Preoperative optimization of modifiable risk factors is associated with decreased superficial surgical site infections after total joint arthroplasty: a prospective case-control study
DOI:
https://doi.org/10.2340/17453674.2024.41012Keywords:
Modifiable risk factors, Periprosthetic joint infection, Postoperative complications, Preoperative optimization, Surgical site infection, Total joint arthroplastyAbstract
Background and purpose: The aim of our study was to investigate change in modifiable risk factors following preoperative optimization and whether risk of superficial surgical site infection (SSI) after total joint arthroplasty (TJA) could be reduced.
Methods: This is a prospective study of implementation of a preoperative optimization pathway for patients waiting for primary TJA. Information regarding the intervention arm was collected from January 2019 to January 2021, first at decision for operation and then at preoperative assessment 1 week prior to operation. The control arm was included between August 2018 and September 2020 after receiving conventional preoperative preparation and information gathered at preoperative assessment. Follow up occurred 6 weeks postoperatively for both groups. The primary outcome was postoperative superficial SSI.
Results: The optimization effort resulted in improvement of weight, anemia, HbA1c, vitamin D, and patient engagement. At preoperative assessment the baseline characteristics of the 2 groups were similar except that the intervention group had substantially more comorbidities. Regarding superficial SSI, association was found with BMI ≥ 30 and HbA1c ≥ 42 mmol/mol in the control group but not in the intervention group. When corrected for differences in ASA classification (reflecting comorbidities), age, and sex, being in the intervention group was associated with lower odds of occurrence of superficial SSI compared with the control group (OR 0.64, 95% confidence interval 0.42–0.97).
Conclusion: We showed that preoperative optimization in a structured cooperation between hospital and primary care was associated with a reduced risk of superficial SSI.
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MacMahon A, Rao S S, Chaudhry Y P, Hasan S A, Epstein J A, Hegde V, et al. Preoperative patient optimization in total joint arthroplasty – the paradigm shift from preoperative clearance: a narrative review. HSS J 2022; 18: 418-27. doi: 10.1177/15563316211030923. DOI: https://doi.org/10.1177/15563316211030923
Moyer R, Ikert K, Long K, Marsh J. The value of preoperative exercise and education for patients undergoing total hip and knee arthroplasty: a systematic review and meta-analysis. JBJS Rev 2017; 5: e2. doi: 10.2106/JBJS.RVW.17.00015. DOI: https://doi.org/10.2106/JBJS.RVW.17.00015
Premkumar A, Kolin D A, Farley K X, Wilson J M, McLawhorn A S, Cross M B, et al. Projected economic burden of periprosthetic joint infection of the hip and knee in the United States. J Arthroplasty 2021; 36: 1484-9.e3. doi: 10.1016/j.arth.2020.12.005. DOI: https://doi.org/10.1016/j.arth.2020.12.005
Xu Y, Huang T B, Schuetz M A, Choong P F M. Mortality, patient-reported outcome measures, and the health economic burden of prosthetic joint infection. EFORT Open Rev 2023; 8: 690-7. doi: 10.1530/EOR-23-0078. DOI: https://doi.org/10.1530/EOR-23-0078
Bernstein D N, Liu T C, Winegar A L, Jackson L W, Darnutzer J L, Wulf K M, et al. Evaluation of a preoperative optimization protocol for primary hip and knee arthroplasty patients. J Arthroplasty 2018; 33: 3642-8. doi: 10.1016/j.arth.2018.08.018. DOI: https://doi.org/10.1016/j.arth.2018.08.018
Bullock M W, Brown M L, Bracey D N, Langfitt M K, Shields J S, Lang J E. A bundle protocol to reduce the incidence of periprosthetic joint infections after total joint arthroplasty: a single-center experience. J Arthroplasty 2017; 32: 1067-73. doi: 10.1016/j.arth.2016.11.028. DOI: https://doi.org/10.1016/j.arth.2016.11.028
Olsen A S, Giunta N M, Jamison M P, Chen A F, Fitz W, Iorio R. A total knee arthroplasty preoperative optimization program managed by an advanced practice provider (physician assistant) decreases complications and cost: a pilot study. J Arthroplasty 2023; 38: S77-S80. doi: 10.1016/j.arth.2023.03.064. DOI: https://doi.org/10.1016/j.arth.2023.03.064
Indelli P F, Iannotti F, Ferretti A, Valtanen R, Prati P, Perez Prieto D, et al. Recommendations for periprosthetic joint infections (PJI) prevention: the European Knee Associates (EKA) – International Committee American Association of Hip and Knee Surgeons (AAHKS) – Arthroplasty Society in Asia (ASIA) survey of members. Knee Surg Sports Traumatol Arthrosc 2022; 30: 3932-43. doi: 10.1007/s00167-021-06742-1. DOI: https://doi.org/10.1007/s00167-021-06742-1
Johns W L, Layon D, Golladay G J, Kates S L, Scott M, Patel N K. Preoperative risk factor screening protocols in total joint arthroplasty: a systematic review. J Arthroplasty 2020; 35: 3353-63. doi: 10.1016/j.arth.2020.05.074. DOI: https://doi.org/10.1016/j.arth.2020.05.074
McLaughlin J, Scott L J, Owens L, McLeod H, Sillero-Rejon C, Reynolds R, et al. Evaluating a pre-surgical health optimisation programme: a feasibility study. Perioper Med (Lond) 2022; 11: 21. doi: 10.1186/s13741-022-00255-2. DOI: https://doi.org/10.1186/s13741-022-00255-2
Sigurdardottir M, Sigurdsson M I, Olafsson Y, Sverrisdottir S H, Gunnarsdottir I, Sigurdsson E L, et al. Prevalence of modifiable risk factors in primary elective arthroplasty and their association with infections. Acta Orthop 2023; 94: 38-44. doi: 10.2340/17453674.2023.8480. DOI: https://doi.org/10.2340/17453674.2023.8480
van Groningen L, Opdenoordt S, van Sorge A, Telting D, Giesen A, de Boer H. Cholecalciferol loading dose guideline for vitamin D-deficient adults. Eur J Endocrinol 2010; 162: 805-811. doi: 10.1530/EJE-09-0932. DOI: https://doi.org/10.1530/EJE-09-0932
Thorsdottir I, Eriksen B, Eysteinsdottir S. Nutritional status at submission for dietetic services and screening for malnutrition at admission to hospital. Clin Nutr 1999; 18: 15-21. doi: 10.1016/s0261-5614(99)80044-2. DOI: https://doi.org/10.1016/S0261-5614(99)80044-2
Surgical site infection event (SSI). National Healthcare Safety Network. Centers for Disease Control and Prevention, 2022. Available from: https://wwwcdcgov/nhsn/pdfs/pscmanual/9pscssicurrentpdf (accessed June 19, 2024)
Parvizi J, Tan T L, Goswami K, Higuera C, Della Valle C, Chen A F, et al. The 2018 definition of periprosthetic hip and knee infection: an evidence-based and validated criteria. J Arthroplasty 2018; 33: 1309-14.e12. doi: 10.1016/j.arth.2018.02.078. DOI: https://doi.org/10.1016/j.arth.2018.02.078
Eriksson H K, Lazarinis S. 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. BMJ Open 2022; 12: e060754. doi: 10.1136/bmjopen-2022-060754. DOI: https://doi.org/10.1136/bmjopen-2022-060754
Saleh K, Olson M, Resig S, Bershadsky B, Kuskowski M, Gioe T, et al. Predictors of wound infection in hip and knee joint replacement: results from a 20 year surveillance program. J Orthop Res 2002; 20: 506-515. doi: 10.1016/S0736-0266(01)00153-X. DOI: https://doi.org/10.1016/S0736-0266(01)00153-X
Zhong J, Wang B, Chen Y, Li H, Lin N, Xu X, et al. Relationship between body mass index and the risk of periprosthetic joint infection after primary total hip arthroplasty and total knee arthroplasty. Ann Transl Med 2020; 8: 464. doi: 10.21037/atm.2020.03.112. DOI: https://doi.org/10.21037/atm.2020.03.112
Aggarwal V K, Rasouli M R, Parvizi J. Periprosthetic joint infection: current concept. Indian J Orthop 2013; 47: 10-17. doi: 10.4103/0019-5413.106884. DOI: https://doi.org/10.4103/0019-5413.106884
Kim K, Zhu M, Coleman B, Munro J T, Young S W. Differing microorganism profile in early and late prosthetic joint infections following primary total knee arthroplasty - implications for empiric antibiotic treatment. J Arthroplasty 2022; 37: 1858-64 e1851. doi: 10.1016/j.arth.2022.04.014. DOI: https://doi.org/10.1016/j.arth.2022.04.014
Nussenbaum F D, Rodriguez-Quintana D, Fish S M, Green D M, Cahill C W. Implementation of preoperative screening criteria lowers infection and complication rates following elective total hip arthroplasty and total knee arthroplasty in a veteran population. J Arthroplasty 2018; 33: 10-13. doi: 10.1016/j.arth.2017.07.031. DOI: https://doi.org/10.1016/j.arth.2017.07.031
Dlott C C, Moore A, Nelson C, Stone D, Xu Y, Morris J C, et al. Preoperative risk factor optimization lowers hospital length of stay and postoperative emergency department visits in primary total hip and knee arthroplasty patients. J Arthroplasty 2020; 35: 1508-15.e2. doi: 10.1016/j.arth.2020.01.083. DOI: https://doi.org/10.1016/j.arth.2020.01.083
Kim K Y, Anoushiravani A A, Chen K K, Li R, Bosco J A, Slover J D, et al. Perioperative orthopedic surgical home: optimizing total joint arthroplasty candidates and preventing readmission. J Arthroplasty 2019; 34: S91-S96. doi: 10.1016/j.arth.2019.01.020. DOI: https://doi.org/10.1016/j.arth.2019.01.020
Dietz M J, Chaharbakhshi E O, Roberts A J, Gilligan P H, Kasicky K R, Pincavitch J D. Maintenance of surgical optimization in total joint arthroplasty patients. J Arthroplasty 2024; 39: 1650-55.e1. doi: 10.1016/j.arth.2024.01.013. DOI: https://doi.org/10.1016/j.arth.2024.01.013
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: 529-6. doi: 10.1111/iwj.12640. DOI: https://doi.org/10.1111/iwj.12640
Kunutsor S K, Beswick A D, Whitehouse M R, Blom A W, Lenguerrand E. Implant fixation and risk of prosthetic joint infection following primary total hip replacement: meta-analysis of observational cohort and randomised intervention studies. J Clin Med 2019; 8. doi: 10.3390/jcm8050722. DOI: https://doi.org/10.3390/jcm8050722
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Copyright (c) 2024 Maria Sigurdardottir, Martin Ingi Sigurdsson, Rafael Daniel Vias, Yngvi Olafsson, Ingibjorg Gunnarsdottir, Emil L Sigurdsson, Sigurbergur Karason
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