Paper of the Week: Aseptic Reoperations Within One Year of Primary Total Hip Arthroplasty Markedly Increase the Risk of Later Periprosthetic Join Infection

Ashton H. Goldman, MD, Douglas R. Osmon, MD, Arlen D. Hanssen, MD, Mark W. Pagnano, MD, Daniel J. Berry, MD, Matthew P. Abdel, MD

Journal of Arthroplasty. June 2020.
DOI: 10.1016/j.arth.2020.02.054

Summary by Parthik D. Patel, MD

Primary total hip arthroplasty (THA) procedures continues to be one of the most successful operations performed by orthopaedic surgeons, with literature showing evidence of improved postoperative patient-reported outcomes and functional status.^1,2 However, postoperative complications continue to be a significant medical and economic burden on patients, with periprosthetic joint infections (PJIs) costing approximately $90,000 per PJI event per patient.³ A variety of risk factors have been associated with PJIs, including: obesity, rheumatologic disease, coagulopathy, preoperative anemia, and intrarticular hip injections within 3 months of THA.^4–6 Current literature has pointed to PJI rates of 10% to 33%, however the data is limited due to small sample sizes.⁷

In this study, Goldman and colleagues conducted a retrospective cohort study of 15,568 patients who underwent a primary THA at a single institution from 2000 to 2015.⁸ Three groups, including a control group, were established: 1) patients not requiring a reoperation within one year (n=15,357), 2) patients requiring a reoperation within 90 days (n=112), and 3) patients requiring a reoperation between 91 and 365 days (n=99). The results of their study showed patients with reoperation for a primary THA within 90 days (hazard ratio [HR] = 7.94, p < 0.001) and between 91-365 days (HR = 13.23, p < 0.001) were significantly more likely to experience a subsequent PJI compared to patients with no reoperations within one year. The risk of mortality was significantly higher in patients with reoperations within 91-365 (HR = 1.52, p 0.047), whereas significance was not achieved in patients with reoperations within 90 days. The majority of reoperations performed within one year were indicated due to dislocations (82 cases, 38.9%) and periprosthetic fractures (67 cases, 31.8%).

Overall, the authors of this study concluded the risk of subsequent PJI following an aseptic reoperation within the first year was 8- to 13-fold more likely compared to patients without a reoperation within the first year. Due in part to dislocations and periprosthetic fracture accounting for the majority of reoperations, surgeons should recognize patients preoperatively at risk for dislocations with hip-spine assessments, as well as assessments for periprosthetic fractures in every case. The present study was limited by: 1) the heterogeneous population requiring reoperations, 2) the varying levels of severity of indications for reoperations, and 3) lack of standardization of perioperative measures to reduce risk of PJI.

References:

1. Matharu GS, Judge A, Deere K, Blom AW, Reed MR, Whitehouse MR. The Effect of Surgical Approach on Outcomes following Total Hip Arthroplasty Performed for Displaced Intracapsular Hip Fractures: An Analysis from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. J Bone Jt Surg – Am Vol. 2020;102(1):21-28. doi:10.2106/JBJS.19.00195
2. Ricciardi BF. Recovery Outcomes in Patients Having Total Hip Arthroplasty Via the Posterolateral Approach Did Not Differ for No Hip Precautions Vs. Standard Hip Precautions. J Bone Joint Surg Am. 2020;102(4):341. doi:10.2106/JBJS.19.01328
3. Kamath AF, Ong KL, Lau E, et al. Quantifying the Burden of Revision Total Joint Arthroplasty for Periprosthetic Infection. J Arthroplasty. 2015;30(9):1492-1497. doi:10.1016/j.arth.2015.03.035
4. Bozic KJ, Lau E, Kurtz S, et al. Patient-Related Risk Factors for Periprosthetic Joint Infection and Postoperative Mortality Following Total Hip Arthroplasty in Medicare Patients. J Bone Jt Surgery-American Vol. 2012;94(9):794-800. doi:10.2106/JBJS.K.00072
5. Werner BC, Cancienne JM, Browne JA. The Timing of Total Hip Arthroplasty After Intraarticular Hip Injection Affects Postoperative Infection Risk. J Arthroplasty. 2016;31(4):820-823. doi:10.1016/j.arth.2015.08.032
6. Wagner ER, Kamath AF, Fruth KM, Harmsen WS, Berry DJ. Effect of body mass index on complications and reoperations after total hip arthroplasty. J Bone Jt Surg – Am Vol. 2016;98(3):169-179. doi:10.2106/JBJS.O.00430
7. Darwiche H, Barsoum WK, Klika A, Krebs VE, Molloy R. Retrospective analysis of infection rate after early reoperation in total hip arthroplasty. In: Clinical Orthopaedics and Related Research. Vol 468. Springer New York; 2010:2392-2396. doi:10.1007/s11999-010-1325-5
8. Goldman AH, Osmon DR, Hanssen AD, Pagnano MW, Berry DJ, Abdel MP. The Lawrence D. Dorr Surgical Techniques & Technologies Award: Aseptic Reoperations Within One Year of Primary Total Hip Arthroplasty Markedly Increase the Risk of Later Periprosthetic Joint Infection. J Arthroplasty. 2020;35(6S). doi:10.1016/j.arth.2020.02.054