Epidemiology of the Infected Total Knee Arthroplasty: Incidence, Causes, and the Burden of Disease


Crowe et al. [37]

Optimization of modifiable risk factors such as Staphylococcus aureus colonization, and tobacco use prior to primary TKA may decrease the incidence of PJI after primary TKA

De Dios and Cordero [15]

Preoperative factors: previous knee surgery, glucocorticoids, immunosuppressants, inflammatory arthritis. Intraoperative factors: prolonged surgical time, inadequate antibiotic prophylaxis, intraoperative fractures. Postoperative factors: secretion of the wound longer than 10 days, deep palpable hematoma, need for a new surgery, and deep venous thrombosis in lower limbs. Distant infections: cutaneous, generalized sepsis, urinary tract, pneumonia, abdominal

Lee et al. [9]

Factors related to PJI after TKA were young age, comorbidities such as diabetes, anemia, thyroid disease, heart disease, lung disease, and long operating time

Pugely et al. [2]

Independent risk factors associated with 30-day SSIs were BMI > 40, hypertension, prolonged operative time, electrolyte disturbance, and previous infection

Tayton et al. [13]

Multivariate analysis showed statistically significant associations with revision for PJI between male gender, previous surgery (osteotomy, ligament reconstruction), the use of laminar flow and the use of antibiotic-laden cement. There was a trend toward significance with the use of surgical helmet systems at 6 months

Ravi et al. [19]

Patients with rheumatoid arthritis were at higher risk of infection (1.26%, compared with 0.84%) that patients with osteoarthritis following TKA

Guirro et al. [16]

A successfully treated superficial wound infection did not result in a chronic deep TKA infection

Werner et al. [17]

The incidence of infection was higher in patients who underwent TKA within 6 months after knee arthroscopy compared to controls. There was no increase in infection when TKA was performed more than 6 months after knee arthroscopy

Boylan et al. [32]

Patients with HIV were at an increased risk for perioperative wound infections after TKA

Kuo et al. [33]

Males with HBV infection had a 4.32-fold risk of PJI compared with males without HBV. HBV infection and diabetes were the risk factors for PJI among males. The incidence of PJI was 58.8 among females with HBV infection and 75.2 among females without HBV (per 10,000 person-years). The risk of PJI was higher for males with HBV infection than for males without 0.5–1 year after TKA and >1 year after TKA. HBV infection was a risk factor for PJI after TKA among males

Cancienne et al. [18]

The incidence of infection within 3 months (2.6%) and 6 months (3.41%) after TKA within 3 months of knee injection was significantly higher than the control cohort. There was no significant difference in patients who underwent TKA more than 3 months after injection. Ipsilateral knee injection within 3 months prior to TKA was associated with a significant increase in infection

Deleuran et al. [34]

Cirrhosis patients had a higher risk (3.1% vs. 1.4%) of postoperative deep prosthetic infection after TKA for primary osteoarthritis than patients without cirrhosis

Jiang et al. [35]

PJIs were more common among patients with cirrhosis who had TKA

Bala et al. [20]

Post-traumatic arthritis patients had higher incidence of periprosthetic infection

Kopp et al. [21]

Increasing BMI and current smoking were found to significantly increase the incidence of SSI in patients undergoing TKA

Singh et al. [22]

The hazard ratios for deep infection and implant revision were higher in current tobacco users than in nonusers

Brimmo et al. [24]

The use of rivaroxaban for thromboprophylaxis leads to a significantly increased incidence of deep SSI in patients undergoing primary TKA. Incidence of early deep SSI in the rivaroxaban group was higher than in the control group (2.5% vs. 0.2%)

Houdek et al. [29]

All-polyethylene tibial components had reduced rates of postoperative infection. That is why the authors stated that all polyethylene should be considered for most of the patients, regardless of age and BMI

Klement et al. [30]

Patients with psychiatric disorders who underwent elective primary TKA had significant increase in PJI

Tai et al. [31]

The risk for TKA infection was 20% lower for patients who received dental scaling at least once within a 3-year period than for patients who never received dental scaling. Moreover, the risk of TKA infection was reduced by 31% among patients who underwent more frequent dental scaling (5–6 times within 3 years)


SSI surgical site infection, BMI body mass index, HIV human immunodeficiency virus, HBV hepatitis B virus






1.4 The Burden of TKA Infection


Kapadia et al. [39] measured the impact of PJIs on the length of hospitalization, readmissions, and the associated costs. Between 2007 and 2011, their prospectively collected infection database was reviewed to identify PJIs that occurred following primary TKA, which required a two-stage revision. They identified 21 consecutive patients and matched them to 21 noninfected patients who underwent uncomplicated primary TKA. The patients who had PJIs had significantly longer hospitalizations (5.3 vs. 3.0 days), more readmissions (3.6 vs. 0.1), and more clinic visits (6.5 vs. 1.3) when compared to the matched group, respectively. The mean annual cost was significantly higher in the infected cohort ($116,383; range, $44,416–$269,914) when compared to the matched group ($28,249; range, $20,454–$47,957). Periprosthetic infections following TKA represented a tremendous economic burden for tertiary care centers and to patients.

Alp et al. [40] evaluated the economic burden of PJIs following TKA. The median total length of the hospital stay was seven times higher in PJI patients than patients without PJI (49 vs. 7 days). All hospital costs were 2- to 24-fold higher in patients with PJI than in those without PJI. In conclusion, the economic burden of PJI was high. Gow et al. [41] calculated the excess costs attributable to PJI following TKA at $40,121, not including the opportunity cost associated with reoperating on such patients when other patients could be receiving their primary joint replacement. Table 1.2 summarizes the burden of PJI following TKA.


Table 1.2
Burden of periprosthetic joint infection (PJI) following total knee arthroplasty (TKA)

















Kapadia et al. [39]

PJI following TKA represented a tremendous economic burden. The patients who had PJIs had significantly longer hospitalizations (5.3 vs. 3 days), more readmissions (3.6 vs. 0.1), and more clinic visits (6.5 vs. 1.3) when compared to the matched group, respectively. The mean annual cost was significantly higher in the infected group ($116,383; range, $44,416–$269,914) when compared to the matched group ($28,249; range, $20,454–$47,957)

Alp et al. [40]

The economic burden of PJI was high. The median total length of the hospital stay was seven times higher in PJI patients than patients without PJI (49 vs. 7 days). All hospital costs were 2- to 24-fold higher in patients with PJI than in those without PJI

Meller et al. [27]

High demand on resources presented a severe challenge for providing treatment for superobese patients. Controlling for patient and institutional factors, each TKA had an average total hospital charges of $75,884 among superobese (BMI ≥ 40 kg/m2) patients, compared to $65,118 for the control group, a difference of $10,767. Medicare payment for the superobese patients was also higher, but only by $2703

Gow et al. [41]

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Mar 10, 2018 | Posted by in ORTHOPEDIC | Comments Off on Epidemiology of the Infected Total Knee Arthroplasty: Incidence, Causes, and the Burden of Disease
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