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. 2020 Jun 26;478(8):1741–1751. doi: 10.1097/CORR.0000000000001389

What Are Risk Factors for Infection after Primary or Revision Total Joint Arthroplasty in Patients Older Than 80 Years?

Nipun Sodhi 1,2,3,4,5, Hiba K Anis 1,2,3,4,5, Rushabh M Vakharia 1,2,3,4,5, Alexander J Acuña 1,2,3,4,5, Peter A Gold 1,2,3,4,5, Luke J Garbarino 1,2,3,4,5, Bilal M Mahmood 1,2,3,4,5, Nicholas R Arnold 1,2,3,4,5, Joseph O Ehiorobo 1,2,3,4,5, Eric L Grossman 1,2,3,4,5, Michael A Mont 1,2,3,4,5,✉, Martin W Roche 1,2,3,4,5
PMCID: PMC7371091  PMID: 32662957

Abstract

Background

Patients older than 80 years of age form an increasing proportion of the patient population undergoing total joint arthroplasty (TJA). With increasing life expectancy and the success of TJA, orthopaedic surgeons are more likely to operate on patients older than 80 years than ever before. Given that most other studies focus on younger populations, only evaluate primary TJA, or limit patient populations to institutional or regional data, we felt a large-database, nationwide analysis of this demographic cohort was warranted, and we wished to consider both primary and revision TJA.

Questions/purposes

In this study, we sought to investigate the risk factors for surgical site infections (SSIs) at 90 days and periprosthetic joint infections (PJIs) at 2 years after surgery in patients aged 80 years and older undergoing (1) primary and (2) revision lower extremity TJA.

Methods

All patients aged 80 years or older who underwent primary or revision TJA between 2005 and 2014 were identified using the Medicare Analytical Files of the PearlDiver Supercomputer using ICD-9 codes. This database is unique in that it is one of the largest nationwide databases, and so it provides a large enough sample size of patients 80 years or older. Additionally, this database provides comprehensive and longitudinal patient data tracking, and a low error rate. Our final cohort consisted of 503,241 patients (TKA: n = 275,717; THA: n = 162,489; revision TKA: n = 28,779; revision THA: n = 36,256). Multivariate logistic regression models were constructed to evaluate the association of risk factors on the incidences of 90-day SSI and 2-year PJI. Variables such as sex, diabetes, BMI, and congestive heart failure, were included in the multivariate regression models. Several high-risk comorbidities as identified by the Charlson and Elixhauser comorbidity indices were selected to construct the models. We performed a Bonferroni-adjusted correction to account for the fact that multiple statistical comparisons were made, with a p value < 0.002 being considered statistically significant.

Results

For primary TKA patients, an increased risk of 90-day SSIs was associated with male sex (OR 1.28 [95% CI 1.25 to 1.52]; p < 0.001), BMI greater than 25 k/m2 (p < 0.001), and other comorbidities. For primary THA patients, an increased risk of 90-day SSIs was associated with patients with obesity (BMI 30-39 kg/m2; OR 1.91 [95% CI 1.60 to 2.26]; p < 0.001) and those with morbid obesity (BMI 40-70 kg/m2; OR 2.58 [95% CI 1.95 to 3.36]; p < 0.001). For revision TKA patients, an increased risk of SSI was associated with iron-deficiency anemia (OR 1.82 [95% CI 1.37 to 2.28]; p < 0.001). For revision THA patients, electrolyte imbalance (OR 1.48 [95% CI 1.23 to 1.79]; p < 0.001) and iron-deficiency anemia (OR 1.63 [95% CI 1.35 to 1.99]; p < 0.001) were associated with an increased risk of 90-day SSI. Similar associations were noted for PJI in each cohort.

Conclusions

These findings show that in this population, male sex, obesity, hypertension, iron-deficiency anemia, among other high-risk comorbidities are associated with a higher risk of SSIs and PJIs. Based on these findings, orthopaedic surgeons should actively engage in comanagement strategies with internists and other specialists to address modifiable risk factors through practices such as weight management programs, blood pressure reduction, and electrolyte balancing. Furthermore, this data should encourage healthcare systems and policy makers to recognize that this patient demographic is at increased risks for PJI or SSI, and these risks must be considered when negotiating payment bundles.

Level of Evidence

Level III, therapeutic study.

Introduction

Annual rates of total joint arthroplasty (TJA) are projected to surge in the coming decades [18, 25, 26, 33]. This is largely attributable to an aging population, the ensuing increase in osteoarthritis prevalence, and the increasing safety and efficacy of arthroplasty [2, 17, 36, 56]. Notably, the number of Americans older than 80 years of age has experienced some of the largest growth [15, 43, 44, 54]. Despite the reservations many surgeons have about operating on older patients because of their high comorbidity burden [28, 38, 54], an increasingly older population has led to an increased demand for and incidence of TJA in these patients [11, 18]. This is partly because patients who previously underwent primary TJA are expected to outlive their implants and subsequently undergo revision TJA by the time they reach their eighth to ninth decade of life [22]. Therefore, updated analyses examining the susceptibility of this patient population to various complications are needed to help providers mitigate these potential risks perioperatively.

Several studies have indicated that patients older than 80 years have a higher risk of adverse outcomes after TJA, including a prolonged length of stay, higher readmission rates, higher costs of care, and numerous other postoperatively complications compared with younger patients [30, 32, 35, 39–41, 47, 55]. Additionally, a recent meta-analysis and systematic review by Kuperman et al. [32] found that patients older than 75 years were at a higher risk of mortality, myocardial infarction, and deep vein thrombosis than younger patients. High complication rates are also seen in this patient population after revision TJA, with dislocation occurring in up to 20% of elderly patients [45, 51, 52]. However, despite the large number of comorbidities and subsequent immunosenescence in this patient population [1, 3], there is a paucity of data regarding the association between advanced age and infection after revision TJA. Further, the available evidence to date reports on small sample sizes (few hundreds of patients), while larger samples are needed when evaluating postoperative periprosthetic joint infections/surgical site infections (PJIs/SSIs); prior studies also used shorter follow-up durations and used other databases [16, 27, 39]. Given these limitations and the lack of consensus regarding the likelihood of infection in this patient population, further studies, as well as those from different databases, are needed to better understand what factors influence the infection risk in patients older than 80 years of age undergoing TJA.

We therefore sought to investigate risk factors for SSIs at 90 days and PJIs at 2 years after surgery in patients aged 80 years and older undergoing (1) primary and (2) revision lower-extremity TJA.

Patients and Methods

Database and IRB Status

The Medicare Analytical Files of the PearlDiver supercomputer (PearlDiver Technologies, Fort Wayne, IN, USA) were queried for our analysis. Containing more than 100 million patient records from Humana and Medicare claims, this database allows the extraction of data through the use of ICD-9 and ICD-10 and Current Procedural Terminology coding. These codes can subsequently be used to obtain information regarding complications, reimbursements, and diagnoses. This database is one of the largest nationwide databases, and as such, it provides a large enough sample size of patients 80 years or older to perform the analyses we wished to perform. Additionally, this database provides comprehensive and longitudinal patient data tracking, and a low error rate (estimated to be 1.3% based on reported coding errors in the Medicare population [10, 42]). Furthermore, the large sample size provided by this database allows for appropriate statistical analyses for PJIs/SSIs and helps mitigate the risks of a type 2 error.

Our study was deemed institutional review board-exempt because information in this database is de-identified and publicly available.

Patient Selection

The following ICD-9 codes were used to identify patients undergoing primary TKA, primary THA, revision TKA, and revision THA between 2005 and 2015: 81.54, 81.51, 81.55, and 81.53, respectively. Similarly, the database was queried using Current Procedural Terminology codes 27447, 27130, 27487, and 27137 for TKA, THA, revision TKA, and revision THA, respectively. Patients older than 80 years were filtered from identified patients (Table 1). Age was the only exclusionary factor. Also, the database longitudinally tracks patients as long as they are enrolled in the Medicare program, so it is possible that some patients left the system before 2 years postoperative and are therefore not accounted for. Our final cohort consisted of 503,241 patients (TKA: n = 275,717; THA: n = 162,489; revision TKA: n = 28,779; revision THA: n = 36,256) (Fig. 1).

Table 1.

Demographic profile of patients aged 80 years and older undergoing primary or revision total joint arthroplasty

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Fig. 1.

Fig. 1.

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The STROBE diagram is shown here.

Study Variables of Interest

The measured outcomes were the 90-day incidence of SSI and the 2-year incidence of PJI. These cutoffs were chosen based on findings by Borchardt and Tzizik [8] and Huotari et al. [7, 24] demonstrating that the incidence of PJI after TJA was the highest within the first 2 postoperative years. SSIs were defined based on ICD-9 and CPT codes: ICD-9-D-68100, CPT-10180, CPT-20005, CPT-26055, ICD-9-P-8604, CPT-10140. PJIs were defined based on ICD-9 code ICD-9-D-996.66. Several comorbidities evaluated by the Charlson comorbidity index and the Elixhauser comorbidity index were investigated as potential risk factors and were selected to construct the models [12, 37]. The following clinical characteristics and comorbidities were included in the models: gender, BMI, alcohol abuse, cannabis use, congestive heart failure, coagulopathies, depression, diabetes mellitus, electrolyte fluid imbalance, hypertension, hypothyroidism, iron-deficiency anemia, opioid use disorder, peptic ulcer disease, peripheral vascular disease, renal failure, rheumatoid arthritis, sleep apnea.

Data Analysis

We performed a multivariate binomial logistic regression analysis to calculate odds ratios, along with their respective 95% CIs and p values, to identify factors independently associated with an increased infection risk. Variables such as sex, BMI, diabetes, congestive heart failure, were included in the multivariate regression model. We performed a Bonferroni-adjusted correction to account for the fact that multiple statistical comparisons were made, and a p value less than 0.002 was considered statistically significant. All statistical analyses were performed using the programming language R (R Foundation for Computation Science, Vienna, Austria).

Results

Primary Lower-extremity Arthroplasty

Primary TKA

A total of 0.73% (2024 of 275,717) of patients experienced 90-day SSIs. After controlling for potential confounding variables such as sex, BMI, diabetes, and congestive heart failure, we found an increased risk of 90-day SSIs was associated with male sex (OR 1.28 [95% CI 1.25 to 1.52; p < 0.001), BMI greater than 25 k/m2 (p < 0.001), and pre-existing diagnoses of coagulopathies (OR 1.24 [95% CI 1.14 to 1.41]; p < 0.001), depression (OR 1.2 [95% CI 1.16 to 1.42]; p < 0.001), electrolyte imbalance (OR 1.3 [95% CI 1.25 to 1.55]; p < 0.001), iron-deficiency anemia (OR 1.42 [95% CI 1.28 to 1.58]; p < 0.001), and peripheral vascular disease (OR 1.21 [95% CI 1.11 to 1.33]; p < 0.001) (Table 2).

Table 2.

Multivariate regression models evaluating risk factors for surgical site infection incidence (SSI) and prosthetic joint infection (PJI) incidence after primary TKA

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A total of 1.2% (3368 of 275,717) of patients experienced 2-year PJIs. A higher risk of 2-year PJI was also associated with male sex (OR 1.67 [95% CI 1.55 to 1.79]; p < 0.001), BMI greater than 30 kg/m2 (p < 0.001), and congestive heart failure (OR 1.19 [95% CI 1.10 to 1.28]; p < 0.001), depression (OR 1.33 [95% CI 1.23 to 1.43]; p < 0.001), diabetes (OR 1.13 [95% CI 1.05 to 1.22]; p < 0.001), electrolyte imbalance (OR 1.6 [95% CI 1.53 to 1.81]; p < 0.001), iron-deficiency anemia (OR 1.81 [95% CI 1.66 to 1.97]; p < 0.001), renal failure (OR 1.22 [95% CI 1.09 to 1.36]; p < 0.001), and rheumatoid arthritis (OR 1.19 [95% CI 1.09 to 1.30]; p < 0.001).

Primary THA

A total of 0.9% (1470 of 162,489) of patients experienced 90-day SSIs. There was an increased risk of 90-day SSIs in patients with obesity (BMI 30-39 kg/m2; OR 1.91 [95% CI 1.60 to 2.26]; p < 0.001) and those with morbid obesity (BMI 40-70 kg/m2; OR 2.58 [95% CI 1.95 to 3.36]; p < 0.001). Congestive heart failure (OR 1.24 [95% CI 1.11 to 1.39]; p = 0.001), depression (OR 1.26 [95% CI 1.13 to 1.42]; p < 0.001), electrolyte imbalance (OR 1.57 [95% CI 1.38 to 1.78]; p < 0.001), and iron-deficiency anemia (OR 1.71 [95% CI 1.50 to 1.96]; p < 0.001) were also associated with an increased risk of 90-day SSIs (Table 3).

Table 3.

Multivariate regression models evaluating risk factors for surgical site infection incidence and prosthetic joint infection incidence after primary THA

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A total of 1.1% (1780 of 162,489) of patients experienced 2-year PJIs. Male sex (OR 1.48 [95% CI 1.33 to 1.64]; p < 0.001), obesity (OR 1.81 [95% CI 1.54 to 2.12]; p < 0.001), and morbid obesity (OR 2.37 [95% CI 1.81 to 3.05]; p < 0.001) were associated with an increased risk of PJI at 2 years. Preexisting coagulopathies (OR 1.26 [95% CI 1.13 to 1.41]; p < 0.001), depression (OR 1.62 [95% CI 1.47 to 1.79]; p < 0.001), electrolyte imbalance (OR 1.62 [95% CI 1.44 to 1.83]; p < 0.001), iron-deficiency anemia (OR 1.95 [95% CI 1.71 to 2.20]; p < 0.001), and rheumatoid arthritis (OR 1.33 [95% CI 1.18 to 1.49]; p < 0.001) were additionally associated with an increased PJI risk.

Revision Lower-extremity Arthroplasty

Revision TKA

A total 2.2% (643 of 28,779) patients experienced 90-day SSI. Patients older than 80 years undergoing revision TKA had an increased risk of SSI at 90 days if they had iron-deficiency anemia (OR 1.82 [95% CI 1.37 to 2.28]; p < 0.001). A total of 3% (874 of 28,779) experienced 2-year PJIs. Depression (OR 1.34 [95% CI 1.17 to 1.56]; p < 0.001), electrolyte or fluid imbalance (OR 1.39 [95% CI 1.16 to 1.67]; p = 0.0002), and iron-deficiency anemia (OR 1.44 [95% CI 1.21 to 1.74]; p < 0.001) were associated with PJI at 2 years in patients undergoing revision TKA (Table 4).

Table 4.

Multivariate regression models evaluating risk factors for surgical site infection incidence and prosthetic joint infection incidence after revision TKA

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Revision THA

A total of 2.3% (834 of 36,256) patients experienced 90-day SSIs. Among patients aged 80 years and older undergoing revision THA, electrolyte imbalance (OR 1.48 [95% CI 1.23 to 1.79]; p < 0.001) and iron-deficiency anemia (OR 1.63 [95% CI 1.35 to 1.99]; p < 0.001) were associated with an increased risk of 90-day SSI.

A total of 2.4% (874 of 36,256) patients experienced 2-year PJIs. Electrolyte imbalance (OR 1.74 [95% CI 1.48 to 2.08]; p < 0.001) and iron-deficiency anemia (OR 1.72 [95% CI 1.45 to 2.06]; p < 0.001) were also risk factors for 2-year PJI. Additionally, men (OR 1.33 [95% CI 1.17 to 1.52]; p < 0.001) and patients with rheumatoid arthritis (OR 1.35 [95% CI 1.17 to 1.56]; p < 0.001) were also at an increased risk of having PJI (Table 5).

Table 5.

Multivariate regression models evaluating risk factors for surgical site infection incidence and prosthetic joint infection incidence after revision THA

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Discussion

The number of patients older than 80 years of age undergoing TJA is expected to increase as the age of the population continues to rise. However, given the numerous adverse outcomes and increased costs associated with this vulnerable patient population, it has been increasingly necessary to help providers identify potentially modifiable factors associated with devastating complications such as infection. Considering the gaps in current studies regarding factors that are associated with the likelihood of infection, we evaluated associated risk factors in patients at least 80 years old. In our analysis, we identified several patient demographics and comorbidities that were associated with an increased risk of SSI at 90 days and PJI at 2 years after primary and revision TJA. To the best of our knowledge, these data provide findings derived from the largest sample size and follow-up duration in addition to revision TJA information, which has not been provided before on this scale. Importantly, this study identified several modifiable risk factors such as obesity, diabetes, and hypertension as key risk factors in this demographic; surgeons should consider preoperative consultation with medical specialists in patients who have these comorbidities to arrange for perioperative comanagement.

Our analysis has some limitations. Given that we reported on patient data from a large administrative database, clinical conditions were queried with coding, rather than laboratory values or other diagnostic criteria, and the extracted information was subject to coding errors. However, any potential data input mistakes likely did not substantially impact our findings, given that we reported on more than 500,000 patients and that this database has a small amount of coding error (estimated to be 1.3% based on reported coding errors in the Medicare population [10, 42]). Additionally, we did not evaluate other patient-specific variables that could affect the infection risk such as behavioral factors, history of surgery, or functional status. Similarly, we did not control for factors related to the index procedure itself, such as operative time, technical approach, or surgical site preparation, which additionally could have affected the infection incidence. These factors were not controlled for as they could not be accounted for in the database; however, our findings should not be disqualified given the large number of patients and comorbidities evaluated. Instead, these findings must be considered in the context of these limitations. Nevertheless, this analysis can be viewed as a foundational study from which institutional-based studies with more granular data collection and controllable factors can be performed. As an observational study, our findings point to associations but cannot prove causation, and readers should interpret our findings accordingly. Finally, our analysis evaluated a large time range; over this span, improvements have been made in surgical techniques and medical management strategies, and our findings should be interpreted regarding this possibility; however, we needed a large set of patients to identify and analyze relatively rare complications such as PJI and SSI.

Primary Lower-extremity Arthroplasty

Previous studies exploring infection among patients undergoing TJA have generally demonstrated similar risk factors for SSI [19, 49, 50]. One analysis of 2170 patients undergoing TJA [50] identified BMI > 40 kg/m2 and electrolyte disturbances as factors independently associated with SSI. Similarly, another study [49] found an increased risk of SSI among patients with TJA who had congestive heart failure, electrolyte or fluid abnormalities, and coagulopathies. Their evaluation of the risk factors for and incidence of SSI included 412,356 patients undergoing THA. Another study [29] found that obesity and chronic obstructive pulmonary disorder were independently associated with SSI in their analysis of SSI in 569 elderly patients. Although these studies provided an initial foundation, our study advances knowledge by analyzing the data from a different large database (one that is not limited to primarily inpatient data) and exclusively evaluating patients 80 years or older.

Multiple studies have similarly evaluated risk factors for SSIs in older patient populations [3, 13, 29, 34, 58, 59]. Lee et al. [34] found that a Charlson comorbidity index score of at least 3 was associated with SSI in their evaluation of 169 elderly patients who underwent orthopaedic surgical procedures. Similarly, Tay et al. [58] found that the comorbidity burden had a greater affect than age alone on TKA outcomes; a Charlson comorbidity index score of at least 3 was an independent risk factor for complications such as superficial infections in octogenarian patients undergoing TKA. Additionally, Yohe et al. [59] found in their analysis of 12,026 patients older than 80 years of age undergoing TKA that patients with American Society of Anesthesiologists class greater than 2 were at an increased risk of having minor complications such as superficial wound infections. Although these studies identified pooled comorbidity burdens to be associated with increased risks for PJI/SSI, our study identified specific associated comorbidities. By identifying individual risk factors, surgeons can better provide preoperative targeted management of modifiable comorbidities.

Revision Lower-extremity Arthroplasty

There is ample information regarding the risk of PJI in the general population undergoing arthroplasty procedures. A recent systematic review and meta-analysis examining risk factors for PJI in 2,470,827 patients undergoing TJA found that male sex and a history of coagulopathy, congestive heart failure, diabetes, and obesity were associated with a higher likelihood of infection [53]. Similarly, Kunutsor et al. [31] found that various comorbidities along with male sex and BMI ≥ 30 kg/m2 were associated with an increased risk of PJI in their systematic review of 512,508 patients with TJA. Compared with these studies, our study evaluated PJI/SSI outcomes in patients 80 years old; the group we studied has important, age-related differences (and increased surgical risks) compared with the overall TJA patient population.

Various factors likely influence the infection risk among older patients undergoing TJA, such as poorer health, prolonged operative time, and increased perioperative blood loss [4, 5]. Specifically, underweight status and malnourishment have been shown to be strong risk factors for PJI [6, 23]. Additionally, rheumatologic disease, anemia, and coagulopathies have been associated with an increased incidence of PJI in patients undergoing TJA [8, 9, 46, 57]. Because older individuals undergoing revision THA frequently present with these various comorbidities [14, 20, 21, 48], the reported influence these illnesses have on PJI likely extends to geriatric patients. However, information on the risk factors for PJI after revision TJA is scarce, especially in relation to patients older than 80 years of age. Therefore, we presented some of the first information regarding factors impacting the PJI risk in elderly patients undergoing revision TJA.

Conclusions

Our analysis found that male sex, obesity, hypertension, iron-deficiency anemia, among other high-risk comorbidities were associated with an increased risks of SSI and PJI. Based on these data, we recommend that when planning arthroplasty in patients who are 80 years or older, surgeons actively seek preoperative comanagement with internists and other specialists to help manage modifiable risk factors through weight loss, antihypertensives, and electrolyte balancing. Additionally, healthcare systems and policy makers should consider that despite extensive preoperative interventions, this patient demographic remains at increased risk for PJI or SSI, and this risk needs to be considered when negotiating payment bundles. Future studies should compare the risk of SSI and PJI in this demographic with and without the aid of preoperative comanagement from internists or hospitalists to help identify efficacious management algorithms for this growing patient population.

Footnotes

One of the authors (MAM) certifies that he, or a member of his immediate family, has received or may receive payments or benefits, during the study period, an amount of less than USD 10,000 from American Academy of Orthopaedic Surgeons (Rosemont, IL, USA); less than USD 10,000 from American Association of Hip and Knee Surgeons (Rosemont, IL); USD 10,000 to USD 100,000 from CyMedica (Scottsdale, AZ, USA); less than USD 10,000 from Flexion Therapeutics (Burlington, MA, USA); USD 10,000 to USD 100,000 from Johnson & Johnson (New Brunswick, NJ, USA); USD 10,000 to USD 100,000 from Journal of Arthroplasty (Philadelphia, PA, USA); less than USD 10,000 from Journal of Knee Surgery (New York, NY, USA); less than USD 10,000] from Knee Society (Rosemont, IL, USA); less than USD 10,000 from Medicus Works LLC; USD 10,000 to USD 100,000 from National Institutes of Health NIAMS & NICHD (Bethesda, MD, USA); less than USD 10,000 from Orthopedics (Thorofare, NJ, USA); less than USD 10,000 from Peerwell (San Francisco, CA, USA); USD 10,000 to USD 100,000] from Pfizer (New York, NY, USA); USD 10,000 to USD 100,000] from Stryker (Kalamazoo, MI, USA); less than USD 10,000 from Surgical Technology International; USD 10,000 to USD 100,000 from Kolon Tissue Gene (Rockville, MD, USA); less than USD 10,000 from Up-to-Date (Waltham, MA, USA); less than USD 10,000 from USMI (Tacoma Park, MD, USA); less than USD 10,000 from Wolters Kluwer Health (Philadelphia, PA, USA).

One of the authors (MWR) certifies that he, or a member of his immediate family, has received or may receive payments or benefits, during the study period, an amount of less than USD 10,000 from Stryker (Kalamazoo, MI, USA); less than USD 10,000 from Orthosensor (Dania Beach, FL, USA), and less than USD 10,000 Smith & Nephew (London, UK).

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his or her institution waived approval for the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.

This work was performed at Long Island Jewish Medical Center, Northwell Health, and Lenox Hill Hospital, New York, NY, USA.

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