Aim

D-dimer is a widely available serum test that detects fibrinolytic activities that occur during infection. Prior studies have explored its utility for diagnosis of chronic periprosthetic joint infections (PJI), but not explored its prognostic value for prediction of subsequent treatment failure. The purpose of this study was to: (1) assess the ability of serum D-dimer and other standard-of-care serum biomarkers to predict failure following reimplantation, and (2) establish a new cutoff value for serum D-dimer for prognostic use prior to reimplantation.

Aim

Persistent wound drainage has been recognized as one of the major risk factors of periprosthetic joint infection (PJI). Currently, there is no consensus on the management protocol for patients who develop wound drainage after total joint arthroplasty (TJA). The objective of our study was to describe a multimodal protocol for managing draining wounds after TJA and assess the outcomes.

Considerable efforts have been invested into identifying risk factors for periprosthetic joint infection (PJI) after total joint arthroplasty (TJA). Preoperative identification of risk factors for developing PJI is imperative for medical optimization and targeted prophylaxis. The purpose of this study was to create a preoperative risk calculator for PJI by assessing a patient's individual risks for developing PJI with resistant organisms and S.aureus.

A retrospective review of 27117 patients (43253 TJAs) from 1999 to 2014, including 1035 PJIs, was performed. A total of 41 risk factors including demographics, comorbidities (using the Elixhauser and Charlson Index), and the number of previous TJAs, were evaluated. Multivariate analysis was performed; coefficients of the models were scaled to produce useful integer scoring. Predictive model strength was assessed employing area under the curve (AUC) analysis.

Among the 41 assessed variables, the following were significant risk factors in descending order of significance: prior surgeries (p<0.0001), drug abuse (p=0.0003), revision surgery (p<0.0001), human immunodeficiency virus (p=0.0004), coagulopathy (p<0.0001), renal disease (p<0.0001), congestive heart-failure (p<0.0001), psychoses (p=0.0024), rheumatological disease (p<0.0001), knee involvement (p<0.0001), diabetes (p<0.0001), anemia (p<0.0001), males (p<0.0001), liver disease (p=0.0093), smoking (p=0.0268), and high BMI (p<0.0001). Furthermore, presence of heart-valve disease (p=0.0409), metastatic disease (p=0.0006), and pulmonary disease (p=0.0042) increased the resistant organism PJIs. Patients with metastatic disease were also more likely to be infected with S. aureus (p=0.0002). AUCs were 0.83 for any PJI, 0.86 for resistant PJI, and 0.84 for S.aureus PJI models.

This large-scale single-institutional study has determined various risk factors for PJI. Some factors are modifiable and need to be addressed before elective arthroplasty. It is imperative that surgeons are aware of these risk factors and implement all possible preventative measures, including targeted prophylaxis, in patients with high-risk of PJI. Continued efforts are needed to find novel and effective solutions to minimize the burden PJI.

Periprosthetic joint infection (PJI) is one of the most devastating complications of total joint arthroplasty (TJA). Only a few studies have investigated PJI's impact on the most worrisome of all endpoints, mortality. The purpose of this study was to perform a large-scale study to determine the rates of PJI associated in-hospital mortality, and compare it to other surgical procedures.

The Nationwide Inpatient Sample was queried from 2002 to 2010 to assess the risk of mortality for patients undergoing revision for PJI or aseptic failures. Elixhauser comorbidity index and ICD-9 codes were used to obtain patients’ medical conditions and identify PJI. Multiple logistic-regression analyses were used to determine the associated variables with mortality. In-hospital mortality was compared to the followings: coronary-artery bypass graft, mastectomy, prostatectomy, appendectomy, kidney transplant, carotid surgery, cholecystectomy, and coronary interventional procedures.

PJI was associated with an increased risk (odds ratio 2.04) of in-hospital mortality (0.77%) compared to aseptic revisions (0.38%). The in-hospital mortality of revision THAs done for PJI (1.38%, 95%CI, 1.12–1.64%) was comparable to or higher than interventional coronary procedure (1.22%, 95%CI, 1.20–1.24%), cholecystectomy (1.13%, 95%CI, 1.11–1.15%), kidney transplantation (0.70%, 95%CI, 0.61%–0.79%) and carotid surgery (0.89%, 95%CI, 0.86%–0.93%) (Figure 1). The following comorbidities were independent risk factors for in-hospital mortality after TJA: liver disease, metastatic disease, fluid and electrolyte disorders, coagulopathy, weight loss and malnutrition, congestive heart failure, pulmonary circulation disorder, renal failure, and peripheral vascular disease.

PJI is associated with a two-fold increase in mortality and have mortality rates comparable to kidney transplantation and carotid surgery. Considering the fact that patients with PJI often require multiple surgical procedures, the rate of actual in-hospital mortality for patients with PJI may be considerably higher. Surgeons should be cognizant of the potentially fatal outcome of PJI and must emphasize the importance of infection control to reduce the risk of mortality.

Preoperative antibiotic prophylaxis remains one of the most important strategies for preventing periprosthetic joint infection (PJI). Current guidelines recommend giving universal antibiotic prophylaxis to all total joint arthroplasty (TJA) patients regardless of their medical conditions or immune status. The aims of this study were to determine if comorbidities influence the organism profile of PJIs and to investigate if the efficacy of the two most frequently used perioperative antibiotics (cefazolin or vancomycin) are affected by patient comorbidities.

Using an institutional database, the influence of comorbidities on the organism profile of 1022 PJIs was evaluated. To investigate the influence of perioperative antibiotic monotherapy (cefazolin or vancomycin therapy) on PJI, 8575 primary TJAs were identified and analyzed based on their comorbidities. Patients with multiple perioperative antibiotics, prior septic arthritis, unavailable perioperative antibiotic information, or who underwent aseptic revision were excluded. PJI was determined from ICD-9 codes.

While no comorbidities were associated with an increased rate of gram-positive or gram-negative infections, metastatic disease (odds ratio [OR] 7.54, p=0.006), rheumatologic disease (OR 1.63, p=0.046), and chronic pulmonary disease (OR 1.46, p=0.030) demonstrated an increased risk of Staphylococcus aureus PJI. In addition, metastatic disease (OR 5.71, 95% confidence interval [CI] 1.12–26.93, p=0.018), congestive heart failure (OR 2.2, 95% CI 1.16–4.00, p=0.010), chronic pulmonary disease (OR 1.76; 95% CI 1.09–2.78, p=0.015), and diabetes (OR 1.66; 95% CI 1.08–2.52, p=0.019) were associated with PJI from antibiotic resistant organisms. However, there was no difference in the rate of PJI between cefazolin and vancomycin monotherapy when stratified for the aforementioned comorbidities.

The present study reveals that comorbidities do not significantly alter the organism profile of high-risk comorbidities and that comorbidities associated with immune deficits do not influence the rate of PJI between two different antibiotics. The results of this study thus support current guidelines, which provide a universal recommendation rather than a protocol that is tailored to a patient's preexisting comorbidities.