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
DOI:
https://doi.org/10.2340/17453674.2023.12307Keywords:
Arthroplasty, Infection, KneeAbstract
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.
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References
FAR: Finnish arthroplasty register. Finnish Inst. Heal. Welf. [Internet]. 2022. Available from: www.thl.fi/FAR.
Cahill J L, Shadbolt B, Scarvell J M, Smith P N. Quality of life after infection in total joint replacement. J Orthop Surg 2008; 16(1): 58-65. doi: 10.1177/230949900801600115. DOI: https://doi.org/10.1177/230949900801600115
Kurtz S M, Ong K L, Lau E, Bozic K J, Berry D, Parvizi J. Prosthetic joint infection risk after TKA in the Medicare population. Clin Orthop Relat Res 2010; 468(1): 52. doi: 10.1007/s11999-009-1013-5. DOI: https://doi.org/10.1007/s11999-009-1013-5
Kong L, Cao J, Zhang Y, Ding W, Shen Y. Risk factors for periprosthetic joint infection following primary total hip or knee arthroplasty: a meta-analysis. Int Wound J 2017; 14(3): 529-36. doi: 10.1111/iwj.12640. DOI: https://doi.org/10.1111/iwj.12640
Jämsen E, Huhtala H, Puolakka T, Moilanen T. Risk factors for infection after knee arthroplasty: a register-based analysis of 43,149 cases. J Bone Joint Surg Am 2009; 91(1): 38-47. doi: 10.2106/JBJS.G.01686. DOI: https://doi.org/10.2106/JBJS.G.01686
Kurtz S M, Ong K L, Schmier J, Mowat F, Saleh K, Dybvik E, et al. Future clinical and economic impact of revision total hip and knee arthroplasty. J Bone Joint Surg Am 2007; 89(SUPPL. 3): 144-51. doi: 10.2106/JBJS.G.00587. DOI: https://doi.org/10.2106/JBJS.G.00587
Pamilo K J, Haapakoski J, Sokka-Isler T, Remes V, Paloneva J. Rapid rise in prevalence of knee replacements and decrease in revision burden over past 3 decades in Finland: a register-based analysis. Acta Orthop 2022; 93: 382-9. doi: 10.2340/17453674.2022.2266. DOI: https://doi.org/10.2340/17453674.2022.2266
Niemeläinen M J, Mäkelä K T, Robertsson O, W-Dahl A, Furnes O, Fenstad A M, et al. Different incidences of knee arthroplasty in the Nordic countries. Acta Orthop 2017; 88(2): 173-8. doi: 10.1080/17453674.2016.1275200. DOI: https://doi.org/10.1080/17453674.2016.1275200
Patel A, Pavlou G, Mújica-Mota R E, Toms A D. The epidemiology of revision total knee and hip arthroplasty in England and Wales: a comparative analysis with projections for the United States. A study using the national joint registry dataset. Bone Joint J 2015; 97-B(8): 1076-81. doi: 10.1302/0301-620X.97B8.35170. DOI: https://doi.org/10.1302/0301-620X.97B8.35170
Dale H, Fenstad A M, Hallan G, Havelin L I, Furnes O, Overgaard S, et al. Increasing risk of prosthetic joint infection after total hip arthroplasty. Acta Orthop 2012; 83(5): 449-58. doi: 10.3109/17453674.2012.733918. DOI: https://doi.org/10.3109/17453674.2012.733918
Schrama J C, Fenstad A M, Dale H, Havelin L, Hallan G, Overgaard S, et al. Increased risk of revision for infection in rheumatoid arthritis patients with total hip replacements. Acta Orthop 2015; 86(4): 469-76. doi: 10.3109/17453674.2015.1017793. DOI: https://doi.org/10.3109/17453674.2015.1017793
Springer B D, Cahue S, Etkin C D, Lewallen D G, McGrory B J. Infection burden in total hip and knee arthroplasties: an international registry-based perspective. Arthroplasty Today 2017; 3(2): 137-40. doi: 10.1016/j.artd.2017.05.003. DOI: https://doi.org/10.1016/j.artd.2017.05.003
Panula V J, Alakylä K J, Venäläinen M S, Haapakoski J J, Eskelinen A P, Manninen M J, et al. Risk factors for prosthetic joint infections following total hip arthroplasty based on 33,337 hips in the Finnish Arthroplasty Register from 2014 to 2018. Acta Orthop 2021; 92(6): 665. doi: 10.1080/17453674.2021.1944529 DOI: https://doi.org/10.1080/17453674.2021.1944529
Puolakka T J, Pajamäki K J, Halonen P J, Pulkkinen P O, Paavolainen P, Nevalainen J K. The Finnish Arthroplasty Register: report of the hip register. Acta Orthop Scand 2001; 72(5): 433-41. doi: 10.1080/000164701753532745. DOI: https://doi.org/10.1080/000164701753532745
Parvizi J, Fassihi S C, Enayatollahi M A. Diagnosis of periprosthetic joint infection following hip and knee arthroplasty. Orthop Clin North Am 2016; 47(3): 505-15. doi: 10.1016/j.ocl.2016.03.001. DOI: https://doi.org/10.1016/j.ocl.2016.03.001
Ranstam J, Robertsson O. The Cox model is better than the Fine and Gray model when estimating relative revision risks from arthroplasty register data. Acta Orthop 2017; 88(6): 578-80. doi: 10.1080/17453674.2017.1361130. DOI: https://doi.org/10.1080/17453674.2017.1361130
Ranstam J, Robertsson O. Statistical analysis of arthroplasty register data. Acta Orthop 2010; 81(1): 10-14. doi: 10.3109/17453671003587168. DOI: https://doi.org/10.3109/17453671003587168
Grambsch P M, Therneau T M. Proportional hazards tests and diagnostics based on weighted residuals. Biometrika 1994; 81(3): 515-26. DOI: https://doi.org/10.1093/biomet/81.3.515
Ranstam J, Kärrholm J, Pulkkinen P, Mäkelä K, Espehaug B, Pedersen A B, et al. Statistical analysis of arthroplasty data, II: Guidelines. Acta Orthop 2011; 82(3): 258-67. doi: 10.3109/17453674.2011.588863. DOI: https://doi.org/10.3109/17453674.2011.588863
Huotari K, Peltola M, Jämsen E. The incidence of late prosthetic joint infections. Acta Orthop 2015; 86(3): 321-5. doi: 10.3109/17453674.2015.1035173 DOI: https://doi.org/10.3109/17453674.2015.1035173
Lenguerrand E, Whitehouse M R, Beswick A D, Kunutsor S K, Foguet P, Porter M, et al. Risk factors associated with revision for prosthetic joint infection following knee replacement: an observational cohort study from England and Wales. Lancet Infect Dis 2019; 19(6): 589. doi: 10.1016/S1473-3099(18)30755-2. DOI: https://doi.org/10.1016/S1473-3099(18)30755-2
Kunutsor S K, Whitehouse M R, Blom A W, Beswick A D. Patient-related risk factors for periprosthetic joint infection after total joint arthroplasty: a systematic review and meta-analysis. Virdi AS, editor. PLoS One 2016; 11(3): e0150866. doi: 10.1371/journal.pone.0150866. DOI: https://doi.org/10.1371/journal.pone.0150866
WHO. WHO global report on trends in prevalence of tobacco smoking 2015. Geneva, WHO; 2015.
WHO. Global status report on alcohol and health 2018. Geneva, WHO; 2018.
Teo B J X, Yeo W, Chong H C, Tan A H C. Surgical site infection after primary total knee arthroplasty is associated with a longer duration of surgery. J Orthop Surg 2018; 26(2). doi: 10.1177/2309499018785647. DOI: https://doi.org/10.1177/2309499018785647
Ravi B, Jenkinson R, O’Heireamhoin S, Austin P C, Aktar S, Leroux T S, et al. Surgical duration is associated with an increased risk of periprosthetic infection following total knee arthroplasty: a population-based retrospective cohort study. EClinicalMedicine 2019; 16: 74-80. doi: 10.1016/j.eclinm.2019.09.015. DOI: https://doi.org/10.1016/j.eclinm.2019.09.015
Patel K, Judd H, Harm R G, Nolan J R, Hummel M, Spanyer J. Robotic-assisted total knee arthroplasty: is there a maximum level of efficiency for the operating surgeon? J Orthop 2022; 31: 13-16. doi: 10.1016/j.jor.2022.02.015. DOI: https://doi.org/10.1016/j.jor.2022.02.015
Theodore W, Twiggs J, Kolos E, Roe J, Fritsch B, Dickison D, et al. Variability in static alignment and kinematics for kinematically aligned TKA. Knee 2017; 24(4): 733-44. doi: 10.1016/j.knee.2017.04.002. DOI: https://doi.org/10.1016/j.knee.2017.04.002
Stake S, Fassihi S, Gioia C, Gu A, Agarwal A, Akman A, et al. Kinematic versus mechanically aligned total knee arthroplasty: no difference in frequency of arthroscopic lysis of adhesions for arthrofibrosis. Eur J Orthop Surg Traumatol 2021; 31(4): 763-8. doi: 10.1007/s00590-020-02836-7. DOI: https://doi.org/10.1007/s00590-020-02836-7
Klasan A, de Steiger R, Holland S, Hatton A, Vertullo C J, Young S W. Similar risk of revision after kinematically aligned, patient-specific instrumented total knee arthroplasty, and all other total knee arthroplasty: combined results from the Australian and New Zealand Joint Replacement Registries. J Arthroplasty 2020; 35(10): 2872-7. doi: 10.1016/j.arth.2020.05.065. DOI: https://doi.org/10.1016/j.arth.2020.05.065
Kurtz S M, Lau E C, Son M-S, Chang E T, Zimmerli W, Parvizi J. Are we winning or losing the battle with periprosthetic joint infection: trends in periprosthetic joint infection and mortality risk for the Medicare population. J Arthroplasty 2018; 33(10): 3238-45. doi: 10.1016/j.arth.2018.05.042. DOI: https://doi.org/10.1016/j.arth.2018.05.042
Si H B, Zeng Y, Shen B, Yang J, Zhou Z K, Kang P D, et al. The influence of body mass index on the outcomes of primary total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2015; 23(6): 1824-32. doi: 10.1007/s00167-014-3301-1. DOI: https://doi.org/10.1007/s00167-014-3301-1
Tayton E R, Frampton C, Hooper G J, Young S W. The impact of patient and surgical factors on the rate of infection after primary total knee arthroplasty. Bone Joint J 2016; 98B(3): 334-40. doi: 10.1302/0301-620X.98B3.36775. DOI: https://doi.org/10.1302/0301-620X.98B3.36775
Ko M S, Choi C H, Yoon H K, Yoo J H, Oh H C, Lee J H, et al. Risk factors of postoperative complications following total knee arthroplasty in Korea: a nationwide retrospective cohort study. Medicine 2021; 100 (48): e28052. doi: 10.1097/MD.0000000000028052. DOI: https://doi.org/10.1097/MD.0000000000028052
Yazdi H, Klement M R, Hammad M, Inoue D, Xu C, Goswami K, et al. Tranexamic acid is associated with reduced periprosthetic joint infection after primary total joint arthroplasty. J Arthroplasty 2020; 35(3): 840-4. doi: 10.1016/j.arth.2019.10.029. DOI: https://doi.org/10.1016/j.arth.2019.10.029
Hesselvig A B, Arpi M, Madsen F, Bjarnsholt T, Odgaard A. Does an antimicrobial incision drape prevent intraoperative contamination? A randomized controlled trial of 1187 patients. Clin Orthop Relat Res 2020; 478(5): 1007. doi: 10.1097/CORR.0000000000001142. DOI: https://doi.org/10.1097/CORR.0000000000001142
Webster J, Alghamdi A. Use of plastic adhesive drapes during surgery for preventing surgical site infection. Cochrane Database Syst Rev 2015; 2015(4). doi: 10.1002/14651858.CD006353.pub4. DOI: https://doi.org/10.1002/14651858.CD006353.pub4
Vertullo C J, Lewis P L, Peng Y, Graves S E, de Steiger R N. The effect of alternative bearing surfaces on the risk of revision due to infection in minimally stabilized total knee replacement: an analysis of 326,603 prostheses from the Australian Orthopaedic Association National Joint Replacement Registry. J Bone Joint Surg Am 2018; 100(2): 115-23. doi: 10.2106/JBJS.17.00269. DOI: https://doi.org/10.2106/JBJS.17.00269
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Copyright (c) 2023 Hannes Keemu, Kasperi J Alakylä, Riku Klén, Valtteri J Panula, Mikko S Venäläinen, Jaason J Haapakoski, Antti P Eskelinen, Konsta Pamilo, Jukka S Kettunen, Ari-Pekka Puhto, Anna I Vasara, Laura L Elo, Keijo T Mäkelä
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