Prevention of Periprosthetic Joint Infections of the Hip and Knee

Nearly 2% of patients who undergo total knee arthroplasty (TKA) or total hip arthroplasty (THA) develop a periprosthetic joint infection (PJI) within 20 years of surgery, and 41% of these infections occur within the first 2 years.¹ PJI is the most common cause of TKA failure and the third leading complication of THA.² The estimated total hospital cost of treating PJI increased from $320 million in 2001 to $566 million in 2009, which can be extrapolated to $1.62 billion in 2020.³ By 2030, the projected increase in demand for TKA and THA will be 673% and 174% of what it was in 2005, respectively.⁴ Treatment of PJI of the knee is estimated to cost 3 to 4 times more than a primary TKA, and the cost of revision THA for PJI is almost $6000 more than that of revision TKA for PJI.³

In this article, we review the numerous preoperative, intraoperative, and postoperative methods of decreasing PJI incidence after total joint arthroplasty (TJA).

Preoperative Risk Prevention

Medical Comorbidities

Preoperative medical optimization is a key element in PJI prevention (Table 1). An American Society of Anesthesiologists classification score of 3 or more has been associated with doubled risk for surgical site infections (SSIs) after THA.5 Autoimmune conditions confer a particularly higher risk. In a retrospective double-cohort study of 924 subjects, Bongartz and colleagues⁶ found that, compared with osteoarthritis, rheumatoid arthritis tripled the risk of PJI. Small case series originally suggested a higher risk of PJI in patients with psoriasis,^7,8 but more recent studies have contradicted that finding.^9,10 Nevertheless, psoriatic plaques have elevated bacterial counts,¹¹ and planned incisions should circumvent these areas.

Diabetes mellitus is a clear risk factor for PJI.^12-16 Regarding whether preoperative glucose control affects risk, findings have been mixed. Mraovic and colleagues¹⁷ showed preoperative hyperglycemia to be an independent risk factor; Jämsen and colleagues,¹⁵ in a single-center analysis of more than 7000 TJAs, suggested preoperative blood glucose levels were not independently associated with PJI; and Iorio and colleagues¹⁶ found no association between surgical infections and hemoglobin A1c levels.

TJA incidence is higher in patients with chronic kidney disease (CKD) than in the general population.¹⁸ Dialysis users have a post-THA PJI rate as high as 13% to 19%.^19,20 Early clinical data suggested that outcomes are improved in dialysis users who undergo renal transplant, but this finding recently has been questioned.^19,21 Deegan and colleagues²² found an increased PJA rate of 3.5% even in low-level CKD (stage 1, 2, or 3), but this may be confounded by the increased association of CKD with other PJI-predisposing comorbidities.

Given a higher incidence of urinary tract infections (UTIs) among patients with PJI, some surgeons think UTIs predispose to PJIs by hematogenous seeding.^12,23,24 Symptomatic UTIs should be cleared before surgery and confirmed on urinalysis. Obstructive symptoms should prompt urologic evaluation. As asymptomatic pyuria and bacteriuria (colony counts, >1 × 105/mL) do not predispose to PJI, patients without symptoms do not require intervention.^25,26 Past history of malignancy may also have a role in PJI. In a case-control study of the Mayo Clinic arthroplasty experience from 1969 to 1991, Berbari and colleagues¹ found an association between malignancy and PJI (odds ratio, 2.4). They theorized the immunosuppressive effects of cancer treatment might be responsible for this increased risk.