Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2023 Oct 2;6(10):e2340457.
doi: 10.1001/jamanetworkopen.2023.40457.

Incidence, Microbiological Studies, and Factors Associated With Prosthetic Joint Infection After Total Knee Arthroplasty

Erica J Weinstein  1   2 , Alisa J Stephens-Shields  2 , Craig W Newcomb  2 , Randi Silibovsky  1 , Charles L Nelson  3 , Judith A O'Donnell  1 , Laurel J Glaser  4 , Evelyn Hsieh  5   6 , Jennifer S Hanberg  5   7 , Janet P Tate  5   8 , Kathleen M Akgün  9   10 , Joseph T King Jr  5   11 , Vincent Lo Re 3rd  1   2
Affiliations

Incidence, Microbiological Studies, and Factors Associated With Prosthetic Joint Infection After Total Knee Arthroplasty

Erica J Weinstein et al. JAMA Netw Open. .

Abstract

Importance: Despite the frequency of total knee arthroplasty (TKA) and clinical implications of prosthetic joint infections (PJIs), knowledge gaps remain concerning the incidence, microbiological study results, and factors associated with these infections.

Objectives: To identify the incidence rates, organisms isolated from microbiological studies, and patient and surgical factors of PJI occurring early, delayed, and late after primary TKA.

Design, setting, and participants: This cohort study obtained data from the US Department of Veterans Affairs (VA) Corporate Data Warehouse on patients who underwent elective primary TKA in the VA system between October 1, 1999, and September 30, 2019, and had at least 1 year of care in the VA prior to TKA. Patients who met these criteria were included in the overall cohort, and patients with linked Veterans Affairs Surgical Quality Improvement Program (VASQIP) data composed the VASQIP cohort. Data were analyzed between December 9, 2021, and September 18, 2023.

Exposures: Primary TKA as well as demographic, clinical, and perioperative factors.

Main outcomes and measures: Incident hospitalization with early, delayed, or late PJI. Incidence rate (events per 10 000 person-months) was measured in 3 postoperative periods: early (≤3 months), delayed (between >3 and ≤12 months), and late (>12 months). Unadjusted Poisson regression was used to estimate incidence rate ratios (IRRs) with 95% CIs of early and delayed PJI compared with late PJI. The frequency of organisms isolated from synovial or operative tissue culture results of PJIs during each postoperative period was identified. A piecewise exponential parametric survival model was used to estimate IRRs with 95% CIs associated with demographic and clinical factors in each postoperative period.

Results: The 79 367 patients (median (IQR) age of 65 (60-71) years) in the overall cohort who underwent primary TKA included 75 274 males (94.8%). A total of 1599 PJIs (2.0%) were identified. The incidence rate of PJI was higher in the early (26.8 [95% CI, 24.8-29.0] events per 10 000 person-months; IRR, 20.7 [95% CI, 18.5-23.1]) and delayed periods (5.4 [95% CI, 4.9-6.0] events per 10 000 person-months; IRR, 4.2 [95% CI, 3.7-4.8]) vs the late postoperative period (1.3 events per 10 000 person-months). Staphylococcus aureus was the most common organism isolated overall (489 [33.2%]); however, gram-negative infections were isolated in 15.4% (86) of early PJIs. In multivariable analyses, hepatitis C virus infection, peripheral artery disease, and autoimmune inflammatory arthritis were associated with PJI across all postoperative periods. Diabetes, chronic kidney disease, and obesity (body mass index of ≥30) were not associated factors. Other period-specific factors were identified.

Conclusions and relevance: This cohort study found that incidence rates of PJIs were higher in the early and delayed vs late post-TKA period; there were differences in microbiological cultures and factors associated with each postoperative period. These findings have implications for postoperative antibiotic use, stratification of PJI risk according to postoperative time, and PJI risk factor modification.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest Disclosures: Dr Weinstein reported receiving grants from the National Institute of Allergy and Infectious Diseases (NIAID) of the National Institutes of Health (NIH) during the conduct of the study. Dr Stephens-Shields reported receiving personal fees from the American College of Physicians, New York University, and Florida Atlantic University outside the submitted work. Dr Nelson reported receiving personal fees from Stryker and Zimmer Biomet outside the submitted work. Dr Tate reported receiving grants from the NIH during the conduct of the study. Dr Akgün reported being an employee of the Veterans Health Administration and receiving support from the National Heart, Lung, and Blood Institute, the National Institute on Alcohol Abuse and Alcoholism, the VA Health Services Research & Development Pain Research, Informatics, Multimorbidities and Education Center, and the Centers for Disease Control and Prevention’s Office of Women’s Health Strategic Health Groups during the conduct of the study. Dr King reported being an employee of the Veterans Health Administration during the conduct of the study. Dr Lo Re reported receiving personal fees from Urovant Sciences, Entasis, and Takeda Pharmaceuticals during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Patients Selected for Inclusion
Analyses of incidence rates of early, delayed, and late prosthetic joint infection and microbiological studies were conducted in the overall cohort. Analyses of factors associated with prosthetic joint infection were evaluated in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) complete case cohort. TKA indicates total knee arthroplasty; VA, US Department of Veterans Affairs.
Figure 2.
Figure 2.. Kaplan-Meier Failure Curves for Prosthetic Joint Infection (PJI) for the Overall Study Period and the First 24 Months After Primary Total Knee Arthroplasty
See this image and copyright information in PMC

References

    1. Cram P, Lu X, Kates SL, Singh JA, Li Y, Wolf BR. Total knee arthroplasty volume, utilization, and outcomes among Medicare beneficiaries, 1991-2010. JAMA. 2012;308(12):1227-1236. doi: 10.1001/2012.jama.11153 - DOI - PMC - PubMed
    1. Singh JA, Yu S, Chen L, Cleveland JD. Rates of total joint replacement in the United States: future projections to 2020-2040 using the National Inpatient Sample. J Rheumatol. 2019;46(9):1134-1140. doi: 10.3899/jrheum.170990 - DOI - PubMed
    1. Beam E, Osmon D. Prosthetic joint infection update. Infect Dis Clin North Am. 2018;32(4):843-859. doi: 10.1016/j.idc.2018.06.005 - DOI - PubMed
    1. Badawy M, Espehaug B, Fenstad AM, et al. Patient and surgical factors affecting procedure duration and revision risk due to deep infection in primary total knee arthroplasty. BMC Musculoskelet Disord. 2017;18(1):544. doi: 10.1186/s12891-017-1915-4 - DOI - PMC - PubMed
    1. Brochin R, Poeran J, Vig KS, et al. Trends in periprosthetic knee infection and associated costs: a population-based study using national data. J Knee Surg. 2021;34(10):1110-1119. doi: 10.1055/s-0040-1701516 - DOI - PubMed

Publication types