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Risk factors for amputation in periprosthetic knee infection

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Risk factors for amputation in periprosthetic knee infection

  1. 1. 1 23 European Journal of Orthopaedic Surgery & Traumatology ISSN 1633-8065 Volume 27 Number 7 Eur J Orthop Surg Traumatol (2017) 27:983-987 DOI 10.1007/s00590-017-1952-6 Risk factors for amputation in periprosthetic knee infection Alan Giovanni Polanco-Armenta, Adrián Miguel-Pérez, Adrián Huetzemani Rivera-Villa, Manuel Ignacio Barrera-García, et al.
  2. 2. 1 23 Your article is protected by copyright and all rights are held exclusively by Springer- Verlag France. This e-offprint is for personal use only and shall not be self-archived in electronic repositories. If you wish to self-archive your article, please use the accepted manuscript version for posting on your own website. You may further deposit the accepted manuscript version in any repository, provided it is only made publicly available 12 months after official publication or later and provided acknowledgement is given to the original source of publication and a link is inserted to the published article on Springer's website. The link must be accompanied by the following text: "The final publication is available at”.
  3. 3. ORIGINAL ARTICLE • KNEE - ARTHROPLASTY Risk factors for amputation in periprosthetic knee infection Alan Giovanni Polanco-Armenta1 • Adria´n Miguel-Pe´rez1 • Adria´n Huetzemani Rivera-Villa1 • Manuel Ignacio Barrera-Garcı´a1 • Marı´a Guadalupe Sa´nchez-Prado1 • Alberto Va´zquez-Noya1 • Fernando Vidal-Cervantes1 • Jose´ de Jesu´s Guerra-Jasso1 • Jose´ Manuel Pe´rez-Atanasio1 Received: 29 December 2016 / Accepted: 23 March 2017 / Published online: 7 April 2017 Ó Springer-Verlag France 2017 Abstract Treatment for prosthetic knee replacement is becoming more common. Infection is an arthroplasty-re- lated complication leading to prolonged hospitalization, multiple surgical procedures, permanent loss of the implant, impaired function, impaired quality of life and even amputation of the limb. Previous studies have eval- uated the risk factors associated with periprosthetic knee infection, but scarce information related to risk factors associated with amputation in this group of patients is available. The purpose of this study was to identify risk factors for amputation in periprosthetic infected knee through a case–control study, analyzing patients treated from January 2012 to November 2016 in a hospital with a high incidence of this diagnosis. We included 183 patients with periprosthetic knee infection; 23 required amputation as definitive management (cases). We found that patients with surgical time [120 min (p = 0.01), surgical risk higher than two points according to the American Society of Anesthesiology score (p = 0.00), smokers (p = 0.04), obesity and diabetes mellitus (p = 0.00) had an increased risk of amputation. Keywords Risk factors Á Amputation Á Periprosthetic knee infection Introduction Periprosthetic infection after total knee arthroplasty occurs in approximately 2% of patients and is associated with medical complications and high socioeconomic cost [1]. Eradication of periprosthetic infection and prevention of recurrence are the main objectives in the treatment of these cases [1–3]. Risk factors for infection following total knee arthro- plasty have been extensively described in the literature [4–6]. For chronic periprosthetic infection, two-stage pros- thetic exchange is considered the gold standard for treat- ment and includes prosthetic removal, extensive debridement of all infected tissue and insertion of an antibiotic spacer [6]. After the parenteral treatment with antibiotics and a negative aspiration of the joint, the second stage includes the reimplantation of a new prosthesis. The recurrence of periprosthetic infection after surgical treatment ranges from 9 to 33% and entails significant morbidity and addi- tional cost for patients [7, 8]. Factors for failure after two stages of treatment include medical comorbidity, pathogenic virulence and resistance to antibiotics in addition to bone condition and adequate skin coverage of soft tissues [9–11]. However, risk factors for amputation after this treatment failure have not been extensively studied. Patients receiving amputation at the knee level for treatment of recurrent periprosthetic infection after total knee arthroplasty have a better function and ambulatory status compared to patients receiving amputation above the knee. Amputation at the knee level should be recom- mended as the treatment of choice for patients who have & Jose´ Manuel Pe´rez-Atanasio 1 High Specialty Medical Unit ‘‘Dr. Victorio de la Fuente Narva´ez’’, Mexican Institute of Social Security, Colector 15 s/n (Av. Fortuna) Esq. Av. Polite´cnico nacional. Col. Magdalena de las Salinas, Delegacio´n Gustavo A. Madero, 07760 Mexico City, Mexico 123 Eur J Orthop Surg Traumatol (2017) 27:983–987 DOI 10.1007/s00590-017-1952-6 Author's personal copy
  4. 4. persistent prosthetic knee infection after failure of the two- stage reimplantation procedure [12]. Female gender, heart disease and psychiatric disorders increase the risk of hip and knee periprosthetic infection recurrence. Patients with periprosthetic infection of the hip and with heart disease are at higher risk of infection per- sistence [13] Therefore, the purpose of this study was to identify risk factors for amputation in periprosthetic knee infected, focusing on medical comorbidity, perioperative and sur- gical factors. Materials and methods A case–control study was carried out in a joint replacements concentration hospital. In this hospital, more than 1400 knee arthroplasties are performed annually, and 28 high-grade orthopedic surgeons participated in the surgeries. The study population consisted of 183 patients who had a diagnosis of periprosthetic knee infection and who were surgically treated from January 2012 to November 2016 systematically registered in a standardized database that includes demographic data, comorbidity, medications, clinical evolution and postoperative complications obtained from the clinical file. Authorization was obtained from the local research and ethics committee with regis- tration number: R-2016-3401-36. Patients who presented amputation as a definitive treat- ment for periprosthetic knee infection were considered as cases. Control group was matched by age and sex in a ratio of 7:1 with cases, which were selected from patients with periprosthetic knee infection who were not undergoing amputation. Risk factors were identified in the literature and by biological plausibility based on clinical experience. There was no verbal, physical or telephone communi- cation with cases or controls for the purposes of this study. Demographics of cases and controls were compared using summary statistics. The descriptive analyses for the variables were based on percentages and frequen- cies, and for continuous variables on the mean and standard deviation (SD) or medians and the interquartile range. The SPSSÒ version 22 program was used to perform linear regression analysis to obtain odds ratios (OR) with 95% confidence intervals (CI) for the association between each risk factor and the presence of amputation considering as significant a p 0.05. Results Of the 183 patients studied, 107 were treated with knee arthrodesis and 53 with two-stage revision surgery con- sisting of surgical debridement, removal of prosthetic components and knee revision arthroplasty. In 23 patients who were considered as cases, supracondylar amputation was performed after treatment failure with knee arthrodesis and multiple joint debridements. The demographic characteristics of the study popula- tion are shown in Table 1. It shows that within the population studied, the right knee was the most affected, mean age was 68.7 for amputees, men were more likely to have incidence of amputation (60.8%) and the main reason for total primary knee arthroplasty was osteoarthritis (91.30%). Table 1 Demographic characteristics of the study population Characteristics Amputated (n = 23) Nonamputated (n = 160) p value Affected knee Right 12 (52.17%) 84 (52.5%) 0.97 Left 11 (47.82%) 76 (47.5%) Age (years) Mean 68.7 (SD 9.7) 69.2 (SD 8.9) 0.7 Sex Male 14 (60.8%) 67 (41.8%) 0.09 Female 9 (39.1%) 93 (58.1%) Reason for joint replacement OA 21 (91.30%) 139 (86.87%) 0.55 RA 2 (8.69%) 16 (10%) 0.84 Sequelae of hip development dysplasia 0 3 (1.87%) 0.97 Osteonecrosis 0 2 (1.25%) 0.84 Septic arthritis 0 1 (0.62%) 0.62 OA osteoarthritis, RA rheumatoid arthritis, SD standard deviation 984 Eur J Orthop Surg Traumatol (2017) 27:983–987 123 Author's personal copy
  5. 5. The mean time between arthroplasty and the diagnosis of prosthetic joint infection was 74 days (range 10–264 days). The pathogens involved in prosthetic joint infections identified by deep intraoperative tissue samples are shown in Table 2. Staphylococcus aureus was the most frequently identified pathogen, of which 58% were resis- tant to methicillin. Secondly, polymicrobial infections that included mainly gram-negative bacilli, enterococci and staphylococci were found. All bacteria identified in polymicrobial infections were isolated from specimens deposited on solid media. Table 3 shows the risk factors for amputation in the patients studied. It was found that patients with prolonged surgical time greater than 120 min had a higher incidence of amputation (p = 0.01), as well as those assigned a surgical risk greater than 2 points on the American Society of Anesthesiology scale (p = 0.00). Smokers with a smoking rate greater than 21 had a higher risk of amputation than nonsmokers (p = 0.04). Those with obe- sity with a body mass index over 30 were also more likely to suffer amputation (p = 0.00), and patients with diabetes mellitus more than 5 years of age (p = 0.00) had an increased risk of amputation compared to patients with persistent periprosthetic knee infection who did not require amputation as a definitive management. Discussion Different studies have addressed the major complications that may occur after total knee arthroplasty [12–14]. However, there are few data on the incidence of amputa- tions due to failure or complications of knee prostheses. From the more than 9000 knee prostheses evaluated, Rand et al. described two cases (0.02%) of infrapatellar ampu- tation related to vascular insufficiency [15, 16]. Table 2 Agent causing prosthetic infection Organism Amputated (n = 23) Nonamputated (n = 160) Total (n = 183) S. aureus 10 (43.47%) 83 (51.87%) 93 (50.81%) Coagulase-negative Staphylococcus 3 (6.97%) 27 (14.75%) 27 (14.75%) Streptococcus sp. 1 (4.34%) 6 (3.75%) 7 (3.8%) Enterococcus sp. 1 (4.34%) 0 1 (0.54%) Corynebacterium sp. 1 (4.34%) 6 (3.75%) 7 (3.82%) Propionibacterium sp. 1 (4.34%) 0 1 (0.54%) Gram-negative bacilli 2 (8.69%) 0 2 (1.09%) Polymicrobial 4 (17.39%) 31 (19.37%) 35 (19.12%) No organism cultured 0 7 (4.37%) 7 (3.82%) Table 3 Risk factors for amputation Risk factors Amputated (n = 23) Nonamputated (n = 160) OR(95% CI) p value ASA score ([II) 22 (95.7%) 107 (66.8%) 10.89 (4.1–236.9) 0.000 BMI ([30) 23 (100%) 82 (51.2%) 44.72 (2.67–748.9) 0.008 Skin–skin time ([120 min) 20 (86.9%) 95 (59.3%) 4.56 (1.3–15.9) 0.017 Blood transfusion 22 (95.7%) 120 (75%) 7.33 (0.95–56.1) 0.055 Drainage tube 21 (91.3%) 155 (96.8%) 0.33 (0.06–1.8) 0.212 Length of stay ([30 days) 23 (100%) 132 (82.5%) 10.10 (0.59–171.3) 0.109 SAH 17 (73.3%) 129 (80.6%) 0.45 (0.18–1.1) 0.084 DM 20 (86.9%) 87 (54.3%) 5.59 (1.59–19.5) 0.007 Dyslipidemia 8 (33.3%) 78 (51.6%) 0.86 (0.22–1.3) 0.213 Cardiac arrhythmia 2 (8.6%) 16 (10%) 0.21 (0.18–3.9) 0.844 RA 3 (13.0%) 25 (15.6%) 0.81 (0.22–2.9) 0.748 PVD 16 (69.5%) 116 (72.5%) 0.75 (0.30–1.8) 0.554 Renal failure 1 (4.3%) 12 (7.5%) 0.56 (0.06–4.5) 0.587 Smoking 14 (60.8%) 61 (38.1%) 2.52 (1.03–6.1) 0.042 ASA American Society of Anesthesiology, BMI body mass index, CI confidence interval, DM diabetes mellitus, SAH systemic arterial hyper- tension, RA rheumatoid arthritis, PVD peripheral vascular disease Eur J Orthop Surg Traumatol (2017) 27:983–987 985 123 Author's personal copy
  6. 6. After performing 12,118 total knee arthroplasties, Bengston and Knutson studied 357 patients who evolved with a deep infection of which 23 were treated with transfemoral amputation; therefore, the incidence was 0.18% of all cases and 6% when only cases of infected arthroplasty were considered [17]. Isiklar et al. Reported an incidence of 0.18%, 9 amputees of the 5045 arthroplasty procedures performed [18]. In the study of Sierra et al. in 25 patients, the cause of the amputation was related to the knee replacement prosthesis, corresponding to a prevalence of 0.14% [19]. The incidence of amputation as a treatment for a com- plication of total knee arthroplasty ranges from 0.02 to 0.41% [20]. In our study, the incidence was higher (12.52%), probably because the osteoarticular rescue ser- vice concentrates the most complicated cases of skeletal muscle disease in our country. In a retrospective study evaluating 462 cases of periprosthetic knee infection, the main risk factors for complications were prolonged duration of surgery, high body mass index (BMI), postoperative bleeding, hematoma formation, advanced age, diabetes mellitus, Rheumatoid arthritis or other immunocompromised conditions [21] The presence of diabetes mellitus in our group of amputees was 86.95% (20 patients) with an average evo- lution time of 10.5 years, in agreement with the national epidemiology report and with Word Health Organization that said Mexico occupies the 10th world place in preva- lence of diabetes mellitus [22]. As a risk factor, diabetes showed an OR of 5.59 with a 95% CI (1.59–19.5). Obesity has a negative effect on outcomes after total knee replacement. In a meta-analysis of 2012, patients who were obese (BMI C 30) showed an increase in infection rates OR 1.90, 95% CI (1.47–2.47) [23]. The association between amputation and obesity has previously been associated with increased complications; in our study, all patients had a BMI greater than 30 with an OR for amputation of 44.72 with a 95% CI (2.6–748.9). Surgery time greater than 120 min was presented as a risk factor for amputation with an incidence of 22%, an OR of 10.89 and 95% CI (4.1–236.9), which is similar to that reported in the literature. Prolonged surgical time had been associated with periprosthetic infection, although the rele- vance of our study is association as a risk factor for amputation [2, 7, 24]. The surgical risk assessment of ASA greater than II in our study was observed as a risk factor associated with amputation in 95.65% with an OR 10.89 and 95% CI (4.1–236.9) which differs from the worldwide literature [5, 8]. This finding may be due to our patients being treated for a complication and not a primary surgical procedure. Bongartz et al. [11] reported in their prospective study 44 patients with joint prosthesis and staphylococcal bacteremia, periprosthetic infection occurred in 34% of patients. In a study with 50 cases of periprosthetic infec- tion, the majority of hematogenous infections were due to Staphylococcus aureus, beta-hemolytic streptococci or gram-negative bacilli [2, 25]. In our study, the main bac- teria found associated with amputation were Staphylococ- cus aureus (43.47%). The presence of smoking in association with amputation in patients with periprosthetic knee infection was present in 9 of the 23 cases (39.13%) with an OR of 1.04, with 95% CI (0.42–2.55), being higher than reported by Pulido et al. [5] and Mortazavi et al. [8]. Our study reflects the practice of multiple orthopedic surgeons and specialists in orthopedic infectious diseases, and despite the implementation of standardized protocols, individualization of treatment was inevitable. The strengths of our study are consistent follow-up of all cases of periprosthetic knee infections, the systematic recording of all medical, surgical and perioperative com- plications that may be associated with the incidence of supracondylar amputation. In conclusion, our study found that the incidence of amputation in periprosthetic knee infection is high. To confirm the risk factors for the present analysis and to investigate whether there are additional risk factors, further studies with larger sample sizes are warranted. This information could help us provide better advice to our patients regarding prognosis, and eventually redefine our treatment strategies for the management of total knee arthroplasties. On the other hand, the value of methicillin- resistant Staphylococcus aureus transmission should be redefined for testing surveillance, patient screening and decolonization using topical and/or systemic agents, as well as emphasizing the importance of the prevention, diagnosis and treatment of obesity as a predisposing factor of complication in total primary knee arthroplasty through timely detection, nutrition programs and individualized physical conditioning and exercise routines for each patient. Compliance with ethical standards Conflict of interest None. References 1. Poultsides LA, Liaropoulos LL, Malizos KN (2010) The socioeconomic impact of musculoskeletal infections. J Bone Jt Surg Am 92:13–17 2. Kurtz SM, Ong KL, Lau E (2010) Prosthetic joint infection risk after TKA in the Medicare population. Clin Orthop Relat Res 468(1):52–57 3. Adeli B, Parvizi J (2012) Strategies for the prevention of periprosthetic joint infection. 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  7. 7. 4. Mortazavi SM, Vegari D, Ho A (2011) Two-stage exchange arthroplasty for infected total knee arthroplasty: predictors of failure. Clin Orthop Relat Res 469(11):3049–3052 5. Pulido L, Ghanem E, Joshi A (2008) Periprosthetic joint infec- tion: the incidence, timing, and predisposing factors. Clin Orthop Relat Res 1710:466–473 6. Poultsides LA, Ma Y, Della Valle AG (2013) In-hospital surgical site infections after primary hip and knee arthroplasty—incidence and risk factors. J Arthroplasty 28(3):385–389 7. Tsezou A, Poultsides L, Kostopoulou F (2008) Influence of interleukin 1alpha (IL- 1alpha), IL-4, and IL-6 polymorphisms on genetic susceptibility to chronic osteomyelitis. Clin Vaccine Immunol 1888:15–27 8. Mortazavi SM, Schwartzenberger J, Austin MS (2010) Revision total knee arthroplasty infection: incidence and predictors. Clin Orthop Relat Res 468(8):2052–2059 9. Zmistowski B, Restrepo C, Kahl LK (2011) Incidence and rea- sons for no revision reoperation after total knee arthroplasty. Clin Orthop Relat Res 469(1):138–145 10. Horan TC, Andrus M, Dudeck MA (2008) CDC/NHSN surveil- lance definition of health care associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 36(5):309–314 11. Bongartz T, Halligan CS, Osmon DR (2008) Incidence and risk factors of prosthetic joint infection after total hip or knee replacement in patients with rheumatoid arthritis. Arthritis Rheum 59(12):1713–1725 12. Review CC (2015) Knee fusion or above-the-knee amputation after failed two-stage reimplantation total knee arthroplasty. Arch Bone Jt Surg 241(4):241–243 13. Triantafyllopoulos GK, Memtsoudis SG, Zhang W, Ma Y, Sculco TP, Poultsides LA (2016) Periprosthetic infection recurrence after 2-stage exchange arthroplasty: failure or fate? J Arthroplasty 32(2):526–531 14. Parvizi J, Ghanem E, Sharkey P (2008) Diagnosis of infected total knee: findings of a multicenter database. Clin Orthop Relat Res 466(11):2628–2634 15. Momohara S, Kawakami K, Iwamoto T (2011) Prosthetic joint infection after total hip or knee arthroplasty in rheumatoid arthritis patients treated with non-biologic and biologic disease- modifying antirheumatic drugs. Mod Rheumatol 21(5):469–473 16. Parvizi J, Zmistowski B, Berbari EF (2011) New definition for periprosthetic joint infection: from the Workgroup of the Mus- culoskeletal Infection Society. Clin Orthop Relat Res 469(11):2992–2998 17. Chen J, Cui Y, Li X (2013) Risk factors for deep infection after total knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg 133:675–687 18. Babkin Y, Raveh D, Lifschitz M (2007) Incidence and risk fac- tors for surgical infection after total knee replacement. Scand J Infect Dis 39(10):890–902 19. Minnema B, Vearncombe M, Augustin A (2004) Risk factors for surgical-site infection following primary total knee arthroplasty. Infect Control Hosp Epidemiol 25(6):477–482 20. Fulkerson E, Valle CJ, Wise B (2008) Antibiotic susceptibility of bacteria infecting total joint arthroplasty sites. J Bone Jt Surg Am 88(6):1231–1237 21. Poultsides LA, Papatheodorou LK, Karachalios TS (2008) Novel model for studying hematogenous infection in an experimental setting of implant-related infection by a community-acquired methicillin-resistant S. aureus strain. J Orthop Res 26(10):1355–1362 22. Parvizi J, Azzam K, Ghanem E (2009) Periprosthetic infection due to resistant staphylococci: serious problems on the horizon. Clin Orthop Relat Res 467(7):1732–1739 23. Leung F, Richards CJ, Garbuz DS (2011) Two-stage total hip arthroplasty: how often does it control methicillin-resistant infection? Clin Orthop Relat Res 469(4):1009–1013 24. Salgado CD, Dash S, Cantey JR (2007) Higher risk of failure of methicillin-resistant Staphylococcus aureus prosthetic joint infections. Clin Orthop Relat Res 48:46–54 25. Jackson WO, Schmalzried TP (2000) Limited role of direct exchange arthroplasty in the treatment of infected total hip replacements. Clin Orthop Relat Res 101:381–385 Eur J Orthop Surg Traumatol (2017) 27:983–987 987 123 Author's personal copy