Risk factors in septic revisions following total hip arthroplasty
Authors: Assem A Sultan, Carlos A Higuera
Journal: The Lancet Infectious Diseases (2018)

In their Article in The Lancet Infectious Diseases, Erik Lenguerrand and colleagues1Lenguerrand E Whitehouse MR Beswick AD et al.Risk factors associated with revision for prosthetic joint infection after hip replacement: a prospective observational cohort study.Lancet Infect Dis. 2018; (published online July 25.)http://dx.doi.org/10.1016/S1473-3099(18)30345-1Summary Full Text Full Text PDF PubMed Scopus (104) Google Scholar identify several risk factors associated with increased or decreased risk of revision due to prosthetic joint infection (PJI) after primary total hip arthroplasty (THA). In this cohort study, the largest to date, the authors followed a novel analytical approach in which they stratified multiple patient, surgery, and health-care system-related risk factors for developing PJI over several chronological postoperative periods. In addition to adding stronger evidence on previously known risk factors,2Zhu Y Zhang F Chen W Liu S Zhang Q Zhang Y Risk factors for periprosthetic joint infection after total joint arthroplasty: a systematic review and meta-analysis.J Hosp Infect. 2015; 89: 82-89Summary Full Text Full Text PDF PubMed Scopus (122) Google Scholar, 3Kunutsor SK Whitehouse MR Blom AW Beswick AD INFORM TeamPatient-related risk factors for periprosthetic joint infection after total joint arthroplasty: a systematic review and meta-analysis.PLoS One. 2016; 11: e0150866Crossref PubMed Scopus (232) Google Scholar the study also identified novel factors, including previous native hip infections and the use of lateral surgical approach. Furthermore, the authors provided stronger evidence to the role of the bearing surface, showing a potentially lower risk with ceramic bearings than metal bearings. PJI remains a rare but catastrophic complication that follows THA and is associated with substantial patient morbidity. Successful management requires costly revision procedures and an experienced multidisciplinary approach to eradicate the infection and reliably restore function. Despite global collaborative efforts and initiatives aiming to improve diagnosis and optimise surgical treatment, reports have indicated that the incidence of PJI is not declining and with the projected increase in THA use, PJI incidence is expected to rise.4Kurtz SM Lau EC Son M-S Chang ET Zimmerli W Parvizi J Are we winning or losing the battle with periprosthetic joint infection: trends in periprosthetic joint infection and mortality risk for the medicare population.J Arthroplasty. 2018; (published online June 1.)DOI:10.1016/j.arth.2018.05.042Summary Full Text Full Text PDF Scopus (153) Google Scholar In this realm, identifying and quantifying risk factors that might be responsible for the development of PJI become extremely important to the firstline of defence, namely prevention. It is self-evident that optimisation of any modifiable conditions before elective THA by medical interventions and team approaches, will help lessen the risk for PJI. Lenguerrand and colleagues have shown that patients with chronic pulmonary disease, liver disease, or dementia had increased risk of PJI. Additionally, understanding which risk factors might come into play during each specific postoperative period will help refine surveillance strategies to prevent the occurrence of PJI. Previous studies have attempted to quantify the overall risk for multiple factors (high vs low). However, little is known about the effects exerted by different risk factors in the specific postoperative stage after primary THA. The authors have shown that patients with liver disease were at higher risk for PJI only after 24 months from the index procedure. This finding shows that in some patient populations, clinicians might be doing well in optimising patients for elective surgery, but they are not performing as well in close monitoring and long-term follow-up. Timing of increased risk of developing PJI after THA might be particularly important in patients with non-modifiable risk factors. For example, those who had THA for indications other than hip osteoarthritis, such as fractured neck of femur and osteonecrosis, and those with previous native joint infection, were at higher risk for early PJI. One finding from the present study1Lenguerrand E Whitehouse MR Beswick AD et al.Risk factors associated with revision for prosthetic joint infection after hip replacement: a prospective observational cohort study.Lancet Infect Dis. 2018; (published online July 25.)http://dx.doi.org/10.1016/S1473-3099(18)30345-1Summary Full Text Full Text PDF PubMed Scopus (104) Google Scholar that we found particularly interesting was the reduced risk of PJI in patients who received ceramic bearing prostheses. Although this finding has been suggested by a few previous studies,5Pitto RP Sedel L Periprosthetic Joint infection in hip arthroplasty: is there an association between infection and bearing surface type?.Clin Orthop Relat Res. 2016; 474: 2213-2218Crossref PubMed Scopus (48) Google Scholar, 6Kurtz SM Lau E Baykal D Springer BD Outcomes of ceramic bearings after primary total hip arthroplasty in the medicare population.J Arthroplasty. 2017; 32: 743-749Summary Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 7Hexter AT Hislop SM Blunn GW Liddle AD The effect of bearing surface on risk of periprosthetic joint infection in total hip arthroplasty: a systematic review and meta-analysis.Bone Joint J. 2018; 100-B: 134-142Crossref PubMed Scopus (34) Google Scholar, 8Wiley KF Ding K Stoner JA Teague DC Yousuf KM Incidence of pseudotumor and acute lymphocytic vasculitis associated lesion (ALVAL) reactions in metal-on-metal hip articulations: a meta-analysis.J Arthroplasty. 2013; 28: 1238-1245Summary Full Text Full Text PDF PubMed Scopus (59) Google Scholar the evidence was inconclusive because these implants were typically used in younger patients who tend to have fewer comorbidities. However, Lenguerrand and colleagues1Lenguerrand E Whitehouse MR Beswick AD et al.Risk factors associated with revision for prosthetic joint infection after hip replacement: a prospective observational cohort study.Lancet Infect Dis. 2018; (published online July 25.)http://dx.doi.org/10.1016/S1473-3099(18)30345-1Summary Full Text Full Text PDF PubMed Scopus (104) Google Scholar accounted for age and comorbidities, and they were able to show stronger evidence suggesting that ceramic-on-ceramic and ceramic-on-polyethylene implants have a lower risk of PJI than metal-on-polyethylene THAs, which also showed a higher long-term risk of revision due to PJI. This particular risk factor needs to be assessed with prospective randomised studies to clarify its real effect on infections. Identification and understanding the dynamics of various risk factors that might contribute to the development of PJI after primary THA will continue to be the aim of future studies. The role of surgeon and hospital volumes, surgical approach selection, and other factors that might exhibit a time-specific influence are yet to be explained by further research. Nevertheless, Lenguerrand and colleagues present an updated and comprehensive reference for clinicians who are at the forefront of battling prosthetic hip joint infections. We declare no competing interests. Risk factors associated with revision for prosthetic joint infection after hip replacement: a prospective observational cohort studySeveral modifiable and non-modifiable factors are associated with the risk of revision for PJI after primary hip replacement. Identification of modifiable factors, use of targeted interventions, and beneficial modulation of some of these factors could be effective in reducing the incidence of PJI. It is important for clinicians to consider non-modifiable factors and factors that exhibit time-specific effects on the risk of PJI to counsel patients appropriately preoperatively. 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