Abstract
Introduction
There has been a renewed interest in the surgical approach used for total hip arthroplasty (THA). Risk factors for periprosthetic joint infection (PJI) have been well studied over the past decade, yet PJI remains one of the most devastating complications following THA. We studied the impact of direct anterior (DA) versus non-direct anterior (NA) surgical approaches on PJI, and examined the impact of new perioperative protocols on PJI rates following all surgical approaches at a single institution.
Methods
6086 continuous patients undergoing primary THA at a single institution from 2013–2016 were retrospectively evaluated. Data obtained from electronic patient medical records included age, sex, body mass index (BMI), medical comorbidities, surgical approach, and presence of deep PJI. Deep PJI was defined according to National Healthcare Safety Network's (NHSN) criteria for joint space infection following prosthetic hip replacement. Infection rates were calculated yearly for the DA and NA approach groups. Covariates were assessed and used in multivariate analysis to calculate adjusted odds ratios for risk of development of PJI with DA compared to NA approaches. In order to determine the effect of adopting a set of infection prevention protocols and patient optimization on PJI, we calculated odds ratios for PJI comparing patients undergoing THA for two distinct time periods: 2013–2014 and 2015–2016. These periods corresponded to before and after we implemented a set of perioperative infection protocols.
Results
There were 1985 patients in the DA group and 4101 patients in the NA group. The overall rate of PJI at our institution during the study period was 0.82% (50/6086) and decreased from 0.96% (12/1245) in 2013 to 0.53% (10/1870) in 2016.
There were 24 deep PJI's in the DA group (1.22%) and 26 deep PJI's in the NA group (0.63%) (p=0.0231). After multivariate analysis, the DA approach was 2.2 times more likely to result in PJI than the NA approach (95% CI OR 1.1–3.9, p=0.0062) for the overall study period. When stratified by time, patients undergoing THA utilizing any approach prior to adopting the infection prevention protocols (2013–2014), were 1.8 times more likely to have PJI compared to patients undergoing THA after the adoption of the protocols, however this result did not reach significance (95% CI OR 0.901–3.653, p=0.0953).
Conclusions
We found a higher rate of PJI in DA versus NA approaches. However, adoption of infection prevention protocols patient optimization mitigated these PJI rates, such that they were equalized between the approach groups for the period following the use of infection prevention and patient optimization protocols. Institutional learning curves and adaptation of interventions aimed at PJI prevention positively contributed to the decreased rate of PJI observed for all approaches over time.
Evidence: Level II – Case control
