Outcomes following Revision Total Knee Arthroplasty Septic versus Aseptic Failure: A National Propensity-Score-Matched Comparison

Abstract

Although periprosthetic joint infection (PJI) has been hypothesized to increase the risk of complications following revision total knee arthroplasty (TKA), strong evidence linking the two is lacking. The aim of this study was to determine whether PJI is an independent risk factor for inpatient perioperative complications, and increased resource use in patients undergoing revision TKA. We relied on the US Nationwide Inpatient Sample (NIS) to identify patients with PJI or non-PJI treated with revision TKA between 2002 and 2014. Overall, 5,316 (16.4%) and 27,033 (83.6%) patients were categorized as PJI and non-PJI, respectively. To adjust for potential baseline differences between the two groups, propensity-score-based matching was performed. This resulted in 5,187 (50%) PJI patients matched to 5,187 (50%) non-PJI patients. The rates of postoperative complications, blood transfusions, prolonged length of stay (pLOS), in-hospital cost, and in-hospital mortality were assessed for both groups. Multivariable logistic regression analyses were performed within the cohort after propensity-score matching. For PJI versus non-PJI, respectively, the following rates were recorded: blood transfusions, 28.3 versus 18.4% (p < 0.0001); postoperative complications, 27.5 versus 19.8% (p < 0.0001); pLOS (>4 d), 61.9 versus 26.9% (p < 0.0001); in-hospital cost (>$39,929), 55.8 versus 44.2% (p < 0.0001); in-hospital mortality, 0.6 versus 0.3% (p = 0.016). In multivariable logistic regression analyses, PJI patients were more likely to receive a blood transfusion (odds ratio [OR]: 1.78; p < 0.0001), to experience postoperative complications (OR: 1.56; p < 0.0001), to have a higher in-hospital cost (OR: 1.65; p < 0.0001), to have a pLOS following surgery following surgery (OR: 4.69; p < 0.0001), and to have a higher in-hospital mortality (OR: 2.14; p = 0.019). After adjustment for potential selection biases, PJI is associated with more adverse perioperative outcomes and resource use than non-PJI patients. This is a Level II (level of evidence), prognostic study.

Understanding the 30-day mortality burden after revision total knee arthroplasty

“…However, similar to our findings, a study conducted by Choi and Bedair [14] reported age greater than 65 years independently increased the risk of mortality within both aseptic and septic revision TKA (odds ratio [OR] 1.13, 95% confidence interval [CI]: 1.05-1.21, P < .001). Additional studies have also implicated advanced age in increased risk of poor clinical outcomes, including the need for higher acuity care [31,32], PJI [8], and inhospital mortality [3]. The latter findings support those of the present study and highlight the need to consider advanced age in risk stratification for revision TKA.…”

“…An increase in revision TKAs among patients older than 80 years has also been observed [7]. This growth in revision arthroplasty will contribute to an estimated annual burden of $13 billion by 2030 [8,9]. Previous literature surrounding revision TKA has investigated survivorship [10,11], complications [12,13], and mortality [14], yet these studies have been limited by heterogeneity of procedures and One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field whichmay be perceived to have potential conflict of interest with this work.…”

“…While previous studies have investigated in-hospital [3,8], midterm [2,15], and long-term [12] mortality after revision TKA, evidence suggests the first 30 postoperative days may be the most critical timeframe to investigate the risk of mortality, as it will be less confounded by deaths from causes unrelated to the index procedure [16]. In addition, revision performed due to septic failure has been reported to increase the risk of mortality 6-fold relative to revision for aseptic failure [12,14].…”

Infection and Mechanical Complications Are Risk Factors for New Diagnosis of a Mental Health Disorder After Total Joint Arthroplasty

“…In addition, although previous studies have shown worse outcomes when comparing PJI to aseptic complications [7,8], our study found no difference between rates of new diagnosis between patients who suffered aseptic complications vs. infection, as well as between a subset of these 2 cohorts who subsequently went on to revision surgery. The authors posit one explanation for this is the inclusion of only acute PJI in the analysis.…”

“…Literature on the consequences of PJI and aseptic failure after total joint arthroplasty (TJA) has been well documented. These complications are associated with poor clinical outcomes, often requiring staged management and leaving patients with poor overall health-related quality of life [ 3 , 6 , 7 ]. Furthermore, compared with aseptic revisions, revisions for PJI have been shown to have a significantly higher risk of major postoperative complications including death, sepsis, non-home discharge, readmissions, and prolonged hospital length of stay [ 8 ].…”