Surgical approach does not affect deep infection rate after primary total hip arthroplasty

The Impact of Surgical Approach on 90-Day Prosthetic Joint Infection After Total Hip Replacement - A Population-Based, Propensity Score-Matched Cohort Study

BACKGROUND

Prosthetic joint infection (PJI) is a devastating complication of total hip arthroplasty (THA). This study aimed to determine if the anterior approach (AP) influenced the incidence of early PJI in THA compared to posterior approach (PP).

METHODS

Record linkage was performed between state-wide hospitalization data and a national joint replacement registry to identify unilateral THA performed via the AP or PP. Complete data on 12,605 AP and 25,569 PP THAs were obtained. Propensity score matching (PSM) was undertaken to match covariates between the approaches. Outcomes were the 90-day PJI hospital readmission rate(using narrow and broad definitions) and 90-day PJI revision rate (defined as component removal or exchange).

RESULTS

The raw PJI readmission rate for AP was lower than PP (0.8% versus 1.1%, respectively). In the PSM analysis, there was no statistically significant difference in PJI readmission rate between approaches using narrow or broad definition of PJI readmission. In terms of revision for infection, both methods showed AP had a significantly lower rate than PP, with an adjusted odds ratio (OR) of 0.47 (95% confidence interval (CI) 0.30, 0.75) for the 1:1 nearest neighbor method and 0.50 (95% CI 0.32, 0.77) for the subclassification method.

CONCLUSION

After addressing known confounders, there was no significant difference in the 90-day hospital readmission rate for hip PJI between approaches. There was a significantly reduced 90-day PJI revision rate for AP. The difference in revision may reflect differences in the surgical management of PJI between hip approaches rather than a difference in the underlying rate of infection.

No Difference in the Rate of Periprosthetic Joint Infection in Patients Undergoing the Posterolateral Compared to the Direct Anterior Approach

BACKGROUND

There remains inconsistent data about the association of surgical approach and periprosthetic joint infection (PJI). We sought to evaluate the risk of reoperation for superficial infection and PJI after primary total hip arthroplasty (THA) in a multivariate model.

METHODS

We reviewed 16,500 primary THAs, collecting data on surgical approach and all reoperations within 1 year for superficial infection (n = 36) or PJI (n = 70). Considering superficial infection and PJI separately, we used Kaplan-Meier survivorship to assess survival free from reoperation and a Cox Proportional Hazards multivariate models to assess risk factors for reoperation.

RESULTS

Between direct anterior approach (DAA) (N = 3,351) and PLA (N = 13,149) cohorts, rates of superficial infection (0.4 versus 0.2%) and PJI (0.3 versus 0.5%) were low and survivorship free from reoperation for superficial infection (99.6 versus 99.8%) and PJI (99.4 versus 99.7%) were excellent at both 1 and 2 years. The risk of developing superficial infection increased with high body mass index (BMI) (hazard ratio [HR] = 1.1 per unit increase, P = .003), DAA (HR = 2.7, P = .01), and smoking status (HR = 2.9, P = .03). The risk of developing PJI increased with the high BMI (HR = 1.04, P = .03), but not surgical approach (HR = 0.68, P = .3).

CONCLUSION

In this study of 16,500 primary THAs, DAA was independently associated with an elevated risk of superficial infection reoperation compared to the PLA, but there was no association between surgical approach and PJI. An elevated patient BMI was the strongest risk factor for superficial infection and PJI in our cohort.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Direct Anterior Approach Provides Superior Prosthesis Adaptability in the Early Postoperative Period of Total Hip Arthroplasty

OBJECTIVES

Prosthesis awareness is the perception of foreign bodies, which has a critical effect on the function of the prosthetic joint. In total hip arthroplasty (THA), the direct anterior approach (DAA) has more advantages than the posterior approach (PA), including superior rehabilitation outcomes. This study was to evaluate the recovery of "prosthesis awareness" through these two approaches.

METHODS

Three hundred and seventy-six patients who received THA with either DAA (n = 41) or PA (n = 335) from January 2016 to December 2017 were retrospectively analyzed. The Forgotten Joint Score-12 (FJS-12), Harris hip score (HHS), and visual analog scale (VAS) analyses were used to evaluate the recovery of "prosthesis awareness" in these patients 2 weeks, 1, 3, 6, and 12 months after surgery. The student t-test, Wilcoxon rank sum test, chi-square test, and MANOVA were used to compare the differences among groups.

RESULTS

We found that DAA patients had higher FJS-12 scores than PA patients at 2 weeks (42.15 ± 3.36 vs. 38.09 ± 3.28, p = 0.042), 1 month (49.06 ± 5.14 vs. 41.11 ± 5.21, p = 0.038), and 3 months (53.23 ± 4.07 vs. 48.09 ± 3.71, t = 3.152, p = 0.045). And the recovery rates of FJS-12 scores in DAA and PA groups at 2 weeks, 1 month, and 3 months after surgery were 75.46% ± 6.04%, 84.05% ± 6.57%, 91.37% ± 7.13%, and 74.14% ± 5.54%, 78.16% ± 6.01%, 88.23% ± 6.42%, respectively. To compare the recovery effects of the two procedures in more detail, we classified the 12 items in FJS-12 that evaluate different types of gravity center motions into three categories: low-movement group (LG), middle-movement group (MG), and high-movement group (HG). Interestingly, DAA patients had significantly higher HG than PA patients at 2 weeks, 1 month, and 3 months after operation (t = 3.225, p = 0.022 at 2 weeks, t = 3.081, p = 0.041 at 1 month and t = 2.783, p = 0.046 at 3 months), whereas no significant differences were observed in LG- and MG-related items. In addition, there were no significant differences in HHS and VAS scores between DAA and PA patients at 2 weeks (p = 0.102, p = 0.093), or from 1 month to 12 months (each p > 0.05).

CONCLUSIONS

DAA-mediated THA is superior to PA in terms of prosthesis adaptability and recovery of hip joint motion in the first 3 months after surgery, especially concerning high-movement gravity center motions.

Periprosthetic joint infection rates across primary total hip arthroplasty surgical approaches: a systematic review and meta-analysis of 653,633 procedures

INTRODUCTION

Evidence demonstrates comparable clinical outcomes across the various surgical approaches to primary total hip arthroplasty (THA). However, high-quality contemporary data regarding periprosthetic joint infection (PJI) risk between direct anterior approach (DAA) and other (THA) approaches is lacking. This systematic review and meta-analysis evaluated PJI rates reported in the literature between the DAA and other approaches.

MATERIALS AND METHODS

Five online databases were queried for all studies published from January 1st, 2000 through February 17th, 2021 that reported PJI rates between DAA and other surgical approaches. Studies reporting on primary THAs for osteoarthritis (OA) and that included PJI rates segregated by surgical approach were included. Articles reporting on revision THA, alternative THA etiologies, or minimally invasive techniques were excluded. Mantel-Haenszel (M-H) models were utilized to evaluate the pooled effect of surgical approach on infection rates. Validated risk of bias and methodological quality assessment tools were applied to each study. Multiple sensitivity analyses were conducted to evaluate the robustness of analyses.

RESULTS

28 articles reporting on 653,633 primary THAs were included. No differences were found between DAA cohorts and combined other approaches (OR: 0.95; 95% CI 0.74-1.21; p = 0.67) as well as segregated anterolateral approach cohorts (OR: 0.82, 95% CI 0.64-1.06; p = 0.13). However, DAA patients had a significantly reduced risk of infection compared to those undergoing posterior (OR: 0.66, 95% CI 0.58-0.74; p < 0.0001) and direct lateral (OR: 0.56, 95% CI 0.48-0.65; p < 0.00001) approaches.

CONCLUSION

The DAA to primary THA had comparable or lower PJI risk when compared to other contemporary approaches. The results of the most up-to-date evidence available serve to encourage adult reconstruction surgeons who have already adopted the DAA. Additionally, orthopaedic surgeons considering adoption or use of the direct anterior approach for other reasons should not be dissuaded over theoretical concern for a general increase in the risk of PJI.

LEVEL OF EVIDENCE

Level III.

Differential microbiological spectrum and resistance pattern in periprosthetic hip joint infections: a matched-cohort analysis comparing direct anterior versus lateral approach

BACKGROUND

In recent years, total hip arthroplasty via the direct anterior approach (DAA) has become more common. Little is known on the influence of the surgical approach on the microbiological spectrum and resistance pattern in periprosthetic hip joint infections. The aim of the present study was to evaluate the microbiological spectrum and resistance pattern in periprosthetic hip joint infections comparing the direct anterior versus lateral approach in a matched-cohort analysis at a single institution.

METHODS

Patients who underwent revision hip arthroplasty due to PJI following primary total hip arthroplasty with culture positive microbiology were analyzed. In all study patients, both the primary surgery and the revisions surgery were performed at the same institution. Only patients in whom primary surgery was performed via a direct anterior or lateral approach were included (n = 87). A matched cohort analysis was performed to compare the microbiological spectrum and resistance pattern in PJI following direct anterior (n = 36) versus lateral (n = 36) primary THA.

RESULTS

We identified both a significantly different microbiological spectrum and resistance pattern in PJI comparing direct anterior versus lateral approach THA. Cutibacterium avidum was obtained more frequently in the anterior subgroup (22.2% vs. 2.8%, p = 0.028). In the subgroup of infections with Staphylococcus aureus (n = 12), methicillin resistance was detected in 3/5 cases in the direct anterior group versus 0/7 cases in the lateral group (p = 0.045). Overall, Staphylococcus epidermidis was the most common causative microorganism in both groups (direct anterior: 36.1%; lateral: 27.8%, p = 0.448).

CONCLUSION

The present study indicates a potential influence of the localization of the skin incision in THA on the microbiological spectrum and resistance pattern in PJI. Cutibacterium avidum seemed to be a more common causative microorganism in PJI in patients who underwent direct anterior compared to lateral approach THA.

Intraoperative Complications and Early Return to the Operating Room in Total Hip Arthroplasty Performed Through the Direct Anterior and Posterior Approaches. An Institutional Experience of Surgeons After Their Learning Curve

BACKGROUND

Proponents of the direct anterior approach (DAA) for total hip arthroplasty (THA) claim a faster recovery, whereas critics claim an increased risk of early femoral complications. This study analyzed intraoperative and postoperative complications requiring reoperation within one year after THA through the DAA and posterior approach (PA).

METHODS

A total of 2348 elective, unilateral DAA THAs in patients with osteoarthritis performed between 2016 and 2019 were matched 1:1 for age (±5 years), gender, body mass index (±5), and femoral fixation with 2348 patients who underwent PA THA during the same period. Mixed-effects logistic regression was used. Odds ratios were reported for the occurrence of intraoperative femoral fracture, postoperative femoral fracture, infection, dislocation, and other etiologies requiring reoperation within one year.

RESULTS

Intraoperative femoral fracture occurred in 12 DAA (0.5%) and 14 PA (0.6%) patients. Twenty-five patients (1.06%) in the DAA and 28 (1.19%) in the PA group underwent reoperation within the first year. Reoperations were due to periprosthetic fracture (40%), infection (28%), dislocation (23%), and other (9%). Regression analysis revealed no difference in intraoperative femoral fracture (odds ratio (OR): 0.86, 95% confidence interval (CI): 0.40-1.86, P = .69), postoperative femoral fracture (OR: 1.10, 95% CI: 0.47-2.60, P = .83), infection (OR: 1.50, 95% CI: 0.53-5.23, P = .44), or reoperation within one year for other reasons (OR: 1.50, 95% CI: 0.25-9.00, P = .65). DAA had fewer dislocations requiring reoperation (OR: 0.20, 95% CI: 0.04-0.91, P = .02).

CONCLUSION

This comparative study did not find differences in intraoperative or postoperative fracture or infection between DAA and PA. DAA was associated with a lower likelihood of reoperation for dislocation within one year of surgery.

Risk factors for complications following pelvic ring and acetabular fractures: A retrospective analysis at an urban level 1 trauma center

Background:

Pelvic ring and acetabular fractures are some of the most morbid in orthopedic trauma. They commonly require large exposures for fixation and are associated with significant morbidity and mortality. This study attempts to identify risk factors for complications following operative fixation of pelvic injuries.

Methods:

126 patients treated for pelvic injuries were reviewed retrospectively. Demographics, procedure characteristics, and outcomes were recorded. Variables associated with complications were analyzed using logistic regression analysis.

Results:

Complications occurred in 12 patients. Higher BMI, longer length of stay, and ilioinguinal approach were significantly associated with increased infection risk. Co-morbid heart disease and concurrent smoking status showed a trend for increased infection risk. Higher BMI and ilioinguinal approach were significantly associated with an increased likelihood of re-operation. Positive psychiatric history and Medicaid payer status showed a trend toward higher reoperation risk.

Conclusion:

Knowledge of these risk factors can help guide management and predict outcomes following pelvic fracture fixation.

Direct Anterior Approach Total Hip Arthroplasty Is Not Associated with Increased Infection Rates: A Systematic Review and Meta-Analysis

BACKGROUND

The direct anterior approach (DAA) for primary total hip arthroplasty (THA) has recently increased in popularity. Recent evidence has raised concerns about whether use of the DAA is associated with increased rates of superficial and deep infection. The aim of this study was to systematically assess the literature and comparatively evaluate the rate of superficial and deep infection following primary THA using the DAA and non-direct anterior (non-DAA) approaches.

METHODS

This study was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) statement. Primary outcome measures evaluated were rates of superficial and deep infection in patients undergoing DAA and non-DAA primary THA.

RESULTS

A total of 1,872 studies were identified in the original search, of which 15 studies satisfied inclusion criteria. Our analysis evaluated 120,910 primary THAs, including 14,908 DAA and 106,002 non-DAA. The rate of superficial infection was 1.08% for DAA compared with 1.24% for non-DAA (odds ratio [OR] = 1.01, 95% confidence interval [CI] = 0.79 to 1.30, p = 0.921). The rate of deep infection was 0.73% for DAA compared with 0.51% for non-DAA (OR = 1.03, 95% CI = 0.80 to 1.32, p = 0.831).

CONCLUSIONS

This study found no difference in the rate of superficial or deep infection after primary THA using the DAA versus other surgical approaches. Our results suggest that comparative infection risk need not be a primary driver in the choice of surgical approach.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Direct anterior approach versus posterolateral approach in total hip arthroplasty: a meta-analysis of results on early post-operative period

Background

This study was performed to compare the advantage and disadvantage of posterolateral approach (PLA) and direct anterior approach (DAA) in total hip arthroplasty (THA).

Methods

Relevant trials were identified via a search of the Cochrane Central Register of Controlled Trials and PubMed from inception to 1 June 2019. A meta-analysis was performed to compare postoperative perioperative and radiographic outcomes between DAA and PLA in THA with respect to the hospital stay, blood loss, incision length, operative time, complications, and femoral and cup component position. The Harris Hip Score (HHS) was also assessed before and after 6 months postoperatively.

Results

Nine eligible studies involving 22698 adult patients (DAA group, n = 2947; PLA group, n = 19751) were identified for analysis. Compared with the PLA group, the DAA group had shorter hospital stay and achieved better HHS within 6 months after operation (P < 0.05), but the HHS was no significant differences between the two groups over 6 months (P > 0.05). The DAA group had significantly longer operative time, more blood loss, and complications than the PLA group (P < 0.05). In addition, the femoral component positioned in neutral and cup component inclination angle was comparable between both groups (P > 0.05); however, cup component anteversion angle was significantly larger in the PLA group (P < 0.05).

Conclusion

Patients in the DAA group had higher HHS within 6 months and shorter hospital stay. The DAA could offer rapid early functional recovery after THA compared with the PLA. However, the DAA group often required longer operative time and had more blood loss. Furthermore, there was a higher early complication rate. Therefore, we believe that the direct anterior approach was a more difficult technique. The surgeon should be a well-trained joint surgeon with extensive prior hip replacement experience before performing THA through a DAA, and DAA was not suitable for beginners performing THA. In addition, we did not observe the difference with regard to the femoral component position and cup component inclination angle except for the smaller cup component anteversion angle in DAA group.

Unicompartmental knee arthroplasty is associated with lower proportions of surgical site infection compared with total knee arthroplasty: A retrospective nationwide database study

BACKGROUND

This study aimed to clarify the association between types of knee arthroplasty (KA) (total knee arthroplasty (TKA) or unicompatmental knee arthroplasty (UKA)) and surgical site infection (SSI) with adjustment for various factors, using a Japanese national database.

METHODS

Data on 181,608 patients who underwent unilateral primary KA for osteoarthritis from 2010 to 2017 were obtained from the Japanese Diagnosis Procedure Combination database. SSI was identified based on International Classification of Diseases 10th Revision codes. Deep SSI (i.e. periprosthetic joint infection (PJI)) was identified as SSI treated with surgical procedures. Multivariable logistic regression analyses for SSI and PJI were performed, in which dependent variables included types of KA, patient backgrounds (sex, age, body mass index (BMI), smoking status, comorbidities), and seasonality.

RESULTS

Eight percent of analyzed patients underwent UKA, while 92% underwent TKA. The proportions of SSI and PJI after UKA were 0.9% and 0.3%, respectively, both of which were lower than those after TKA (1.9% and 0.6%) (P < 0.001). Multivariable analyses showed lower proportions of SSI for UKA (adjusted odds ratio, 0.47; 95% confidence interval, 0.37-0.60; P < 0.001) and PJI (adjusted odds ratio, 0.47; 95% confidence interval, 0.34-0.65; P < 0.001) than TKA. Other factors associated with both SSI and PJI included male sex, BMI >30 kg/m², renal dysfunction and summer season.

CONCLUSION

UKA was associated with lower proportions of SSI and PJI than TKA. Surgeons should carefully consider the indication of UKA before performing TKA, especially in patients with knee unicompartmental osteoarthritis who are at a high risk for SSI or PJI.

Direct anterior versus posterolateral approaches for clinical outcomes after total hip arthroplasty: a systematic review and meta-analysis

OBJECTIVE

The main objective of our study was to compare the intraoperative and postoperative outcomes of direct anterior approach (DAA) with posterolateral approaches (PLA).

METHODS

We searched Cochrane library, Web of Science, and PubMed for literatures comparing DAA with PLA. On the basis of inclusion and exclusion criteria, relevant literatures were selected. Two members independently screened qualified literatures, evaluated the literature quality, and extracted data information.

RESULTS

Eighteen randomized controlled trials (RCTs) and non-RCTs totaling 34,873 patients (DAA = 9636, PLA = 25237) were contained in this systematic review and meta-analysis. The results showed that DAA were reduced in terms of length of hospital stay (weighted mean difference (WMD) = -0.43, 95% confidence interval (CI) -0.78 to -0.09, P = 0.01), LLD (WMD = -2.00, 95% CI -2.75 to -1.25, P < 0.00001), PE/DVT (WMD = 0.36, 95% CI 0.15 to 0.85, P = 0.02), dislocation (WMD = 0.42, 95% CI 0.30 to 0.59, P < 0.00001) and visual analog scale (VAS) (WMD = -0.57, 95% CI -0.91 to -0.23, P = 0.0009) compared with PLA; however, DAA compared with the PLA was increasing in terms of operative time (WMD = 14.81, 95% CI 7.18 to 22.44, P = 0.0001), intraoperative blood loss (WMD = 105.13, 95% CI 25.35 to 184.90, P = 0.01), fracture (WMD = 1.46, 95% CI 1.00 to 2.11, P = 0.05), and Harris hip score (HHS) (WMD = 1.19, 95% CI 0.77 to 1.61, P < 0.00001).

CONCLUSIONS

DAA was preferable effectiveness to PLA in early pain relief and functional recovery; however, PLA has a shorter operation time, intraoperative less blood loss and fracture.

TRIAL REGISTRATION

Registration ID, CRD42020151208.

Establishing a patient centered, outpatient total joint home recovery program within an integrated healthcare system

Outpatient total joint home recovery (HR) is a rapidly growing initiative being developed and employed at high volume orthopedic centers. Minimally invasive surgery, improved pain control and home health services have made HR possible. Multidisciplinary teams with members ranging from surgeons and anesthesiologists to hospital administrators, physical therapists, nurses and research analysts are necessary for success. Eligibility criteria for outpatient total joint arthroplasty will vary between medical centers. Surgeon preference in addition to medical comorbidities, social support, preoperative patient mobility and safety of the HR location are all factors to consider when selecting patients for outpatient total joint HR. As additional knowledge is gained, the next steps will be to establish 'best practices' and speciality society-endorsed guidelines for patients undergoing outpatient total joint arthroplasty.