Luke J. Garbarino, MD, Peter A. Gold, MD, Hiba K. Anis, MD, Nipun Sodhi, MD, Jonathan R. Danoff, MD, Sreevathsa Boraiah, MD, Vijay J. Rasquinha, MD, Michael A. Mont, MD

Journal of Arthroplasty. February 2020.
Doi: 10.1016/j.arth.2020.02.055

Summary by Daniel R. Bowles, MD

Urinary bladder catheterization is commonly utilized in total knee arthroplasty (TKA) patients either as prophylaxis or as a treatment for postoperative urinary retention, which may occur in up to 9.3% of patients undergoing opioid-free anesthesia.^1,2 Indwelling urinary catheterization is associated with an increased risk of urinary tract infections (UTIs), but provides an opportunity to limit morbidity in elective surgery.³ Separate studies have identified relationships between UTIs and periprosthetic joint infections (PJIs).^4–6 However, limited data exists associating catheterization techniques and the downstream risk for PJI.

In this study, Garbarino et al. compiled data on patients undergoing TKA from 15 hospitals in a large health system between 2017 and 2019. They retrospectively reviewed 9123 TKAs, with 734 patients receiving an indwelling catheter, 299 patients with intermittent straight catheterization, and 160 patients with indwelling and intermittent straight catheterizations. They found that PJIs were significantly lower (1.1% vs. 2.3% p = .002) in the no-catheter patients compared to patients treated with bladder catheterization. Significantly increased risk for PJI was found for indwelling catheter use (odds ratio [OR] 2.647, P < .001), diabetes (OR 1.837, P = .005), and peripheral vascular disease (OR 2.372, P = .046). The use of intermittent straight catheterization (OR 1.249, P = .668) or both indwelling and intermittent (OR 1.171, P = .828) did not increase the risk for PJIs.

The authors concluded that indwelling catheterization, but not intermittent catheterization, was associated with an increased risk for PJI, and surgeons should limit the duration of catheterization to decrease the risk for PJI. Limitations of the study include: gender was left out of the data set, which may have implications on the rates of UTIs within this sample, and that outpatient follow-up was limited to patients managed by providers with visits recorded within the institutional EMR.

References:

1. Balderi T, Carli F. Urinary retention after total hip and knee arthroplasty. Minerva Anestesiol. 2010;76(2):120-130.
2. Tischler EH, Restrepo C, Oh J, Matthews CN, Chen AF, Parvizi J. Urinary Retention is Rare After Total Joint Arthroplasty When Using Opioid-Free Regional Anesthesia. J Arthroplasty. 2016;31(2):480-483. doi:10.1016/j.arth.2015.09.007
3. Ma Y, Lu X. Indwelling catheter can increase postoperative urinary tract infection and may not be required in total joint arthroplasty: A meta-analysis of randomized controlled trial. BMC Musculoskelet Disord. 2019;20(1):11. doi:10.1186/s12891-018-2395-x
4. Parvizi J, Koo K-H. Should a Urinary Tract Infection Be Treated before a Total Joint Arthroplasty? Hip Pelvis. 2019;31(1):1. doi:10.5371/hp.2019.31.1.1
5. Pulido L, Ghanem E, Joshi A, Purtill JJ, Parvizi J. Periprosthetic joint infection: The incidence, timing, and predisposing factors. Clin Orthop Relat Res. 2008;466(7):1710-1715. doi:10.1007/s11999-008-0209-4
6. David TS, Vrahas MS. Perioperative lower urinary tract infections and deep sepsis in patients undergoing total joint arthroplasty. J Am Acad Orthop Surg. 2000;8(1):66-74. doi:10.5435/00124635-200001000-00007