Increasing risk of prosthetic joint infection after total hip arthroplasty

Håvard Dale, Anne M Fenstad, Geir Hallan, Leif I Havelin, Ove Furnes, Søren Overgaard, Alma B Pedersen, Johan Kärrholm, Göran Garellick, Pekka Pulkkinen, Antti Eskelinen, Keijo Mäkelä, Lars B Engesæter, Håvard Dale, Anne M Fenstad, Geir Hallan, Leif I Havelin, Ove Furnes, Søren Overgaard, Alma B Pedersen, Johan Kärrholm, Göran Garellick, Pekka Pulkkinen, Antti Eskelinen, Keijo Mäkelä, Lars B Engesæter

Abstract

Background and purpose: The risk of revision due to infection after primary total hip arthroplasty (THA) has been reported to be increasing in Norway. We investigated whether this increase is a common feature in the Nordic countries (Denmark, Finland, Norway, and Sweden).

Materials and methods: The study was based on the Nordic Arthroplasty Register Association (NARA) dataset. 432,168 primary THAs from 1995 to 2009 were included (Denmark: 83,853, Finland 78,106, Norway 88,455, and Sweden 181,754). Adjusted survival analyses were performed using Cox regression models with revision due to infection as the endpoint. The effect of risk factors such as the year of surgery, age, sex, diagnosis, type of prosthesis, and fixation were assessed.

Results: 2,778 (0.6%) of the primary THAs were revised due to infection. Compared to the period 1995-1999, the relative risk (with 95% CI) of revision due to infection was 1.1 (1.0-1.2) in 2000-2004 and 1.6 (1.4-1.7) in 2005-2009. Adjusted cumulative 5-year revision rates due to infection were 0.46% (0.42-0.50) in 1995-1999, 0.54% (0.50-0.58) in 2000-2004, and 0.71% (0.66-0.76) in 2005-2009. The entire increase in risk of revision due to infection was within 1 year of primary surgery, and most notably in the first 3 months. The risk of revision due to infection increased in all 4 countries. Risk factors for revision due to infection were male sex, hybrid fixation, cement without antibiotics, and THA performed due to inflammatory disease, hip fracture, or femoral head necrosis. None of these risk factors increased in incidence during the study period.

Interpretation: We found increased relative risk of revision and increased cumulative 5-year revision rates due to infection after primary THA during the period 1995-2009. No change in risk factors in the NARA dataset could explain this increase. We believe that there has been an actual increase in the incidence of prosthetic joint infections after THA.

Figures

Figure 1.
Figure 1.
Adjusted cumulative revision rates for THAs revised due to infection in 3 time periods of primary surgery, for all THAs (upper left panel) and 5 subgroups of THAs. Adjusted for age, sex, diagnosis, prosthesis, and cement. *Adjusted for age and sex only.
Figure 2.
Figure 2.
Graphical display of the relationship between year of primary surgery and relative risk of revision due to infection (with 95% CI), for all THAs (upper left panel) and 5 subgroups of THAs. The broken lines represent no difference in relative risk from the beginning of the period (RR = 1). Adjusted for age, sex, diagnosis, prosthesis, and cement. *Adjusted for age and sex.
Figure 3.
Figure 3.
A graphical display of the relationship between relative risk of revision due to infection and time after primary THAs for the period 2000–2004 (left panel) and 2005–2009 (right panel) compared to 1995–1999 (blue lines). Smoothed Schoenfeld residuals adjusted for age, sex, diagnosis, prosthesis and cement (solid lines) with 95% confidence intervals (broken lines).

References

    1. Dale H, Hallan G, Espehaug B, Havelin LI, Engeæter LB. Increasing risk of revision due to deep infection after hip arthroplasty. Acta Orthop. 2009;80(6):639–45.
    1. Dale H, Skramm I, Lower HL, Eriksen HM, Espehaug B, Furnes O, Skjeldestad FE, Havelin LI, Engesaeter LB. Infection after primary hip arthroplasty. Acta Orthop. 2011;82(6):646–54.
    1. Danaei G, Finucane MM, Lu Y, Singh GM, Cowan MJ, Paciorek CJ, Lin JK, Farzadfar F, Khang YH, Stevens GA, Rao M, Ali MK, Riley LM, Robinson CA, Ezzati M. National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2.7 million participants. Lancet. 2011;378(9785):31–40.
    1. Doak CM, Wijnhoven TM, Schokker DF, Visscher TL, Seidell JC. Age standardization in mapping adult overweight and obesity trends in the WHO European Region. Obes Rev. 2012;13(2):174–91.
    1. Engesæter LB, Dale H, Schrama JC, Hallan G, Lie SA. Surgical procedures in the treatment of 784 infected THAs reported to the Norwegian Arthroplasty Register. Acta Orthop. 2011;82(5):530–7.
    1. Espehaug B, Furnes O, Havelin LI, Engesæter LB, Vollset SE, Kindseth O. Registration completeness in the Norwegian Arthroplasty Register. Acta Orthop. 2006;77(1):49–56.
    1. Fevang BT, Lie SA, Havelin LI, Engesaeter LB, Furnes O. Improved results of primary total hip replacement. Acta Orthop. 2010;81(6):649–59.
    1. Gillam MH, Ryan P, Graves SE, Miller LN, de Steiger RN, Salter A. Competing risks survival analysis applied to data from the Australian Orthopaedic Association National Joint Replacement Registry. Acta Orthop. 2010;81(5):548–55.
    1. Hastie TJ, Tibshirani RJ. Generalized additive models. Chapman & Hall, London. 1990.
    1. Havelin LI, Engesæter LB, Espehaug B, Furnes O, Lie SA, Vollset SE. The Norwegian Arthroplasty Register: 11 years and 73,000 arthroplasties. Acta Orthop Scand. 2000;71(4):337–53.
    1. Havelin LI, Fenstad AM, Salomonsson R, Mehnert F, Furnes O, Overgaard S, Pedersen AB, Herberts P, Karrholm J, Garellick G. The Nordic Arthroplasty Register Association: a unique collaboration between 3 national hip arthroplasty registries with 280,201 THRs. Acta Orthop. 2009;80(4):393–401.
    1. Haverkamp D, Klinkenbijl MN, Somford MP, Albers GH, van der Vis HM. Obesity in total hip arthroplasty--does it really matter? A meta-analysis. Acta Orthop. 2011;82(4):417–22.
    1. Health Protection Agency Sixth report of the mandatory surveillance of surgical site infection in orthopaedic surgery: April 2004 to March 2010. 2011 Available from.
    1. HELICS. Hospital in Europe Link for Infection Control through Surveillance Surgical Site Infection Surveillance of Surgical Site Infections, Protocol. European Centre for Disease Prevention and Control. 2004 Available from.
    1. Herberts P, Malchau H. Long-term registration has improved the quality of hip replacement: a review of the Swedish THR Register comparing 160,000 cases. Acta Orthop Scand. 2000;71(2):111–21.
    1. Herberts P, Ahnfelt L, Malchau H, Stromberg C, Andersson GB. Multicenter clinical trials and their value in assessing total joint arthroplasty. Clin Orthop. 1989;(249):48–55.
    1. Huotari K, Lyytikainen O. Impact of postdischarge surveillance on the rate of surgical site infection after orthopedic surgery. Infect Control Hosp Epidemiol. 2006;27(12):1324–9.
    1. Ince A, Rupp J, Frommelt L, Katzer A, Gille J, Lohr JF. Is “aseptic” loosening of the prosthetic cup after total hip replacement due to nonculturable bacterial pathogens in patients with low-grade infection? Clin Infect Dis. 2004;39(11):1599–603.
    1. Iorio R, Williams KM, Marcantonio AJ, Specht LM, Tilzey JF, Healy WL. Diabetes mellitus. hemoglobin A1C, and the incidence of total joint arthroplasty infection. J Arthroplasty. 2012;27(5):726–9.
    1. Kerttula AM, Lyytikainen O, Karden-Lilja M, Ibrahem S, Salmenlinna S, Virolainen A, Vuopio-Varkila J. Nationwide trends in molecular epidemiology of methicillin-resistant Staphylococcus aureus. Finland, 1997–2004. 2007;7:94. BMC Infect Dis.
    1. Kurtz SM, Lau E, Schmier J, Ong KL, Zhao K, Parvizi J. Infection Burden for Hip and Knee Arthroplasty in the United States. J Arthroplasty. 2008;23(7):984–91.
    1. Lie SA, Engesæter LB, Havelin LI, Gjessing HK, Vollset SE. Dependency issues in survival analyses of 55,782 primary hip replacements from 47,355 patients. Stat Med. 2004;23(20):3227–40.
    1. Liu SS, Della Valle AG, Besculides MC, Gaber LK, Memtsoudis SG. Trends in mortality, complications, and demographics for primary hip arthroplasty in the United States. Int Orthop. 2009;33(3):643–51.
    1. Lucht U. The Danish Hip Arthroplasty Register. Acta Orthop Scand. 2000;71(5):433–9.
    1. Lutro O, Langvatn H, Schrama J, Hallan G, Dale H, Espehaug B, Sjursen H, Engesæter L. Resistance of staphylococci isolated from infected hip arthroplasties in Norway. NOF Congress 2010 . 2010 Available from.
    1. Malchau H, Garellick G, Eisler T, Karrholm J, Herberts P. Presidential guest address: the Swedish Hip Registry: increasing the sensitivity by patient outcome data. Clin Orthop. 2005;(441):19–29.
    1. Mannien J, van den HS, Muilwijk J, van den Broek PJ, van Benthem B, Wille JC. Trends in the incidence of surgical site infection in the Netherlands. Infect Control Hosp Epidemiol. 2008;29(12):1132–8.
    1. Moojen DJ, Spijkers SN, Schot CS, Nijhof MW, Vogely HC, Fleer A, Verbout AJ, Castelein RM, Dhert WJ, Schouls LM. Identification of orthopaedic infections using broad-range polymerase chain reaction and reverse line blot hybridization. J Bone Joint Surg (Am) 2007;89(6):1298–305.
    1. Moojen DJ, van HG, Vogely HC, Burger BJ, Walenkamp GH, Tulp NJ, Schreurs BW, de Meulemeester FR, Schot CS, van d P, I, Fujishiro T, Schouls LM, Bauer TW, Dhert WJ. Incidence of low-grade infection in aseptic loosening of total hip arthroplasty. Acta Orthop. 2010;81(6):667–73.
    1. Mraovic B, Suh D, Jacovides C, Parvizi J. Perioperative hyperglycemia and postoperative infection after lower limb arthroplasty. J Diabetes Sci Technol. 2011;5(2):412–8.
    1. National Institute of Health and Clinical Excellence (NICE) Surgical site infection, prevention and treatment of surgical site infection, clinical guideline. CG74. 2008 Available from.
    1. Parvizi J, Zmistowski B, Berbari EF, Bauer TW, Springer BD, Della Valle CJ, Garvin KL, Mont MA, Wongworawat MD, Zalavras CG. New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop. 2011;469(11):2992–4.
    1. Pedersen A, Johnsen S, Overgaard S, Soballe K, Sorensen HT, Lucht U. Registration in the Danish Hip Arthroplasty Registry: completeness of total hip arthroplasties and positive predictive value of registered diagnosis and postoperative complications. Acta Orthop Scand. 2004;75(4):434–41.
    1. Pedersen AB, Mehnert F, Johnsen SP, Sorensen HT. Risk of revision of a total hip replacement in patients with diabetes mellitus: a population-based follow up study. J Bone Joint Surg (Br) 2010a;92(7)(34):929.
    1. Pedersen AB, Svendsson JE, Johnsen SP, Riis A, Overgaard S. Risk factors for revision due to infection after primary total hip arthroplasty. A population-based study of 80,756 primary procedures in the Danish Hip Arthroplasty Registry. Acta Orthop. 2010b;81(5):542–7.
    1. Pulido L, Ghanem E, Joshi A, Purtill JJ, Parvizi J. Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop. 2008;7(466):1710–5.
    1. Puolakka TJ, Pajamaki KJ, Halonen PJ, Pulkkinen PO, Paavolainen P, Nevalainen JK. The Finnish Arthroplasty Register: report of the hip register. Acta Orthop Scand. 2001;72(5):433–41.
    1. Ranstam J, Robertsson O. Statistical analysis of arthroplasty register data. Acta Orthop. 2010;81(1):10–4.
    1. Ranstam J, Karrholm J, Pulkkinen P, Makela K, Espehaug B, Pedersen AB, Mehnert F, Furnes O. Statistical analysis of arthroplasty data. II. Guidelines. Acta Orthop. 2011;82(3):258–67.
    1. Ridgeway S, Wilson J, Charlet A, Kafatos G, Pearson A, Coello R. Infection of the surgical site after arthroplasty of the hip. J Bone Joint Surg (Br) 2005;87(6):844–50.
    1. Soderman P, Malchau H, Herberts P, Johnell O. Are the findings in the Swedish National Total Hip Arthroplasty Register valid? A comparison between the Swedish National Total Hip Arthroplasty Register, the National Discharge Register, and the National Death Register. J Arthroplasty. 2000;15(7):884–9.
    1. Stefansdottir A, Johansson D, Knutson K, Lidgren L, Robertsson O. Microbiology of the infected knee arthroplasty: report from the Swedish Knee Arthroplasty Register on 426 surgically revised cases. Scand J Infect Dis. 2009a;41(11–12):831–40.
    1. Stefansdottir A, Robertsson O, Dahl A, Kiernan S, Gustafson P, Lidgren L. Inadequate timing of prophylactic antibiotics in orthopedic surgery. We can do better. Acta Orthop. 2009b;80(6):633–8.
    1. The Norwegian Arthroplasty Register Annual Report 2010. The Norwegian Arthroplasty Register. 2010 Available from.
    1. Trampuz A, Widmer AF. Infections associated with orthopedic implants. Curr Opin Infect Dis. 2006;19(4):349–56.
    1. Tunney MM, Patrick S, Gorman SP, Nixon JR, Anderson N, Davis RI, Hanna D, Ramage G. Improved detection of infection in hip replacements. A currently underestimated problem. J Bone Joint Surg (Br) 1998;80(4):568.
    1. von Eiff C, Arciola CR, Montanaro L, Becker K, Campoccia D. Emerging Staphylococcus species as new pathogens in implant infections. Int J Artif Organs. 2006;29(4):360–7.

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