Risk factors in prosthetic hip/knee joint replacement infections incidence and patient outcomes

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Cardiff Unversity
Background: Periprosthetic joint infection (PJI) is a severe complication following total joint arthroplasty which is associated with mortality and morbidity risks. Perioperative identification of modifiable and not modifiable PJI risk factors is essential for educating patients on their risks of complication and improving surgical decision-making. Aims: 1. Examining the association between uncertain variables of smoking, intraarticular steroid injection, anticoagulants and fixation types, and risk of PJI in hip arthroplasty. 2. Identifying risk factors of PJI in total hip and knee joint replacement surgery in the UK. Methods: • Systematic review and meta-analysis. Systematic search conducted through MEDLINE, EMBASE, CINAHL and Cochrane databases. Odds ratio (OR) with 95% confidence interval (CI) using random effect models utilised. • Conducting a retrospective observational study involving 91,038 hip or knee joint replacements performed between 2007-2019 in England and Wales. Investigating the association between PJI risk and patient characteristics, medical and treatment histories, and surgery characteristics using Cox proportional hazards. Data obtained from Clinical Practice Research Datalink linked to Hospital Episode Statistics data. Results: • Overall OR to develop PJI for steroid injection is 2.12 (95% CI 0.58-7.72, p = 0.250); smoking is 1.54 (95% CI 1.25-1.91, p < 0.05). The systematic search found no association between anticoagulants and PJI risk, while it was difficult to draw conclusions regarding fixation method due to inconsistencies in the literature. • For THA, DM, active cancer, hypertension, using NSAIDs and DMARDs < 3 months were risk factors for PJI. Male gender, BMI 25-30 kg/m2, DM, active cancer, using NSAIDs < 3 months were risk factors for PJI following TKA. Conclusion: This study's findings provide information that allows healthcare providers to develop and incorporate preventative strategies for PJI for patients undergoing TKA/THA in clinical practice
The focus of this research has been specifically on patients undergoing THA. This is due to the current saturation of research pertaining to the identification of risk factors for periprosthetic joint infections after total knee arthroplasty. In contrast, further research is needed to identify the risk factors for THA. There are likely to be many studies investigating risk factors for PJI in this area due to the fact that total knee arthroplasty has been a popular surgery for many years. Hip arthroplasty, in comparison, is a relatively new medical procedure. Consequently, fewer studies have been conducted to identify risk factors for PJI. Therefore, this growing field offers more opportunities for research than total knee replacement. A further analysis of the risk factors for PJI in UK patients with THA and TKA is also included within this study. Clinical Practice Research Datalink (CPRD) data was used to identify associated factors for PJI in relation to both joints. Due to the differences between hip and knee arthroplasty operations and their associated risks, a separate risk factor analysis was performed. Despite the primary focus of this research being on patients undergoing THA, the rationale for including knee joint arthroplasty was to take full advantage of available resources after obtaining ethical approval from CPRD. Therefore, the scope of the study was expanded to include potential PJI risk factors in knee arthroplasty populations as well. To the best of our knowledge, there are no studies in existence on a UK population level which use CPRD data to examine PJI risks in both hip and knee arthroplasty. Research aims The aims of this research are to add to the existing evidence base surrounding the epidemiology and burden of PJI, thereby guiding orthopaedic teams in decision-making and improving health outcomes by: 1. Examining the associations between uncertain variables (factors) and incidence of PJI; including smoking, intra-articular steroid injection, anticoagulant prophylaxis prior to surgery, and type of fixation. 2. Identifying PJI risk factors in total hip and knee joint replacement surgery in the UK population by utilising Clinical Practice Research Datalink and linked Hospital Episode Statistics (HES) data. Based on the resulting quantitative analysis of studies examining the association between these risk factors and PJI development, it was concluded that smoking is associated with a higher risk of PJI in patients undergoing THA, while intra-articular steroid injections is not correlated with PJI risk. Additionally, the systematic search yielded no evidence linking anticoagulant agents to PJI risk, while inconclusive results were obtained regarding the association with fixation method due to inconsistencies in the literature. Based on descriptive analysis of data extracted from the Clinical Practice Research Datalink database covering 63,944 patients undergoing THA and TKA. The CPRD data was used in this research to provide a comprehensive electronic medical record (EMR) based on NHS primary health care and HES. This population is also large enough to draw sufficiently robust conclusions that are representative of the UK population. The multivariate model results showed a significant association between PJI and NSAIDs usage < 3 months, biological DMARDs usage < 3 months, DM, active cancer, and hypertension. Multivariate analysis further showed that, in patients undergoing TKA, the risk of PJI is significantly associated with the male gender, BMI 25-30 kg/m2, DM, active cancer, and using NSAIDs < 3 months. The results of this research show that administration of NSAIDs before THA and TKA is associated with an increase in risk of PJI. This raises questions around what may be the safest drug in the NSAIDs group, based on lower PJI risk, with similar questions emerging for other medications such as DMARDs. Moreover, this research has shown that DM is significantly associated with increased PJI risk following THA and TKA, leading to additional speculation as to the optimum glucose level that reduces PJI risk. Based on these results, practitioners should consider modifying PJI risk factors prior to surgery to reduce infection risk and to develop better hip and knee arthroplasty outcomes.
Periprosthetic joint infection, total hip joint replacement, Total hip arthroplasty, Total knee arthroplasty, Risk factors
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