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What Are the Long-term Outcomes of Mortality, Quality of Life, and Hip Function after Prosthetic Joint Infection of the Hip? A 10-year Follow-up from Sweden
Örebro University, School of Medical Sciences. Department of Orthopedics.
Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Swedish Hip Arthroplasty Register, Centre of Registers, Västra Götalandsregionen, Gothenburg, Sweden .
Örebro University, School of Medical Sciences. Department of Infectious Diseases.ORCID iD: 0000-0001-5939-2932
Örebro University, School of Medical Sciences. Department of Orthopedics.
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2021 (English)In: Clinical Orthopaedics and Related Research, ISSN 0009-921X, E-ISSN 1528-1132, Vol. 479, no 10, p. 2203-2213Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Prosthetic joint infection (PJI) is a complication after arthroplasty that negatively affects patient health. However, prior reports have not addressed the long-term consequences of hip PJI in terms of patient mortality, quality of life, and hip function.

QUESTIONS/PURPOSES: At a minimum of 10 years after PJI in patients undergoing primary THA, in the context of several large, national databases in Sweden, we asked: (1) Is mortality increased for patients with PJI after THA compared with patients with a noninfected THA? (2) Does PJI of the hip have a negative influence on quality of life as measured by the Euro-QoL-5D-5L (EQ-5D-5L), ambulatory aids, residential status, and hip function as measured by the Oxford Hip Score (OHS)? (3) Which factors are associated with poor patient-reported outcome measure (PROMs) for patients with PJI after primary THA?

METHODS: This study included 442 patients with a PJI after primary THA, from a previously published national study, including all patients with a THA performed from 2005 to 2008 in Sweden (n = 45,570) recruited from the Swedish Hip Arthroplasty Registry (SHAR). Possible deep PJIs were identified in the Swedish Dispensed Drug Registry and verified by review of medical records. Mortality in patients with PJI was compared with the remaining cohort of 45,128 patients undergoing primary THA who did not have PJI. Mortality data were retrieved from the SHAR, which in turn is updated daily from the population registry. A subgroup analysis of patients who underwent primary THA in 2008 was performed to adjust for the effect of comorbidities on mortality, as American Society of Anesthesiologists (ASA) scores became available in the SHAR at that time. For the PROM analysis, we identified three controls matched by age, gender, indication for surgery, and year of operation to each living PJI patient. A questionnaire including EQ-5D-5L, ambulatory aids, residential status, and OHS was collected from patients with PJI and controls at a mean of 11 years from the primary procedure. Apart from age and gender, we analyzed reoperation data (such as number of reoperations and surgical approach) and final prosthesis in situ to explore possible factors associated with poor PROM results.

RESULTS: After controlling for differences in sex, age, and indication for surgery, we found the all-cause 10-year mortality higher for patients with PJI (45%) compared with patients undergoing THA without PJI (29%) (odds ratio 1.4 [95% CI 1.2 to 1.6]; p < 0.001). The questionnaire, with a minimum of 10 years of follow-up, revealed a lower EQ-5D-5L index score (0.83 versus 0.94, -0.13 [95% CI -0.18 to -0.08; p < 0.001]), greater proportion of assisted living (21% versus 12%, OR 2.0 [95% CI 1.2 to 3.3]; p = 0.01), greater need of ambulatory aids (65% versus 42%, OR 3.1 [95% 2.1 to 4.8]; p < 0.001), and a lower OHS score (36 versus 44, -5.9 [-7.7 to -4.0]; p < 0.001) for patients with PJI than for matched controls. Factors associated with lower OHS score for patients with PJI were three or more reoperations (-8.0 [95% CI -13.0 to -3.2]; p = 0.01) and a direct lateral approach used at revision surgery compared with a posterior approach (-4.3 [95% CI -7.7 to -0.9]; p = 0.01).

CONCLUSION: In this study, we found that PJI after THA has a negative impact on mortality, long-term health-related quality of life, and hip function. Furthermore, the subgroup analysis showed that modifiable factors such as the number of reoperations and surgical approach are associated with poorer hip function. This emphasizes the importance of prompt, proper initial treatment to reduce repeated surgery to minimize the negative long-term effects of hip PJI.

LEVEL OF EVIDENCE: Level III, therapeutic study.

Place, publisher, year, edition, pages
Lippincott Williams & Wilkins, 2021. Vol. 479, no 10, p. 2203-2213
National Category
Orthopaedics
Identifiers
URN: urn:nbn:se:oru:diva-92063DOI: 10.1097/CORR.0000000000001838ISI: 000711675000016PubMedID: 34061486Scopus ID: 2-s2.0-85117426152OAI: oai:DiVA.org:oru-92063DiVA, id: diva2:1559329
Note

Funding agency:

Research Committee of Region Örebro län

Available from: 2021-06-02 Created: 2021-06-02 Last updated: 2023-06-30Bibliographically approved
In thesis
1. Prosthetic Joint Infection of the Hip: Cause and Effect
Open this publication in new window or tab >>Prosthetic Joint Infection of the Hip: Cause and Effect
2021 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Every year, 18 000 patients in Sweden and more than 1 million worldwide undergo total hip arthroplasty (THA). The operation is of great benefit to patients, but is associated with several complications. Prosthetic joint infections (PJIs) are among the most common complications, and can be devastating in terms of suffering for the patient and cost for the healthcare provider. The aim of this thesis was to investigate different aspects of PJIs in order to gain a better understanding of the causes and effects of infection. 

Four studies were conducted covering genomic analysis of the causative organism, identification of risk factors for failure of treatment, evaluation of a national infection control program aimed at reducing the burden of infections (PRISS: Prosthesis-related infections shall be stopped), and examination of the long-term impact of a PJI on the patient’s health through patient-reported measurement questionnaires.

The main findings were as follows. Commensal bacteria such as Cutibacterium avidum have the potential to cause PJIs, and should be specially accounted for when performing hip surgery with an anterior approach. S. aureus is both a commensal and a pathogen with invasive capacity, and the commensal strains do not differ from the PJI strains regarding prevalence of virulence genes and clonal complexes. The genomic traits of pathogens had no impact on treatment success or eradication of infection in S. aureus PJIs The long-term effects of a PJI in the hip include increased mortality, lower quality of life, and decreased hip function. The incidence of PJIs was higher following the PRISS project. Increasing risk factors contributing to PJI explain the increasing incidence of PJI after primary THA.

In conclusion, PJIs of the hip have multifactorial causes which are difficult to reduce, and long-term effects are severe.

Place, publisher, year, edition, pages
Örebro: Örebro University, 2021. p. 98
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 246
Keywords
Prosthetic joint infection, infection, arthroplasty, hip, Staphylococcus aureus, Cutibacterium avidum, hip, outcome, PROM
National Category
Surgery
Identifiers
urn:nbn:se:oru:diva-92269 (URN)978-91-7529-398-1 (ISBN)
Public defence
2021-10-01, Örebro universitet, Campus USÖ, hörsal C1, Södra Grev Rosengatan 32, Örebro, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2021-06-09 Created: 2021-06-09 Last updated: 2023-08-29Bibliographically approved

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Wildeman, PeterSöderquist, BoWretenberg, Per

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