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Anneberg M, Kristiansen EB, Troelsen A, Gundtoft P, Sørensen HT, Pedersen AB. Enhancing the data capture of periprosthetic joint infections in the Danish Knee Arthroplasty Registry: validity assessment and incidence estimation. Acta Orthop 2024; 95:166-173. [PMID: 38595072 PMCID: PMC11004670 DOI: 10.2340/17453674.2024.40358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 03/06/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND AND PURPOSE Revisions due to periprosthetic joint infection (PJI) are underestimated in national arthroplasty registries. Our primary objective was to assess the validity in the Danish Knee Arthroplasty Register (DKR) of revisions performed due to PJI against the Healthcare-Associated Infections Database (HAIBA). The secondary aim was to describe the cumulative incidences of revision due to PJI within 1 year of primary total knee arthroplasty (TKA) according to the DKR, HAIBA, and DKR/HAIBA combined. METHODS This longitudinal observational cohort study included 56,305 primary TKAs (2010-2018), reported in both the DKR and HAIBA. In the DKR, revision performed due to PJI was based on pre- and intraoperative assessment disclosed by the surgeon immediately after surgery. In HAIBA, PJI was identified from knee-related revision procedures coinciding with 2 biopsies with identical microbiological pathogens. We calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of revision due to PJI in the DKR (vs. HAIBA, within 1 year of TKA) with 95% confidence intervals (CI). Cumulative incidences were calculated using the Kaplan-Meier method. RESULTS The DKR's sensitivity for PJI revision was 58% (CI 53-62) and varied by TKA year (41%-68%) and prosthetic type (31% for monoblock; 63% for modular). The specificity was 99.8% (CI 99.7-99.8), PPV 64% (CI 62-72), and NPV 99.6% (CI 99.6-99.7). 80% of PJI cases not captured by the DKR were caused by non-reporting rather than misclassification. 33% of PJI cases in the DKR or HAIBA were culture-negative. Considering potential misclassifications, the best-case sensitivity was 64%. The cumulative incidences of PJI were 0.8% in the DKR, 0.9% in HAIBA, and 1.1% when combining data. CONCLUSION The sensitivity of revision due to PJI in the DKR was 58%. The cumulative incidence of PJI within 1 year after TKA was highest (1.1%) when combining the DKR and HAIBA, showing that incorporating microbiology data into arthroplasty registries can enhance PJI validity.
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Affiliation(s)
- Marie Anneberg
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus University.
| | | | | | - Per Gundtoft
- Department of Orthopedic Surgery, Aarhus University Hospital
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus University
| | - Alma B Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus University; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Anneberg M, Troelsen A, Gundtoft P, Sørensen HT, Pedersen AB. Temporal trends in revision rate due to knee periprosthetic joint infection: a study of 115,120 cases from the Danish Knee Arthroplasty Register. Acta Orthop 2023; 94:616-624. [PMID: 38153296 PMCID: PMC10755676 DOI: 10.2340/17453674.2023.33294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 11/16/2023] [Indexed: 12/29/2023] Open
Abstract
BACKGROUND AND PURPOSE We aimed to examine the temporal trends in periprosthetic joint infection (PJI) revision incidence after knee arthroplasty (KA) from 1997 through 2019. PATIENTS AND METHODS 115,120 primary KA cases from the Danish Knee Arthroplasty Register were followed until the first PJI revision. We computed cumulative incidences and adjusted hazard ratios (aHRs) of PJI revision by calendar periods and several patient- and surgical-related risk factors. Results were analyzed from 0-3 months and from 3-12 months after KA. RESULTS The overall 1-year PJI revision incidence was 0.7%, increasing from 0.5% to 0.7% (1997 through 2019). The incidence of PJI revision within 3 months increased from 0.1% to 0.5% (1997 through 2019). The adjusted hazard ratio (aHR) within 1 year of primary KA was 5.1 comparing 2017-2019 with 2001-2004. The PJI revision incidence from 3-12 months of KA decreased from 0.4% to 0.2%, with an aHR of 0.5 for 2017-2019 vs. 2001-2004. Male sex, age 75-84 (vs. 65-74), and extreme obesity (vs. normal weight) were positively associated with the risk of PJI revision within 3 months, whereas only male sex was associated from 3-12 months. Partial knee arthroplasty (PKA) vs. total KA was associated with a lower risk of PJI revision both within 3 months and 3-12 months of KA. CONCLUSION We observed an increase in PJI revision within 3 months of KA, and a decrease in PJI revision incidence from 3-12 months from 1997 through 2019. The reasons for this observed time-trend are thought to be multifactorial. PKA was associated with a lower risk of PJI revision.
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Affiliation(s)
- Marie Anneberg
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus University.
| | | | - Per Gundtoft
- Department of Orthopedic Surgery, Aarhus University Hospital
| | - Henrik T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus University
| | - Alma B Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus University; Department of Clinical Medicine, Aarhus University Hospital, Denmark
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SIGURDARDOTTIR M, SIGURDSSON MI, OLAFSSON Y, SVERRISDOTTIR SH, GUNNARSDOTTIR I, SIGURDSSON EL, KARASON S. Prevalence of modifiable risk factors in primary elective arthroplasty and their association with infections. Acta Orthop 2023; 94:38-44. [PMID: 36727913 PMCID: PMC9893833 DOI: 10.2340/17453674.2023.8480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND AND PURPOSE The aim of this study was to identify the prevalence of modifiable risk factors of surgical site infections (SSI) in patients undergoing primary elective total joint arthroplasty (TJA) receiving conventional preoperative preparation, and to explore their association with infectious outcomes. PATIENTS AND METHODS Information regarding modifiable risk factors (anemia, diabetes, obesity, nutritional status, smoking, physical activity) was prospectively gathered in patients undergoing primary TJA of hip or knee in 2018-2020 at a single institution with 6 weeks' follow-up time. RESULTS 738 patients (median age 68 years [IQR 61-73], women 57%) underwent TJA (knee 64%, hip 36%). Anemia was detected in 8%, diabetes was present in 9%, an additional 2% had undiagnosed diabetes (HbA1c > 47 mmol/mol), and 8% dysglycemia (HbA1c 42-47 mmol/mol). Obesity (BMI ≥ 30) was observed in 52%. Serum albumin, total lymphocyte count, and vitamin D below normal limits was identified in 0.1%, 18%, and 16%, respectively. Current smokers were 7%. Surgical site complications occurred in 116 (16%), superficial SSI in 57 (8%), progressing to periprosthetic joint infection in 7 cases. Univariate analysis identified higher odds of superficial SSI for BMI ≥ 30 (OR 2.1, 95%CI 1.2-3.8) and HbA1c ≥ 42 mmol/mol (OR 2.2, CI 1.1-4.2), but no association was found with other factors. CONCLUSION In a general population undergoing primary TJA an association was found between obesity (52%) and dysglycemia/diabetes (19%) and superficial SSI (8%), which progressed to PJI in 12% of cases, generating a 1% total rate of PJI. Modification of these risk factors might mitigate infectious adverse outcomes.
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Affiliation(s)
- Maria SIGURDARDOTTIR
- Department of Anaesthesia and Intensive Care, Landspitali, The National University Hospital of Iceland, Reykjavik,University of Iceland, Faculty of Medicine, Reykjavik
| | - Martin Ingi SIGURDSSON
- Department of Anaesthesia and Intensive Care, Landspitali, The National University Hospital of Iceland, Reykjavik,University of Iceland, Faculty of Medicine, Reykjavik
| | - Yngvi OLAFSSON
- Department of Orthopeadics, Landspitali, The National University Hospital of Iceland, Reykjavik
| | | | - Ingibjorg GUNNARSDOTTIR
- Department of Clinical Nutrition, Landspitali – The National University Hospital of Iceland, Reykjavik,University of Iceland, Faculty of Food Science and Nutrition
| | - Emil L SIGURDSSON
- University of Iceland, Faculty of Medicine, Reykjavik,Development Centre for Primary Health Care in Iceland
| | - Sigurbergur KARASON
- Department of Anaesthesia and Intensive Care, Landspitali, The National University Hospital of Iceland, Reykjavik,University of Iceland, Faculty of Medicine, Reykjavik
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Thompson O, W-Dahl A, Stefánsdóttir A. Increased short- and long-term mortality amongst patients with early periprosthetic knee joint infection. BMC Musculoskelet Disord 2022; 23:1069. [PMID: 36474195 PMCID: PMC9724335 DOI: 10.1186/s12891-022-06024-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) following total knee arthroplasty (TKA) is a severe complication in terms of disability, morbidity, and cost. We performed a study to investigate whether early PJI (within 90 days of primary TKA) is associated with increased mortality. Secondary aims were to compare mortality rates over time and between surgical treatment methods. METHODS Patients with suspected PJI were identified by linkage of the Swedish Knee Arthroplasty Register (SKAR) and the Swedish Prescribed Drug Register (SPDR) in 2007-2008 and 2012-2013. Medical records of patients receiving more than 4 weeks of continuous antibiotic therapy were subsequently reviewed to verify the PJI diagnosis. Information on mortality was obtained through the SKAR which is updated daily from the tax agency and patients with PJI were compared to patients without PJI. RESULTS Four hundred sixty-six patients were diagnosed with PJI within 90 days and compared to 40,362 patients without PJI. Mortality rates were significantly higher for PJI patients in both short- and long term: 2.6% vs. 0.8% at 1 year, 4.9% vs. 1.9% at 2 years, 15.7% vs. 7.1% at 5 years, and 38% vs. 21.4% at 10 years. The difference in mortality rate remained after adjusting for sex, age, diagnosis, and time period for surgery with Hazard Ratio 1.8 (95% CI:1.6-2.1). Mortality rates did not differ between time periods, and we found no correlation to surgical treatment. CONCLUSION Patients with early PJI after primary TKA have an increased mortality rate compared to TKA patients without PJI. Improvements in surgical treatment strategy has not resulted in better survival. Long term difference in mortality rates indicates that PJI is not the sole reason for mortality suggesting a general frailty in PJI patients.
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Affiliation(s)
- Olof Thompson
- grid.4514.40000 0001 0930 2361Department of Clinical Sciences Lund, Division of Infection Medicine, Lund University, Lund, Sweden ,grid.411843.b0000 0004 0623 9987Department of Infectious Diseases, Skåne University Hospital, Lund, Sweden
| | - Annette W-Dahl
- grid.4514.40000 0001 0930 2361Department of Clinical Sciences Lund, Division of Orthopedics, Lund University, Lund, Sweden ,Swedish Arthroplasty Register, Gothenburg, Sweden
| | - Anna Stefánsdóttir
- grid.4514.40000 0001 0930 2361Department of Clinical Sciences Lund, Division of Orthopedics, Lund University, Lund, Sweden ,grid.411843.b0000 0004 0623 9987Department of Orthopedics, Skåne University Hospital, Lund, Sweden
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Rodriguez-Merchan EC, Delgado-Martinez AD. Risk Factors for Periprosthetic Joint Infection after Primary Total Knee Arthroplasty. J Clin Med 2022; 11:6128. [PMID: 36294449 PMCID: PMC9605414 DOI: 10.3390/jcm11206128] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 08/29/2023] Open
Abstract
Periprosthetic joint infection (PJI) is a major adverse event of primary total knee arthroplasty (TKA) from the patient's perspective, and it is also costly for health care systems. In 2010, the reported incidence of PJI in the first 2 years after TKA was 1.55%, with an incidence of 0.46% between the second and tenth year. In 2022, it has been published that 1.41% of individuals require revision TKA for PJI. The following risk factors have been related to an increased risk of PJI: male sex, younger age, type II diabetes, obesity class II, hypertension, hypoalbuminemia, preoperative nutritional status as indicated by prognostic nutritional index (PNI) and body mass index, rheumatoid arthritis, post-traumatic osteoarthritis, intra-articular injections prior to TKA, previous multi-ligament knee surgery, previous steroid therapy, current tobacco use, procedure type (bilateral), length of stay over 35 days, patellar resurfacing, prolonged operative time, use of blood transfusions, higher glucose variability in the postoperative phase, and discharge to convalescent care. Other reported independent risk factors for PJI (in diminishing order of importance) are congestive heart failure, chronic pulmonary illness, preoperative anemia, depression, renal illness, pulmonary circulation disorders, psychoses, metastatic tumor, peripheral vascular illness, and valvular illness. Preoperative intravenous tranexamic acid has been reported to diminish the risk of delayed PJI. Knowing the risk factors for PJI after TKA, especially those that are avoidable or controllable, is critical to minimizing (ideally preventing) this complication. These risk factors are outlined in this article.
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Affiliation(s)
- Emerito Carlos Rodriguez-Merchan
- Department of Orthopedic Surgery, La Paz University Hospital, Paseo de la Castellana 261, 28046 Madrid, Spain
- Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research—IdiPAZ (La Paz University Hospital—Autonomous University of Madrid), 28046 Madrid, Spain
| | - Alberto D. Delgado-Martinez
- Department of Orthopedic Surgery, Hospital Universitario de Jaen, 23007 Jaen, Spain
- Department of Surgery, University of Jaen, 23071 Jaen, Spain
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Treatment outcomes of patients with Cutibacterium acnes-positive cultures during total joint replacement revision surgery: a minimum 2-year follow-up. Arch Orthop Trauma Surg 2022; 143:2951-2958. [PMID: 35759014 DOI: 10.1007/s00402-022-04489-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/16/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Periprosthetic joint infection (PJI) is a devastating complication following total joint replacement (TJR). Cutibacterium acnes (C. acnes) is a low virulent skin commensal, commonly found during TJR revision surgery for "aseptic" causes. The purpose of the present study was to report the treatment outcomes of patients with C. acnes contamination or infection in the presence of a TJR treated with a revision surgery ± implant exchange ± prolonged (≥ 8 weeks) postoperative antibiotics. METHODS Medical records of patients with at least one positive C. acnes culture in intraoperative tissue samples or sonication fluid from a TJR revision surgery between January 2005 and December 2014 were retrospectively evaluated. The primary endpoint was infection eradication according to Delphi criteria. The diagnostic accuracy of preoperative TJR aspiration regarding the diagnosis of C. acnes PJI was also investigated. RESULTS A total of 52 TJR (28 shoulders, 17 hips, 7 knees) in 52 patients (35 males, 17 females) with an average age of 63 ± 11 (33-86) years were included. At an average follow-up of 67 ± 33 (24-127) months, the infection eradication of C. acnes PJI was 97% regardless of the surgical treatment or administration of prolonged postoperative antibiotics. The incidence of unsuspected C. acnes PJI was 28.8%. The sensitivity and specificity of preoperative joint aspiration in detecting C. acnes PJI were 59% and 88%, whereas the PPV and NNV were 83% and 67%, respectively. CONCLUSION Infection eradication of C. acnes PJI was very high at a minimum follow-up of 24 months, suggesting that C. acnes PJI could be adequately treated with a combination of revision surgery and prolonged postoperative antibiotics. The preoperative diagnosis of C. acnes PJI might be challenging with more than one-quarter of patients presenting without suspicion of C. acnes PJI. The appropriate treatment of patients with a single positive culture remains still unclear. A negative TJR aspiration should not rule out a C. acnes PJI, especially in the presence of clinical correlates of infection. LEVEL OF EVIDENCE Retrospective case-control study, Level III. IRB APPROVAL Kantonale Ethikkommission Zürich, BASEC Nr.:2017-00567.
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Rodriguez-Merchan EC, De la Corte-Rodriguez H, Alvarez-Roman T, Gomez-Cardero P, Encinas-Ullan CA, Jimenez-Yuste V. Total knee arthroplasty in hemophilia: lessons learned and projections of what's next for hemophilic knee joint health. Expert Rev Hematol 2022; 15:65-82. [PMID: 35041571 DOI: 10.1080/17474086.2022.2030218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The purpose of this article has been to review the literature on total knee arthroplasty (TKA) in people with hemophilia (PWH), to mention the lessons we have learned from our own experience and to try to find out what the future of this type of surgery will be. AREAS COVERED A Cochrane Library and PubMed (MEDLINE) search of studies related to TKA PWH was analyzed. In PWH, the complication rate after TKA can be up to 31.5%. These include infection (7.1%) and bleeding in the form of hematoma, hemarthrosis or popliteal artery injury (8.9%). In a meta-analysis the revision arthroplasty rate was 6.3%. One-stage or two-stage revision arthroplasty due to infection (septic loosening) is not always successful despite providing correct treatment (both hematological and surgical). In fact, the risk of prosthetic re-infection is about 10%. It is necessary to perform a re-revision arthroplasty, which is a high-risk and technically difficult surgery that can sometimes end in knee arthrodesis or above-the-knee amputation of the limb. EXPERT OPINION TKA (both primary and revision) should be performed in centers specialized in orthopedic surgery and rehabilitation (knee) and hematology (hemophilia), and with optimal coordination between the medical team.
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Affiliation(s)
- E Carlos Rodriguez-Merchan
- Department of Orthopedic Surgery, La Paz University Hospital-IdiPaz, Madrid, Spain.,Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital - Autonomous University of Madrid), Madrid, Spain
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