Jämsen E, Nevalainen P, Eskelinen A, et al. Obesity, diabetes, and preoperative hyperglycemia as predictors of periprosthetic joint infection: a single-center analysis of 7181 primary hip and knee replacements for osteoarthritis. J Bone Joint Surg Am.94(14):e101

Coxa, Hospital for Joint Replacement, P.O. Box 652, FIN-33101, Tampere, Finland.
The Journal of Bone and Joint Surgery (Impact Factor: 5.28). 07/2012; 94(14):e101. DOI: 10.2106/JBJS.J.01935
Source: PubMed


Diabetes and obesity are common in patients undergoing joint replacement. Studies analyzing the effects of diabetes and obesity on the occurrence of periprosthetic joint infection have yielded contradictory results, and the combined effects of these conditions are not known.
The one-year incidence of periprosthetic joint infections was analyzed in a single-center series of 7181 primary hip and knee replacements (unilateral and simultaneous bilateral) performed between 2002 and 2008 to treat osteoarthritis. The data regarding periprosthetic joint infection (defined according to Centers for Disease Control and Prevention criteria) were collected from the hospital infection register and were based on prospective, active surveillance. Patients diagnosed with diabetes were identified from the registers of the Social Insurance Institution of Finland. The odds ratios (ORs) for infection and the accompanying 95% confidence intervals (CIs) were calculated with use of binary logistic regression with adjustment for age, sex, American Society of Anesthesiologists risk score, arthroplasty site, body mass index, and diabetic status.
Fifty-two periprosthetic joint infections occurred during the first postoperative year (0.72%; 95% CI, 0.55% to 0.95%). The infection rate increased from 0.37% (95% CI, 0.15% to 0.96%) in patients with a normal body mass index to 4.66% (95% CI, 2.47% to 8.62%) in the morbidly obese group (adjusted OR, 6.4; 95% CI, 1.7 to 24.6). Diabetes more than doubled the periprosthetic joint infection risk independent of obesity (adjusted OR, 2.3; 95% CI, 1.1 to 4.7). The infection rate was highest in morbidly obese patients with diabetes; this group contained fifty-one patients and periprosthetic infection developed in five (9.8%; 95% CI, 4.26% to 20.98%). In patients without a diagnosis of diabetes at the time of the surgery, there was a trend toward a higher infection rate in association with a preoperative glucose level of ≥6.9 mmol/L (124 mg/dL) compared with <6.9 mmol/L. The infection rate was 1.15% (95% CI, 0.56% to 2.35%) in the former group compared with 0.28% (95% CI, 0.15% to 0.53%) in the latter, and the adjusted OR was 3.3 (95% CI, 0.96 to 11.0). The type of diabetes medication was not associated with the infection rate.
Diabetes and morbid obesity increased the risk of periprosthetic joint infection following primary hip and knee replacement. The benefits of joint replacement should be carefully weighed against the incidence of postoperative infection, especially in morbidly obese patients.
Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

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    • "Reports have shown that the general condition of the patient's health has a direct link with the rate of postoperative complications; and conditions such as ASA > 2, uncontrolled diabetes, and rheumatoid arthritis can significantly increase the risk of PJI.[4,22,262728Therefore, it is mandatory to assess all patients in a multidisciplinary approach prior to TJA and to manage comorbidities if required. These assessments have shown to reduce the postoperative mortality rate and per-admission costs significantly in complex orthopaedic surgeries, including TJA.[30]Marchant et al. found that patients with a higher level of hemoglobin A1c had significantly higher incidence of PJI, at an odds ratio of 2.31.[31]Furthermore, "
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    ABSTRACT: Prosthetic joint infection (PJI) is a serious complication with high morbidity, mortality, and substantial cost. The reported incidence is probably underestimated due to the problems of proper diagnosis. PJI has haunted the orthopedic community for several years and despite all the advances in this field, it is still a demanding issue with a huge impact on patients, surgeons, and healthcare. Numerous elements can predispose patients to PJI. In this chapter, we tried to summarize the effective prevention strategies along with the recommendations of a recent International Consensus Meeting on Surgical Site and Periprosthetic Joint Infection.
    Full-text · Chapter · Jan 2016
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    • "Inclusion of the type of cup fixation (cemented or uncemented) or the type of polyethylene (conventional or highly crosslinked ) did not influence parameter estimates notably (data not shown), but this type of information was not available for the entire study population, and these exploratory findings must therefore be regarded with caution. Some other confounders that are known or suspected to influence outcome after THA, such as obesity, diabetes mellitus or other comorbidities, and intake of immunosuppressive or non-steroidal inflammatory drugs (Persson et al. 2005, Gilson et al. 2010, Bozic et al. 2012, Jamsen et al. 2012), were not registered in the database. "
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    ABSTRACT: Background and purpose — It is still being debated whether HA coating of uncemented stems used in total hip arthroplasty (THA) improves implant survival. We therefore investigated different uncemented stem brands, with and without HA coating, regarding early and long-term survival. Patients and methods — We identified 152,410 THA procedures using uncemented stems that were performed between 1995 and 2011 and registered in the Nordic Arthroplasty Register Association (NARA) database. We excluded 19,446 procedures that used stem brands less than 500 times in each country, procedures performed due to diagnoses other than osteoarthritis or pediatric hip disease, and procedures with missing information on the type of coating. 22 stem brands remained (which were used in 116,069 procedures) for analysis of revision of any component. 79,192 procedures from Denmark, Norway, and Sweden were analyzed for the endpoint stem revision. Unadjusted survival rates were calculated according to Kaplan-Meier, and Cox proportional hazards models were fitted in order to calculate hazard ratios (HRs) for the risk of revision with 95% confidence intervals (CIs). Results — Unadjusted 10-year survival with the endpoint revision of any component for any reason was 92.1% (CI: 91.8–92.4). Unadjusted 10-year survival with the endpoint stem revision due to aseptic loosening varied between the stem brands investigated and ranged from 96.7% (CI: 94.4–99.0) to 99.9% (CI: 99.6–100). Of the stem brands with the best survival, stems with and without HA coating were found. The presence of HA coating was not associated with statistically significant effects on the adjusted risk of stem revision due to aseptic loosening, with an HR of 0.8 (CI: 0.5–1.3; p = 0.4). The adjusted risk of revision due to infection was similar in the groups of THAs using HA-coated and non-HA-coated stems, with an HR of 0.9 (CI: 0.8–1.1; p = 0.6) for the presence of HA coating. The commonly used Bimetric stem (n = 25,329) was available both with and without HA coating, and the adjusted risk of stem revision due to aseptic loosening was similar for the 2 variants, with an HR of 0.9 (CI: 0.5–1.4; p = 0.5) for the HA-coated Bimetric stem. Interpretation — Uncemented HA-coated stems had similar results to those of uncemented stems with porous coating or rough sand-blasted stems. The use of HA coating on stems available both with and without this surface treatment had no clinically relevant effect on their outcome, and we thus question whether HA coating adds any value to well-functioning stem designs.
    Full-text · Article · Sep 2014 · Acta Orthopaedica
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    • "In addition, AAHKS has emphasized the importance of a nutritional evaluation prior to surgery2). Regarding diabetes, a large Finnish study corroborated its relevance as a strong risk factor for infections3). Although Hemoglobin A1C has been used to evaluate arthroplasty patients, a recent publication from Iorio et al.4) showed that it is probably a suboptimal preoperative measurement due to its inability to prognosticate complications. "
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    ABSTRACT: Periprosthetic joint infection (PJI) is one of the most serious complications following total knee arthroplasty (TKA). The demand for TKA is rapidly increasing, resulting in a subsequent increase in infections involving knee prosthesis. Despite the existence of common management practices, the best approach for several aspects in the management of periprosthetic knee infection remains controversial. This review examines the current understanding in the management of the following aspects of PJI: preoperative risk stratification, preoperative antibiotics, preoperative skin preparation, outpatient diagnosis, assessing for infection in revision cases, improving culture utility, irrigation and debridement, one and two-stage revision, and patient prognostic information. Moreover, ten strategies for the management of periprosthetic knee infection based on available literature, and experience of the authors were reviewed.
    Full-text · Article · Dec 2013
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