medial hip neck fracture: influence of pre-operative delay on the quality of outcome. Results of data from the external in-hospital quality assurance within the framework of secondary data analysis. Unfallchirurg. 2010;113:287–92. https://doi.org/10.1007/s00113-009-1674-2.CrossRef

24.

Liu W, Wahafu T, Cheng M, Cheng T, Zhang Y, Zhang X. The influence of obesity on primary total hip arthroplasty outcomes: a meta-analysis of prospective cohort studies. Orthop Traumatol Surg Res. 2015;101:289–96. https://doi.org/10.1016/j.otsr.2015.01.011.CrossRef

25.

George J, Klika AK, Navale SM, Newman JM, Barsoum WK, Higuera CA. Obesity epidemic: is its impact on total joint arthroplasty underestimated? An analysis of national trends. Clin Orthop Relat Res. 2017;475:1798–806. https://doi.org/10.1007/s11999-016-5222-4.CrossRefPubMedPubMedCentral

26.

Anay DA, Dellinger EP. The obese surgical patient: a susceptible host for infection. Surg Infect (Larchmt). 2006;7:473–80.CrossRef

27.

Greco JA 3rd, Castaldo ET, Nanney LB, et al. The effect of weight loss surgery and body mass index on wound complications after abdominal contouring operations. Ann Plast Surg. 2008;61:235–42.CrossRefPubMed

28.

Wilson JA, Clark JJ. Obesity: impediment to postsurgical wound healing. Crit Care Nurs Q. 2003;26:119–32.CrossRefPubMed

29.

Parvizi J, Gehrke T, Chen AF. Proceedings of the international consensus on periprosthetic joint infection. Bone Joint J 2013;95-B:1450–52.

30.

Lübbeke A, Zingg M, Vu D, Miozzari HH, Christofilopoulos P, Uçkay I, Harbarth S, Hoffmeyer P. Body mass and weight thresholds for increased prosthetic joint infection rates after primary total joint arthroplasty. Acta Orthop. 2016;87:132–8. https://doi.org/10.3109/17453674.2015.1126157.CrossRefPubMed

31.

Wroblewski BM, Siney PD, Fleming PA. Charnley low-frictional torque arthroplasty in young rheumatoid and juvenile rheumatoid arthritis: 292 hips followed for an average of 15 years. Acta Orthop. 2007;78:206–10.CrossRefPubMed

32.

Lau AC, Neo GH, Lee HC. Risk factors of surgical site infections in hip hemiarthroplasty: a single-institution experience over nine years. Singapore Med J. 2014;55:535–8.CrossRefPubMedPubMedCentral

33.

Klement MR, Penrose CT, Bala A, Green CL, Mather RC 3rd, Wellman SS, Bolognesi MP, Seyler TM. Complications of total hip arthroplasty following solid organ transplantation. J Orthop Sci. 2017;22:295–9. https://doi.org/10.1016/j.jos.2016.12.004 (Epub 24 Dec 2016).CrossRefPubMed

34.

Schmitt JW, Benden C, Dora C, Werner CM. Is total hip arthroplasty safely performed in lung transplant patients? Current experience from a retrospective study of the Zurich lung transplant cohort. Patient Saf Surg. 2016;10:17. https://doi.org/10.1186/s13037-016-0105-x (eCollection 2016).CrossRefPubMedPubMedCentral

35.

Chrastil J, Anderson MB, Stevens V, Anand R, Peters CL, Pelt CE. Is hemoglobin A1c or perioperative hyperglycemia predictive of periprosthetic joint infection or death following primary total joint arthroplasty? J Arthroplasty. 2015;30:1197–202. https://doi.org/10.1016/j.arth.2015.01.040.CrossRef

Title: Risk factors for early infection following hemiarthroplasty in elderly patients with a femoral neck fracture
Authors: Dirk Zajonz
Alexander Brand
Christian Lycke
Orkun Özkurtul
Jan Theopold
Ulrich J. A. Spiegl
Andreas Roth
Christoph Josten
Johannes K. M. Fakler
Publication date: 01-04-2019
Publisher: Springer Berlin Heidelberg
Published in: European Journal of Trauma and Emergency Surgery / Issue 2/2019
Print ISSN: 1863-9933
Electronic ISSN: 1863-9941
DOI: https://doi.org/10.1007/s00068-018-0909-8

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Risk factors for early infection following hemiarthroplasty in elderly patients with a femoral neck fracture

Abstract

Purpose

Methods

Results

Conclusion

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

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