The Risk for Infection Patient in Arthroplasty

Periprosthetic joint infection (PJI) is one of the most severe complications in arthroplasty. The PJI risk is up to 2% in primary procedures and raises to approximately 5% in revision surgery.1

There are various risk factors that increase the chance of infection in primary and revision arthroplasty. Out of 10 patients, 3 patients present with at least 2 risk factors for infection.2

Crucial for the prevention of infection is to take into account both the patient’s comorbidities and procedure related risk factors:

Risk Factors

Patient Related Risk Factors

Definition of risk for infection patient according to Sanz-Ruiz & Berberich (2020)
Definition of risk for infection patient according to Sanz-Ruiz & Berberich (2020)

To effectively prevent PJI when facing a risk for infection patient, it is necessary to clarify who is really considered a risk for infection patient?

  • Combination of 3 or more risk factors in elective primary THA/trauma hip surgery3
  • Combination of 2 or more risk factors in elective primary TKA3

There are many risk factors that have been described to be associated with higher periprosthetic joint infection (PJI) rates. Every patient brings with them individual factors which may imply a potential risk for infection. The risk factors obesity, diabetes and cardiovascular disease have been selected for a closer look.

Why is obesity a risk factor?

People with obesity are more likely to receive joint arthroplasty and to develop serious postoperative complications like PJI. What exactly makes obesity a risk factor for PJI is shown below:4-7

Obesity-related metabolic syndrome leads to chronic inflammation and triggers other diseases

Leading cause for early development of osteoarthritis

Increased bacterial colonisation

Higher chances of contamination due to prolonged surgery time

Prolonged wound healing and wound leakage

Need for weight-adapted antibiotic dosing and coverage

What is the impact of obesity on orthopaedic procedures?

Many studies have shown a correlation between an increased body mass index (BMI) and increased infection rates. Compared with non-obese patients, obese patients had higher rates of polymicrobial infection (60.3% vs 33.3%, p<0.001).8 Obesity has become a global problem.9 E.g. in the UK the prevalence for overweight and obesity are 35% and 28% respectively.10

Why is diabetes a risk factor?

Studies have demonstrated that the infection risk may double or even triple in people with poor glycaemic control. What exactly makes diabetes a risk factor for PJI is explained in this picture:11-14

What is the impact of diabetes on orthopaedic procedures?

8.5% of the world´s population is diabetic.15 The prevalence of diabetes is even higher in arthroplasty patients (e.g. 16% prevalence among arthroplasty patients in Germany16). Uncontrolled diabetes is a known, independent risk factor for developing PJI.17

Why is cardiovascular disease a risk factor?

The prevalence of cardiovascular diseases is high among arthroplasty patients. Cardiovascular disease refers to a wide variety of heart and blood vessel disorders and includes:

  • atherosclerosis;
  • deep vein thrombosis;
  • coronary heart disease;
  • cerebrovascular disease;
  • peripheral vascular disease.

These disorders often correlate with impaired blood flow and a weaker immune system.18-20

What is the impact of cardiovascular disease on orthopaedic procedures?

Patients with cardiovascular diseases are generally more fragile. Chronic blood vessel damage and medications affecting coagulation and platelet functions make them more susceptible to infection.21-24

Prevention in Risk for Infection Procedures

In a risk-adapted approach dual antibiotic-loaded bone cements play an important role for prevention of infection in high risk primary procedures25, aseptic revision26 arthroplasty and fractured neck of femur27. Dual antibiotic-loaded bone cements offer a broad effectiveness against the pathogens commonly causing an infection and prevent periprosthetic joint infections.

Find out more about PJI prevention in the following procedures:

1 Sanz-Ruiz P., Berberich C. Infection Risk-Adjusted Antibiotic Prophylaxis Strategies in Arthroplasty: Short Review of Evidence and Experiences of a Tertiary Centerin Spain. OrthopRes Rev. 2020 Aug 6; 12: 89-96.
2 OECD. Multilingual Summaries Health at a Glance 2019 OECD Indicators . Visited on 11/02/21.
3 Sanz-Ruiz P., Berberich C. Infection Risk-Adjusted Antibiotic Prophylaxis Strategies in Arthroplasty: Short Review of Evidence and Experiences of a Tertiary Centerin Spain. OrthopRes Rev. 2020 Aug 6; 12: 89-96.
4 Cheng H. et al. Prolonged Operative Duration Increases Risk of Surgical Site Infections: A Systematic Review. Surg Infect (Larchmt). 2017 Aug/Sep; 18(6): 722-735.
5 Engin A. The Definition and Prevalence of Obesity and Metabolic Syndrome. Adv Exp Med Biol. 2017; 960: 1-17.
6 Löwik CAM. et al. Obese patients have higher rates of polymicrobial and Gram-negative early periprosthetic joint infections of the hip than non-obese patients. PLoSOne. 2019 Apr 8; 14(4): e0215035.
7 World Health Organization. Obesity and overweight . Visited on 11/02/21.
8 Löwik CAM. et al. Obese patients have higher rates of polymicrobial and Gram-negative early periprosthetic joint infections of the hip than non-obese patients. PLoSOne. 2019 Apr 8; 14(4): e0215035.
9 Havard T. H. Chan. Adult Obesity . Visited on 29/03/21.
10 NHS. Statistics on Obesity, Physical Activity and Diet, England, 2020 . Visited on 11/02/21.
11 Eka A., Chen AF. Patient-related medical risk factors for periprosthetic joint infection of the hip and knee. Ann TranslMed. 2015 Sep; 3(16): 233.
12 Jämsen E. 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. 2012 Jul 18; 94(14): e101.
13 Marchant MH. Jr. et al. The impact of glycemic control and diabetes mellitus on perioperative outcomes after total jointarthroplasty. J Bone Joint SurgAm. 2009 Jul; 91(7): 1621-9.
14 Mayo Clinic. Diabetes . Visited on 11/02/21.
15 World Health Organization. Diabetes. Visited on 11/02/21.
16 Bleß HH., Kip M. Weissbuch Gelenkersatz - Versorgungssituation bei endoprothetischen Hüft- und Knieoperationen in Deutschland. Heidelberg: Springer Verlag, 2017: 11-12; 49-50.
17 Jämsen E. et al. Obesity, diabetes, and preoperative hyperglycemia as predictors of periprosthetic jointinfection: a single-center analysis of 7181 primary hip and knee replacements for osteoarthritis. J Bone Joint Surg Am. 2012 Jul 18; 94(14): e101.
18 Bleß HH.,Kip M. Weissbuch Gelenkersatz - Versorgungssituation bei endoprothetischen Hüft- und Knieoperationen in Deutschland. Heidelberg: Springer Verlag, 2017: 11-12; 49-50.
19 Eka A., Chen AF. Patient-related medical risk factors for periprosthetic joint infection of the hip and knee. Ann Transl Med. 2015 Sep; 3(16): 233.
20 World Health Organization. Cardiovascular diseases (CVDs) . Visited on 12.02.2021
21 Antonelli B., Chen AF. Reducing the risk of infection after total joint arthroplasty: preoperative optimization. Arthroplasty 1, 4 (2019).
22 Avishai E., Yeghiazaryan K., Golubnitschaja O. Impaired wound healing: facts and hypotheses for multi-professional considerations in predictive, preventive and personalised medicine. The EPMA journal, 2017 8(1), 23–33.
23 Eka A., Chen AF. Patient-related medical risk factors for periprosthetic joint infection of the hip and knee. Ann Transl Med. 2015 Sep; 3(16): 233.
24 Yu S. et al. Preventing Hospital Readmissions and Limiting the Complications Associated With Total Joint Arthroplasty. J Am Acad Orthop Surg. 2015 Nov; 23(11): e60-71.
25 Sanz-Ruiz P., Berberich C. Infection Risk-Adjusted Antibiotic Prophylaxis Strategies in Arthroplasty: Short Review of Evidence and Experiences of a Tertiary Center in Spain. Orthop Res Rev. 2020 Aug 6; 12: 89-96.
26 Sanz-Ruiz P. et al. Is Dual Antibiotic-Loaded Bone Cement More Effective and Cost-Efficient Than a Single Antibiotic-Loaded Bone Cement to Reduce the Risk of Prosthetic Joint Infection in Aseptic Revision Knee Arthroplasty? J Arthroplasty. 2020 Dec; 35(12): 3724-3729.
27 Sprowson AP. et al. The use of high-dose dual-impregnated antibiotic-laden cement with hemiarthroplasty for the treatment of a fracture of the hip. Bone Joint J; 2016 Nov; 98-B: 1534–1541.