What Are Risk Factors for Infection after Primary or Revision Total Joint Arthroplasty in Patients Older Than 80 Years?

Abstract

Background Patients older than 80 years of age form an increasing proportion of the patient population undergoing total joint arthroplasty (TJA). With increasing life expectancy and the success of TJA, orthopaedic surgeons are more likely to operate on patients older than 80 years than ever before. Given that most other studies focus on younger populations, only evaluate primary TJA, or limit patient populations to institutional or regional data, we felt a large-database, nationwide analysis of this demographic cohort was warranted, and we wished to consider both primary and revision TJA. Questions/purposes In this study, we sought to investigate the risk factors for surgical site infections (SSIs) at 90 days and periprosthetic joint infections (PJIs) at 2 years after surgery in patients aged 80 years and older undergoing (1) primary and (2) revision lower extremity TJA. Methods All patients aged 80 years or older who underwent primary or revision TJA between 2005 and 2014 were identified using the Medicare Analytical Files of the PearlDiver Supercomputer using ICD-9 codes. This database is unique in that it is one of the largest nationwide databases, and so it provides a large enough sample size of patients 80 years or older. Additionally, this database provides comprehensive and longitudinal patient data tracking, and a low error rate. Our final cohort consisted of 503,241 patients (TKA: n = 275,717; THA: n = 162,489; revision TKA: n = 28,779; revision THA: n = 36,256). Multivariate logistic regression models were constructed to evaluate the association of risk factors on the incidences of 90-day SSI and 2-year PJI. Variables such as sex, diabetes, BMI, and congestive heart failure, were included in the multivariate regression models. Several high-risk comorbidities as identified by the Charlson and Elixhauser comorbidity indices were selected to construct the models. We performed a Bonferroni-adjusted correction to account for the fact that multiple statistical comparisons were made, with a p value < 0.002 being considered statistically significant. Results For primary TKA patients, an increased risk of 90-day SSIs was associated with male sex (OR 1.28 [95% CI 1.25 to 1.52]; p < 0.001), BMI greater than 25 k/m2 (p < 0.001), and other comorbidities. For primary THA patients, an increased risk of 90-day SSIs was associated with patients with obesity (BMI 30-39 kg/m2; OR 1.91 [95% CI 1.60 to 2.26]; p < 0.001) and those with morbid obesity (BMI 40-70 kg/m2; OR 2.58 [95% CI 1.95 to 3.36]; p < 0.001). For revision TKA patients, an increased risk of SSI was associated with iron-deficiency anemia (OR 1.82 [95% CI 1.37 to 2.28]; p < 0.001). For revision THA patients, electrolyte imbalance (OR 1.48 [95% CI 1.23 to 1.79]; p < 0.001) and iron-deficiency anemia (OR 1.63 [95% CI 1.35 to 1.99]; p < 0.001) were associated with an increased risk of 90-day SSI. Similar associations were noted for PJI in each cohort. Conclusions These findings show that in this population, male sex, obesity, hypertension, iron-deficiency anemia, among other high-risk comorbidities are associated with a higher risk of SSIs and PJIs. Based on these findings, orthopaedic surgeons should actively engage in comanagement strategies with internists and other specialists to address modifiable risk factors through practices such as weight management programs, blood pressure reduction, and electrolyte balancing. Furthermore, this data should encourage healthcare systems and policy makers to recognize that this patient demographic is at increased risks for PJI or SSI, and these risks must be considered when negotiating payment bundles. Level of Evidence Level III, therapeutic study.

The Impact of Corticosteroid Injection Timing on Infection Rates Following Spine Surgery: A Systematic Review and Meta-Analysis

“…66 The notion that underlying confounders may skew the data in PearlDiver toward demonstrating a positive association between CSI and infection is partially supported by the finding that PearlDiver-derived analyses regarding the timing of CSI prior to arthroscopic shoulder surgery and TKA, for example, are also among the only studies to identify a link between CSI and subsequent postoperative infection in these fields. 37,[39][40][41][42]44,45,67,68 There are other limitations to the current systematic review and meta-analysis. Because much of the data included in the current study was from large registry databases, it is difficult to perform sub-group analyses to identify risk factors and drivers that may modulate the risk of infection following CSI.…”

“…In fact, preoperative CSIs have been identified as a risk factor for postoperative infection in a wide variety of orthopaedic procedures, from shoulder and hip arthroscopy, to total shoulder and total joint arthroplasty (TJA). [33][34][35][36][37][38][39][40][41][42][43][44][45] Based on these findings, it is commonplace in the field of TJA, for example, to delay operative treatment for 3 months following intraarticular CSI. 42,46 Even in the field of TJA, however, where these practices are largely standard-of-care, the growing number of studies, systematic reviews, and meta-analyses refuting this association have caused some to take pause and reassess the validity of this commonly held practice.…”

Preoperative Patient Optimization in Total Joint Arthroplasty—The Paradigm Shift from Preoperative Clearance: A Narrative Review

“…Our purpose was to review the current evidence on the clinical implications of obesity, malnutrition, hypoalbuminemia, diabetes, anemia, smoking, and opioid use [52,68,79] in TJA and to propose evidence-based recommendations for the optimization of these risk factors. We found that they were associated with worse outcomes, including increased rates of in-hospital complications, transfusions, periprosthetic joint infections, revisions, and mortality.…”

“…Previous studies have identified modifiable risk factors in TJA that increase the risk of complications; these include deep and superficial infections, pulmonary emboli, and myocardial infarction [7,8]. Modifiable risk factors have also been associated with increased readmissions, length of stay, costs, and revisions [52,68,79]. Pruzansky et al [62] found that 80% of patients undergoing any TJA and 93% of patients undergoing revision TJA for periprosthetic joint infection had at least 1 modifiable risk factor, with the most common being morbid obesity (46%), anemia (29%), malnutrition (26%), and diabetes (20%).…”

Tobacco Use Is Associated with More Severe Adverse Outcomes Than Morbid Obesity after Aseptic Revision TKA

“…a Abbreviations: BMI, body mass index; CHF, congestive heart failure; DVT, deep vein thrombosis; PE, pulmonary embolism. a p < 0.01. b p < 0.05.these conditions exist individually 12,14,16,17,19,21,[23][24][25]30,31. In contrast to the study hypothesis, morbid obesity was not associated with an increased risk of reoperation or component revision.…”