Paper of the Week: Risk factors for periprosthetic joint infection following total ankle replacement

Paper of the Week: Risk factors for periprosthetic joint infection following total ankle replacement

ICM Philly May 11, 2021

Smyth NA, Kennedy JG, Parvizi J, Schon LC, Aiyer AA

Foot Ankle Surg. 2020 Jul;26(5):591-595
doi: 10.1016/j.fas.2019.07.015

Summary by: Joseph Brutico, BS

Periprosthetic joint infection (PJI) is a significant complication and accounts for nearly 80% of implant failures following total ankle replacement (TAR)1. Although several risk factors for PJI following TAR have been identified, the evidence for many of these factors is conflicting. In this study, Smyth et al. systematically reviewed the current scientific literature to identify risk factors associated with periprosthetic joint infection following total ankle replacement. The authors searched PubMed/MEDLINE electronic databases in February 2019 for studies that assessed clinical risk factors for developing PJI following TAR. Eligible studies included prospective and retrospective designs with level of evidence I-IV.

After a review of 80 studies, 8 articles comprising 12,704 patients met the final inclusion and exclusion criteria. Six publications were level III retrospective case-control studies and two were level III retrospective database reviews. The authors determined that the following preoperative patient characteristics were associated with an increased risk of PJI following TAR: inflammatory arthritis, previous ankle surgery, age < 65 years, body mass index < 19, peripheral vascular disease, chronic lung disease, hypothyroidism, and a low preoperative American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score. Both inflammatory arthritis and history of previous ankle surgery were identified by multiple studies as independent risk factors for PJI.

Obesity (BMI > 30) is a documented risk factor for PJI following total hip and knee arthoplasty3,4. However, there is conflicting evidence in the literature regarding the effect of high BMI on total ankle arthroplasty2. Smoking status and diabetes were also met with conflicting evidence. Therefore, the authors suggested caution when considering TAR in these patient populations. The major limitation of this study was the paucity of literature on the subject and, therefore, the low quality of articles included in the final analysis. The low-quality limits the strength of the recommendation and warrants further, high-level research to definitively identify risk factors for periprosthetic joint infections following total ankle replacement.


  1. Glazebrook MA, Arsenault K, Dunbar M. Evidence-based classification of complications in total ankle arthroplasty. Foot Ankle Int 2009;30(10):945–9.
  2. Patton D, Kiewiet N, Brage M. Infected total ankle arthroplasty: risk factors and treatment options. Foot Ankle Int 2015;36(6):626–34.
  3. 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 Joint Surg 2016;98(3):169–79.
  4. Meller MM, Toossi N, Johanson NA, Gonzalez MH, Son MS, Lau EC. Risk and cost of 90-day complications in morbidly and superobese patients after total knee arthroplasty. J Arthroplasty 2016;31(10):2091–8.
%d bloggers like this: