Skip to main content
SpringerLink
Log in

Risk factors for periprosthetic joint infection after total knee arthroplasty

  • Knee Arthroplasty
  • Published:
Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript

Abstract

Introduction

Periprosthetic joint infection (PJI) is the most serious and feared complication in total knee arthroplasty (TKA) and can have catastrophic consequences. The number of total knee arthroplasties is increasing, so infections could also be greater in the future. The aim of this study is to identify the most relevant risk factors associated with infection after a total knee arthroplasty.

Methods

This is a case–control study of patients who underwent total knee arthroplasty at the University Hospital of Salamanca. We included 66 TKA PJI patients and 66 control TKA patients. Demographic and clinical variables were collected. A descriptive and inferential analysis was performed by logistic regression and attributable risk fraction assessed.

Results

Prolonged operative time (> 90′) and tourniquet time (> 60′) were the most relevant risk factors described (OR 40.77, AFE 0.97, p > 0.001 and OR 37.14, AFE 0.97, p < 0.001, respectively). The use of non-antibiotic-laded cement (OR 3.62), obesity (BMI > 30, OR 8.86), diabetes (OR 2.33), high ASA grade (III–IV, OR 15.30), and blood transfusion requirement (OR 4.60) were also statistically significant risk factors for TKA PJI.

Conclusions

Our study provides evidence concerning that operative time, tourniquet time, cement type, diabetes, obesity, ASA grade, and blood transfusion requirement as independently associated risk factors for TKA PJI. Modifiable risk factors were specifically relevant, so we should be able to reduce the infection rate.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Abbreviations

BMI:

Body mass index

ESR:

Erythrocyte sedimentation rate

PJI:

Periprosthetic joint infection

PMN:

Polymorphonuclear

CRP:

C-reactive protein

TKA:

Total knee arthroplasty

UHS:

University Hospital of Salamanca

References

  1. Ritter MA, Farris A (2010) Outcome of infected total joint replacement. Orthopedics. https://doi.org/10.3928/01477447-20100129-09

    Article  PubMed  Google Scholar 

  2. Lum ZC, Natsuhara KM, Shelton TJ et al (2018) Mortality during total knee periprosthetic joint infection. J Arthroplasty 33:3783–3788. https://doi.org/10.1016/j.arth.2018.08.021

    Article  PubMed  Google Scholar 

  3. Poultsides LA, Ma Y, Della Valle AG et al (2013) In-hospital surgical site infections after primary hip and knee arthroplasty—incidence and risk factors. J Arthroplasty 28:385–389. https://doi.org/10.1016/j.arth.2012.06.027

    Article  PubMed  Google Scholar 

  4. Gathen M, Wimmer MD, Ploeger MM et al (2018) Comparison of two-stage revision arthroplasty and intramedullary arthrodesis in patients with failed infected knee arthroplasty. Arch Orthop Trauma Surg 138:1443–1452. https://doi.org/10.1007/s00402-018-3007-9

    Article  PubMed  Google Scholar 

  5. Kurtz S, Ong K, Lau E et al (2007) Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Jt Surg 89:780. https://doi.org/10.2106/JBJS.F.00222

    Article  Google Scholar 

  6. Jaén F, Sanz-Gallardo M, Arrazola M et al (2012) Multicentre study of infection incidence in knee prosthesis. Rev Esp Cir Ortop Traumatol 56:38–45. https://doi.org/10.1016/j.recot.2011.08.001

    Article  PubMed  Google Scholar 

  7. Wu C, Qu X, Liu F et al (2014) Risk factors for periprosthetic joint infection after total hip arthroplasty and total knee arthroplasty in Chinese patients. PLoS ONE 9:e95300. https://doi.org/10.1371/journal.pone.0095300

    Article  PubMed  PubMed Central  Google Scholar 

  8. Malinzak RA, Ritter MA, Berend ME et al (2009) Morbidly obese, diabetic, younger, and unilateral joint arthroplasty patients have elevated total joint arthroplasty infection rates. J Arthroplasty 24:84–88. https://doi.org/10.1016/j.arth.2009.05.016

    Article  PubMed  Google Scholar 

  9. Everhart JS, Altneu E, Calhoun JH (2013) Medical comorbidities are independent preoperative risk factors for surgical infection after total joint arthroplasty. Clin Orthop Relat Res 471:3112–3119. https://doi.org/10.1007/s11999-013-2923-9

    Article  PubMed  PubMed Central  Google Scholar 

  10. Bozic KJ, Lau E, Kurtz S et al (2012) Patient-related risk factors for postoperative mortality and periprosthetic joint infection in medicare patients undergoing TKA. Clin Orthop Relat Res 470:130–137. https://doi.org/10.1007/s11999-011-2043-3

    Article  PubMed  Google Scholar 

  11. Namba RS, Inacio MC, Paxton EW (2013) Risk factors associated with deep surgical site infections after primary total knee arthroplasty. J Bone Jt Surg Am 95:775–782. https://doi.org/10.2106/JBJS.L.00211

    Article  Google Scholar 

  12. Wu C-T, Chen I-L, Wang J-W et al (2016) Surgical site infection after total knee arthroplasty: risk factors in patients with timely administration of systemic prophylactic antibiotics. J Arthroplasty 31:1568–1573. https://doi.org/10.1016/j.arth.2016.01.017

    Article  PubMed  Google Scholar 

  13. Wang H, Qiu G-X, Lin J et al (2015) Antibiotic bone cement cannot reduce deep infection after primary total knee arthroplasty. Orthopedics 38:e462–e466. https://doi.org/10.3928/01477447-20150603-52

    Article  PubMed  Google Scholar 

  14. Naranje S, Lendway L, Mehle S, Gioe TJ (2015) Does operative time affect infection rate in primary total knee arthroplasty? Clin Orthop Relat Res 473:64–69. https://doi.org/10.1007/s11999-014-3628-4

    Article  PubMed  Google Scholar 

  15. Yi S, Tan J, Chen C et al (2014) The use of pneumatic tourniquet in total knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg 134:1469–1476. https://doi.org/10.1007/s00402-014-2056-y

    Article  PubMed  Google Scholar 

  16. Parvizi J, Zmistowski B, Berbari EF et al (2011) New definition for periprosthetic joint infection: from the workgroup of the musculoskeletal infection society. Clin Orthop Relat Res 469:2992–2994. https://doi.org/10.1007/s11999-011-2102-9

    Article  PubMed  PubMed Central  Google Scholar 

  17. Nilsdotter A-K, Toksvig-Larsen S, Roos EM (2009) A 5 year prospective study of patient-relevant outcomes after total knee replacement. Osteoarthr Cartil 17:601–606. https://doi.org/10.1016/j.joca.2008.11.007

    Article  Google Scholar 

  18. Koh CK, Zeng I, Ravi S et al (2017) Periprosthetic joint infection is the main cause of failure for modern knee arthroplasty: an analysis of 11,134 knees. Clin Orthop Relat Res 475:2194–2201. https://doi.org/10.1007/s11999-017-5396-4

    Article  PubMed  PubMed Central  Google Scholar 

  19. Daines BK, Dennis DA, Amann S (2015) Infection prevention in total knee arthroplasty. J Am Acad Orthop Surg 23:356–364. https://doi.org/10.5435/JAAOS-D-12-00170

    Article  PubMed  Google Scholar 

  20. López-Contreras J, Limón E, Matas L et al (2012) Epidemiology of surgical site infections after total hip and knee joint replacement during 2007–2009: a report from the VINCat Program. Enferm Infecc Microbiol Clin 30(Suppl 3):26–32. https://doi.org/10.1016/S0213-005X(12)70093-9

    Article  PubMed  Google Scholar 

  21. Springer BD, Cahue S, Etkin CD et al (2017) Infection burden in total hip and knee arthroplasties: an international registry-based perspective. Arthroplast Today 3:137–140. https://doi.org/10.1016/j.artd.2017.05.003

    Article  PubMed  PubMed Central  Google Scholar 

  22. Meehan JP, Danielsen B, Kim SH et al (2014) Younger age is associated with a higher risk of early periprosthetic joint infection and aseptic mechanical failure after total knee arthroplasty. J Bone Jt Surg Am 96:529–535. https://doi.org/10.2106/JBJS.M.00545

    Article  Google Scholar 

  23. Rodríguez-Baño J, del Toro MD, Lupión C et al (2008) Arthroplasty-related infection: incidence, risk factors, clinical features, and outcome. Enferm Infecc Microbiol Clin 26:614–620

    Article  PubMed  Google Scholar 

  24. Zhu M, Ravi S, Frampton C et al (2016) New Zealand Joint Registry data underestimates the rate of prosthetic joint infection. Acta Orthop 87:346–350. https://doi.org/10.3109/17453674.2016.1171639

    Article  PubMed  PubMed Central  Google Scholar 

  25. Rhee C, Lethbridge L, Richardson G, Dunbar M (2018) Risk factors for infection, revision, death, blood transfusion and longer hospital stay 3 months and 1 year after primary total hip or knee arthroplasty. Can J Surg 61:165–176. https://doi.org/10.1503/cjs.007117

    Article  PubMed  PubMed Central  Google Scholar 

  26. Tayton ER, Frampton C, Hooper GJ, Young SW (2016) The impact of patient and surgical factors on the rate of infection after primary total knee arthroplasty: an analysis of 64,566 joints from the New Zealand Joint Registry. Bone Jt J 98-B:334–340. https://doi.org/10.1302/0301-620X.98B3.36775

    Article  CAS  Google Scholar 

  27. Poultsides LA, Triantafyllopoulos GK, Sakellariou VI et al (2018) Infection risk assessment in patients undergoing primary total knee arthroplasty. Int Orthop 42:87–94. https://doi.org/10.1007/s00264-017-3675-z

    Article  PubMed  Google Scholar 

  28. Teo BJX, Yeo W, Chong HC, Tan AHC (2018) Surgical site infection after primary total knee arthroplasty is associated with a longer duration of surgery. J Orthop Surg 26:1–7. https://doi.org/10.1177/2309499018785647

    Article  Google Scholar 

  29. Crowe B, Payne A, Evangelista PJ et al (2015) Risk factors for infection following total knee arthroplasty: a series of 3836 cases from one institution. J Arthroplasty 30:2275–2278. https://doi.org/10.1016/j.arth.2015.06.058

    Article  PubMed  Google Scholar 

  30. Jung P, Morris AJ, Roberts SA et al (2017) BMI is a key risk factor for early periprosthetic joint infection following total hip and knee arthroplasty. N Z Med J 130:24–34

    PubMed  Google Scholar 

  31. Lee QJ, Mak WP, Wong YC (2015) Risk factors for periprosthetic joint infection in total knee arthroplasty. J Orthop Surg 23:282–286. https://doi.org/10.1177/230949901502300303

    Article  Google Scholar 

  32. Jämsen E, Nevalainen P, Eskelinen A et al (2012) Obesity, diabetes, and preoperative hyperglycemia as predictors of periprosthetic joint infection: a single-center analysis of 7181 primary hip and knee replacements for osteoarthritis. J Bone Jt Surg Am 94:e101. https://doi.org/10.2106/JBJS.J.01935

    Article  Google Scholar 

  33. Dowsey MM, Choong PFM (2009) Obese diabetic patients are at substantial risk for deep infection after primary TKA. Clin Orthop Relat Res 467:1577–1581. https://doi.org/10.1007/s11999-008-0551-6

    Article  PubMed  Google Scholar 

  34. Jämsen E, Nevalainen P, Kalliovalkama J, Moilanen T (2010) Preoperative hyperglycemia predicts infected total knee replacement. Eur J Intern Med 21:196–201. https://doi.org/10.1016/j.ejim.2010.02.006

    Article  CAS  PubMed  Google Scholar 

  35. Windisch C, Brodt S, Roehner E, Matziolis G (2017) C-reactive protein course during the first 5 days after total knee arthroplasty cannot predict early prosthetic joint infection. Arch Orthop Trauma Surg 137:1115–1119. https://doi.org/10.1007/s00402-017-2709-8

    Article  PubMed  Google Scholar 

  36. Bohm E, Zhu N, Gu J et al (2014) Does adding antibiotics to cement reduce the need for early revision in total knee arthroplasty? Clin Orthop Relat Res 472:162–168. https://doi.org/10.1007/s11999-013-3186-1

    Article  PubMed  Google Scholar 

  37. Hinarejos P, Guirro P, Leal J et al (2013) The use of erythromycin and colistin-loaded cement in total knee arthroplasty does not reduce the incidence of infection: a prospective randomized study in 3000 knees. J Bone Jt Surg Am 95:769–774. https://doi.org/10.2106/JBJS.L.00901

    Article  Google Scholar 

  38. Kim JL, Park J-H, Han S-B et al (2017) Allogeneic blood transfusion is a significant risk factor for surgical-site infection following total hip and knee arthroplasty: a meta-analysis. J Arthroplasty 32:320–325. https://doi.org/10.1016/j.arth.2016.08.026

    Article  PubMed  Google Scholar 

  39. Everhart JS, Sojka JH, Mayerson JL et al (2018) Perioperative allogeneic red blood-cell transfusion associated with surgical site infection after total hip and knee arthroplasty. J Bone Jt Surg 100:288–294. https://doi.org/10.2106/JBJS.17.00237

    Article  Google Scholar 

  40. Dong Z, Han L, Song Y et al (2019) Hemostatic techniques to reduce blood transfusion after primary TKA: a meta—analysis and systematic review. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-019-03271-y

    Article  PubMed  Google Scholar 

  41. Kurtz SM, Ong KL, Lau E et al (2010) Prosthetic joint infection risk after TKA in the medicare population. Clin Orthop Relat Res 468:52–56. https://doi.org/10.1007/s11999-009-1013-5

    Article  PubMed  Google Scholar 

  42. Peersman G, Laskin R, Davis J et al (2006) Prolonged operative time correlates with increased infection rate after total knee arthroplasty. HSS J 2:70–72. https://doi.org/10.1007/s11420-005-0130-2

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  43. Lau RL, Perruccio AV, Gandhi R, Mahomed NN (2012) The role of surgeon volume on patient outcome in total knee arthroplasty: a systematic review of the literature. BMC Musculoskelet Disord 13:250. https://doi.org/10.1186/1471-2474-13-250

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

Authors would like to specially thank Dr. Agustín Soler (Department of Orthopedic Surgery, Lister Hospital, United Kingdom) for English language support.

Author information

Authors and Affiliations

  1. Department of Trauma and Orthopedic Surgery, University Hospital of Salamanca, Salamanca, Spain

    Juan F. Blanco, Francisco R. Melchor & David Pescador

  2. Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain

    Juan F. Blanco, Agustín Díaz, Carmen da Casa & David Pescador

  3. Department of Anesthesia, University Hospital of Salamanca, Salamanca, Spain

    Agustín Díaz

Authors
  1. Juan F. Blanco
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Agustín Díaz
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Francisco R. Melchor
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Carmen da Casa
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. David Pescador
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Juan F. Blanco.

Ethics declarations

Conflict of interest

Juan F Blanco, Agustin Díaz, Francisco R Melchor, Carmen da Casa and David Pescador declare that they have no conflict of interest.

Availability of data

All data are available from the corresponding author upon reasonable request.

Ethical approval

All procedures were in accordance with the ethical standards of the University Hospital of Salamanca Clinical Research Committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Blanco, J.F., Díaz, A., Melchor, F.R. et al. Risk factors for periprosthetic joint infection after total knee arthroplasty. Arch Orthop Trauma Surg 140, 239–245 (2020). https://doi.org/10.1007/s00402-019-03304-6

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00402-019-03304-6

Keywords

Search

Navigation