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The Effect of Surgeon Volume on Revision for Periprosthetic Joint Infection: An Analysis of 602,919 Primary Total
D Vaotuua1, P O'Connor2, M Belford2
1Gold Coast University Hospital, Southport, Queensland, Australia.
Background:
Periprosthetic joint infection (PJI) is a devastating complication of total knee arthroplasty (TKA). An association between low surgeon volume and higher rates of infection following primary TKA has been suggested. The purpose of the present study was to determine if there was a relationship between surgeon volume and the rate of revision for infection after primary TKA.
Methods:
We searched the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) to identify all primary TKA procedures that were performed for the treatment of osteoarthritis from September 1, 1999, to December 31, 2020, and were subsequently revised because of infection. Surgeon volume was defined as the annual volume of procedures performed by a surgeon during the same year in which the primary TKA (which was subsequently revised for infection) was performed. Surgeon volume was defined as <25, 25 to 49, 50 to 74, 75 to 99, or ≥100 primary TKA procedures/year. The cumulative percent revision (CPR) for infection was determined with use of Kaplan-Meier estimates. Cox proportional hazards methods were used to compare rates of revision for infection by surgeon volume, with subanalyses for patellar resurfacing and polyethylene use. Further analyses for patients <65 years of age and male patients were undertaken.
Results:
Overall, 602,919 primary TKA procedures were performed for the treatment of osteoarthritis, of which 5,295 were revised because of infection. High-volume surgeons (≥100 TKAs/year) had a significantly lower rate of revision for infection, with a CPR at 1 and 19 years of 0.4% (95% confidence interval [CI], 0.3 to 0.4) and 1.5% (95% CI, 1.2 to 2.0), respectively, compared with 0.6% (95% CI, 0.5 to 0.7) and 2.1% (95% CI, 1.8 to 2.3), respectively, for low-volume surgeons (<25 TKAs/year). Hazard ratios (HRs), adjusted for age and sex, comparing these 2 groups varied, depending on the time point, between 3.07 (95% CI, 2.02 to 4.68) and 1.44 (95% CI, 1.26 to 1.63) but remained significant (p < 0.001). When the analysis was adjusted for age, sex, American Society of Anesthesiologists (ASA) classification, and body mass index (BMI), there remained an increased risk of revision for PJI for all lower surgeon volume levels in comparison with the high- surgeon-volume group (≥100 TKAs/year). The results were similar when stratified by patellar resurfacing and cross-linked polyethylene (XLPE) and adjusted for age and sex.
Conclusions:
High-volume surgeons had lower rates of revision for infection. A better understanding of how surgical volume contributes to decreasing this complication is important and requires in-depth study.
Level Of Evidence:
Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
Insights
High-volume surgeons performing total knee arthroplasty (TKA) have significantly lower rates of periprosthetic joint infection (PJI) revision. This study highlights surgeon volume as a key factor in reducing TKA complications.
Area of Science:
- Orthopedic Surgery
- Infection Control
- Health Services Research
Background:
- Periprosthetic joint infection (PJI) is a serious complication following total knee arthroplasty (TKA).
- Previous research suggests a link between lower surgeon volume and increased infection rates after primary TKA.
- This study investigates the relationship between surgeon volume and revision rates for infection post-TKA.
Purpose of the Study:
- To determine if surgeon volume impacts the rate of revision surgery due to infection after primary total knee arthroplasty.
- To analyze the association between annual surgeon procedure volume and subsequent PJI revision rates.
Main Methods:
- Utilized the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) data from 1999-2020.
- Included primary TKA procedures for osteoarthritis revised for infection.
- Categorized surgeon volume into <25, 25-49, 50-74, 75-99, and ≥100 procedures/year; analyzed revision rates using Kaplan-Meier and Cox proportional hazards models.
Main Results:
- Analyzed 602,919 primary TKAs, with 5,295 revised for infection.
- High-volume surgeons (≥100 TKAs/year) demonstrated significantly lower revision rates for PJI compared to low-volume surgeons (<25 TKAs/year).
- Adjusted analyses confirmed an increased risk of PJI revision for lower surgeon volume groups, with hazard ratios ranging from 1.44 to 3.07 (p < 0.001).
Conclusions:
- Higher surgeon volume in TKA is associated with a reduced risk of periprosthetic joint infection.
- Surgeon experience and volume appear to be critical factors in minimizing PJI complications.
- Further research is warranted to understand the mechanisms by which surgical volume influences infection rates.
