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Prior Cellulitis as a Risk Factor for Periprosthetic Joint Infection in Total Knee Arthroplasty: Influence of Timing
Alexandra Erling1, Amy Y Zhao2, Majd Marrache2
1Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia.
Background:
Periprosthetic joint infection (PJI) is a leading cause of implant failure and revision surgery after total knee arthroplasty (TKA), occurring in 1 to 3% of patients. Despite the high incidence of cellulitis and shared causative organisms with PJI, little is known about its impact on PJI risk. This study aimed to assess whether a prior history of cellulitis is associated with an increased risk of PJI after TKA, with attention to timing, and to evaluate the role of extended oral antibiotic (EOA) prophylaxis in reducing PJI risk.
Methods:
Patients who underwent elective TKA were identified in a large national database. Those who had cellulitis of the lower extremities before TKA were matched 1:1 to those who did not have a history of cellulitis based on age, sex, Charlson Comorbidity Index, obesity status, diabetes, and smoking status. Patients were stratified by timing of cellulitis and receipt of EOA prophylaxis. The 2-year PJI incidence and odds were calculated using Chi-square analyses and logistic regressions. A total of 105,926 patients were included.
Results:
Patients who had prior cellulitis had a higher incidence of PJI than controls (7.2 versus 3.1%; odds ratio: 2.4, 95% confidence interval: 2.3 to 2.6, P < 0.001). Those who had cellulitis within one year of surgery had higher PJI incidence than patients who had more remote cellulitis (9.3 versus 4.7%; odds ratio: 2.0, 95% confidence interval: 1.9 to 2.2, P < 0.001). Although EOA prophylaxis was more common in the cellulitis group, these patients still had a higher incidence of PJI (10.4 versus 5.4%, P < 0.001).
Conclusions:
Prior cellulitis is a risk factor for PJI after TKA, especially when it occurs within a year of surgery. Enhanced preoperative screening and postoperative surveillance are critical to identifying and managing high-risk patients. Although EOA prophylaxis is often used in this population, it does not appear to fully mitigate the elevated risk, highlighting the need for additional preventative strategies.
Insights
A history of cellulitis increases the risk of periprosthetic joint infection (PJI) after total knee arthroplasty (TKA), particularly when occurring within one year. Extended oral antibiotic prophylaxis may not fully reduce this elevated PJI risk.
Area of Science:
- Orthopedic Surgery
- Infectious Disease
- Biostatistics
Background:
- Periprosthetic joint infection (PJI) is a significant complication following total knee arthroplasty (TKA), leading to implant failure and revision surgery.
- Cellulitis, a common skin infection, shares causative organisms with PJI, but its specific impact on PJI risk post-TKA is not well understood.
Purpose of the Study:
- To determine if a history of lower extremity cellulitis increases the risk of PJI after TKA.
- To investigate the influence of the timing of cellulitis relative to TKA on PJI risk.
- To evaluate the effectiveness of extended oral antibiotic (EOA) prophylaxis in mitigating PJI risk in patients with prior cellulitis.
Main Methods:
- A retrospective cohort study utilizing a large national database of patients undergoing elective TKA.
- 1:1 matching of patients with and without prior lower extremity cellulitis based on key demographic and comorbidity factors.
- Analysis of 2-year PJI incidence and odds, stratified by cellulitis timing and EOA prophylaxis receipt, using Chi-square and logistic regression.
Main Results:
- Patients with prior cellulitis had a significantly higher incidence of PJI (7.2% vs. 3.1%; OR 2.4).
- Cellulitis occurring within one year of TKA was associated with a greater PJI risk compared to more remote cases (9.3% vs. 4.7%; OR 2.0).
- Despite higher EOA use, the cellulitis group still exhibited increased PJI rates (10.4% vs. 5.4%).
Conclusions:
- Prior cellulitis is an independent risk factor for PJI after TKA, with timing being a critical factor.
- Enhanced preoperative screening and postoperative surveillance are crucial for high-risk patients.
- Current EOA prophylaxis strategies may be insufficient to fully counteract the heightened PJI risk associated with prior cellulitis, necessitating further research into preventative measures.
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