The Otto Aufranc Award: Modifiable versus Nonmodifiable Risk Factors for Infection After Hip Arthroplasty

Abstract

Background Periprosthetic joint infections (PJIs) are associated with increased morbidity and cost. It would be important to identify any modifiable patient-and surgicalrelated factors that could be modified before surgery to decrease the risk of PJI. Questions/purposes We sought to identify and quantify the magnitude of modifiable risk factors for deep PJIs after primary hip arthroplasty. Methods A series of 3672 primary and 406 revision hip arthroplasties performed at a single specialty hospital over a 3-year period were reviewed. All deep PJIs were identified using the Centers for Disease Control and Prevention case definitions (ie, occurs within 30-90 days postoperatively, involves deep soft tissues of the incision, purulent drainage, dehiscence and fever, localized pain or tenderness). Univariate and multivariate analyses determined the association between patient and surgical risk factors and PJIs. For the elective patients, the procedure was performed on the day of admission (''same-day procedure''), whereas for the fracture and nonelective patients, the procedure was performed 1 or more days postadmission (''nonsame-day procedure''). Staphylococcus aureus colonization, tobacco use, and body mass index (BMI) were defined as patient-related modifiable risk factors. Results Forty-seven (1.3%) deep PJIs were identified. Infection developed in 20 of 363 hips of nonsame-day procedures and 27 of 3309 same-day procedures (p = 0.006). There were eight (2%) infections in the revision group. After controlling for confounding variables, our multivariate analysis showed that BMI 3 40 kg/m 2 (odds ratio [OR], 4.13; 95% confidence interval [CI], 1.3-12.88; p = 0.01), operating time [ 115 minutes (OR, 3.38; 95% CI, 1.23-9.28; p = 0.018), nonsame-day surgery (OR, 4.16; 95% CI, 1.44-12.02; p = 0.008), and revision surgery (OR, 4.23; 95% CI, 1.67-10.72; p \ 0.001) are significant risk factors for PJIs. Tobacco use and S aureus colonization were additive risk factors when combined with other significant risk factors (OR, 12.76; 95% CI,; p = 0.017). Conclusions Nonsame-day hip and revision arthroplasties have higher infection rates than same-day primary surgeries. These characteristics are not modifiable and should be categorized as a separate cohort for complication-reporting purposes. Potentially modifiable risk factors in our patient population include operating time, elevated BMI, tobacco use, and S aureus colonization. Modifying risk factors may

Risk Factors Predict Increased Length of Stay and Readmission Rates in Revision Joint Arthroplasty

“…Readmission rate in particular has become a centerpiece for performance as hospitals can lose on upfront reimbursement due to Medicare's Readmission Reduction Program, face risk-based losses in pay-for-performance models, or receive no reimbursement at all for readmissions related to "never" or "zero-tolerance" events [7,11]. At the same time, several primary TJA bundled payment programs have credited reduction of inpatient LOS as a major lever for creating cost savings relative to baseline [9,12,13].…”

The Prevention of Periprosthetic Joint Infections

“…Alcohol cessation or a reduction in consumption four weeks prior to surgery is effective in reducing the risk of developing postoperative complications. [2, 25]…”

“…This includes proper timing of surgery, cessation of DMARDs, proper skin preparation, and antibiotic prophylaxis. The cessation of DMARDS should be performed in consultation with a rheumatologist, which can be arranged based on the specific medication, the individual patient, and the half-life of the particular medication [2]. Although there is no clear evidence, routine use of antibiotic-laden cement for fixation in IJD patients may be justified.…”

“…Several modifiable factors may influence the outcome of TJA. Identification of risk factors is important so that resources can be focused more effectively and greater attempts at risk reduction can be pursued [2]. In this review, the current evidence for the optimization of patient and surgery-related modifiable risk factors are assessed in the preoperative, intraoperative and postoperative periods.…”

Principles of Antibiotic Prophylaxis in Total Joint Arthroplasty

“…[41][42][43] Nasal carriers have increased rates of skin colonization, which is important to note because the skin is directly exposed to the surgical field at incision. Maoz et al 44 found that S aureus colonization was a risk factor for infection following THA; compared with patients without preoperative colonization, patients colonized with the bacteria had a 2.36 relative risk for infection. In patients with multiple risk factors, S aureus colonization can further magnify the risk of infection ( Table 2).…”