Rev. bras. ortop. vol.50 número6

w w w . r b o . o r g . b r

Original

Article

Characterization

of

hip

and

knee

arthroplasties

and

factors

associated

with

infection

夽

Cibele

Zdebsky

da

Silva

Pinto

_,

_Francine

_Taporosky

_Alpendre

,

Christiane

Johnscher

Niebel

Stier

_,

_Eliane

_Cristina

_Sanches

_Maziero

_,

Paulo

Gilberto

Cimbalista

de

Alencar

_,

_Elaine

_Drehmer

_de

_Almeida

_Cruz

a_{DepartmentofNursing,UniversidadeFederaldoParaná(UFPR),Curitiba,PR,Brazil} b_{NursingPost-graduateProgram,UniversidadeFederaldoParaná(UFPR),Curitiba,PR,Brazil}

c_{HospitalInfectionControlService,HospitaldeClínicas,UniversidadeFederaldoParaná(UFPR),Curitiba,PR,Brazil} d_{HipandKneeSurgeryService,HospitaldeClínicas,UniversidadeFederaldoParaná(UFPR),Curitiba,PR,Brazil}

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Articlehistory:

Received9September2014 Accepted14January2015 Availableonline20October2015

Keywords: Patientsafety Hospitalinfection Arthroplasty Intraoperativecare Epidemiology

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Objective:Tocharacterizearthroplastyprocedures,calculatethesurgicalinfectionrateand identifyrelatedriskfactors.

Methods:Thiswasaretrospectivecohortstudy.Dataonoperationsperformedbetween2010 and2012weregatheredfromdocumentalsourcesandwereanalyzedwiththeaidof statisti-calsoftware,usingFisher’sexacttest,Student’sttestandthenonparametricMann–Whitney andWilcoxontests.

Results:421totalarthroplasty proceduresperformed on346 patientswereanalyzed,of which208wereonthekneeand213onthehip.Itwasfoundthat18patients(4.3%)were infected.Amongthese,15(83.33%)werereoperatedand2(15.74%)died.Theprevalence ofinfectioninprimarytotalhiparthroplastyprocedureswas3%;inprimarytotalknee arthroplasty,6.14%;andinrevisionoftotalkneearthroplasty,3.45%.Staphylococcusaureus wasprevalent.Thelengthofthesurgicalprocedureshowedatendencytowardbeingarisk factor(p=0.067).

Conclusion:Theprevalenceofinfectionin casesofprimarytotal kneearthroplastywas greaterthaninothercases.Nostatisticallysignificantriskfactorsforinfectionwere iden-tified.

©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

夽

StudycarriedoutatHospitaldeClínicas,UniversidadeFederaldoParaná(UFPR),Curitiba,PR,Brazil.

∗ _{Correspondingauthor.}

E-mail:[email protected](F.T.Alpendre).

http://dx.doi.org/10.1016/j.rboe.2015.09.004

Caracterizac¸ão

de

artroplastias

de

quadril

e

joelho

e

fatores

associados

à

infecc¸ão

Palavras-chave: Seguranc¸adopaciente Infecc¸ãohospitalar Artroplastia

Cuidadosintraoperatórios Epidemiologia

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Objetivo: Caracterizarasartroplastias,calculara taxadeinfecc¸ãocirúrgicaeidentificar fatoresderiscorelacionados.

Métodos: Estudodecoorteretrospectivo.Osdadosdascirurgiasfeitasentre2010e2012 foramcoletadosemfontesdocumentaiseanalisadoscomauxíliodeprogramaestatístico etestesexatodeFisher,tdeStudentenãoparamétricodeMann–WhitneyeWilcoxon. Resultados: Foramanalisadas421artroplastiastotaisem346pacientes,208dejoelhoe 213dequadril;18(4,3%)pacientesinfectaram;entreesses,15(83,33%)foramreoperados edois(15,74%)evoluíramparaóbito.Aprevalênciadeinfecc¸ãoemartroplastiatotalde quadrilprimáriafoide3%,emartroplastiatotaldejoelhoprimáriade6,14%eemrevisão deartroplastiatotaldejoelhode3,45%;Staphylococcusaureusfoiprevalente.Otempode durac¸ãodacirurgiaindicouumatendênciacomofatorderisco(p=0,067).

Conclusão: Aprevalênciadeinfecc¸ãoemartroplastiatotaldejoelhoprimáriafoisuperioràs demaisenãoforamidentificadosfatoresderiscoparainfecc¸ãocomsignificânciaestatística. ©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.

Introduction

Ofthe234millionsurgeriesperformedintheworldin2004,the equivalentofoneoperationforevery25people,twomillion resulted indeath inthe perioperative period and approxi-matelysevenmillionhadcomplications,ofwhich50%were consideredpreventable.

Consideringthe magnitude ofthe problem, in 2009the WorldHealth Organization(WHO)established10 objectives aimingtoensureandpromotethesurgicalpatient’ssafety;the sixthobjectiverecommendsthatthehealthteamuseknown methodstominimizetheriskofsurgicalinfection andthe tenthdeliberates that hospitalsand public healthsystems mustestablishsurveillanceonthesurgicalcapacity,volume andresults.1_{Thus,itisconsideredthatepidemiological} stud-iescancontributetotheplanningofpreventionmeasuresfor surgicalinfectionsandimprovetheprovidedqualityofcare.

Thesurgicalsiteinfection(SSI)isoneofthemostsevere complicationsanddefinedasonethatmanifestswithin30 daysafterthesurgicalprocedure.Insurgicalproceduresthat includeimplantorprosthesis,aperiodofuptooneyearafter surgeryisconsideredasadiagnosticcriterion.2

FortheCenterforDiseasesControlandPrevention,inthe UnitedStatesofAmerica,SSIisresponsibleforapproximately 17%ofallhealthcare-associatedinfections(HAI)3_;inBrazil,it isthethirdmostfrequentinfection,affectingbetween14%to 16%ofhospitalizedpatients4_{andfortheWHO,thiscomplaint} represents37%ofallinfections.1_{TheSSIcanbeclassifiedas} superficialordeep;thoseconsideredsuperficialaretheones involvingonlytheskinandthesubcutaneouslayer,whereas thoseinvolvingdeepincisiontissue,suchasfasciaand mus-cles,areconsidereddeep.4

Amongthe orthopedicsurgical procedures that include prostheses,thetotal hiparthroplasty (THA)and totalknee arthroplasty (TKA) are performed for the treatment of chronic refractory pain, mostly caused by osteoarthritis,

lesionscausedbyrheumatoidarthritis,avascularnecrosisand fractures.5 _{The arthroplasty provides better quality of life;} however, amongthepossiblecomplications theoccurrence of postoperativeinfection stands out.6,7 _{Thisis considered} aseverecomplicationduetothemorbidityassociatedwith prolonged hospitalizationand needforsurgical reinterven-tionsandmayresultinshorteningoftheaffectedlimb,severe deformitiesanddeath.7

TheNationalHealthSurveillanceAgencyofBrazil recog-nizestheimportanceofpreventiveactionsand experimen-tally launched in 2014 the National Arthroplasty Register program.Thisinitiativewillallowthesurveillanceofimplants andbasedonthedatabaseandepidemiologicalstudies,the establishmentofactionstoreducerisks,assessthe quality ofimplants,aswellaspreventpostoperativecomplications, whichwillcontributetothesafetyofsurgicalpatients.8

ArapidclinicalandlaboratorydiagnosisofSSIinjoint pros-thesesmayincreasethechancesofsolvingtheproblem,as theyaresevereandhigh-costevents9_{andtheknowledgeof} thesecomplications’epidemiologywillcontributetotheir pre-vention.Epidemiological surveillance,reportingofinfection casesandinformationfeedbacktothesurgicalteamarealso strategiesinthepreventionofthesediseases,inadditionto stimulatingthemultidisciplinaryteam’scommitment.10

Inthissense,theepidemiologyofcasesofarthroplasties thathavedevelopedinfectioncontributestopromote correc-tiveandpreventiveactions,aswellaspromotethesafetyof the surgicalpatient. Therefore,the aimsofthisstudywere tocharacterizearthroplasties,calculatethesurgicalinfection rateandidentifyassociatedriskfactors.

Method

0026.0.091.208-11, carried out in a teaching hospital in Curitiba,statecapitalofParana,Brazil.

Thestudy periodcomprised36 months(January2010to December2012)andincludedallsurgicalproceduresforhipor kneereplacements.Fromthedatabaserelatedtostudyperiod surgeries,physicalandelectronicmedicalrecordsand infec-tion notificationforms generatedbythe Hospital Infection ControlServicewereassessed.Notificationofhospital infec-tionsresultedfromprospectiveepidemiologicalsurveillance duringhospitalizationandoutpatientreturn,intheperiodup tooneyearaftersurgery;thecriteria,diagnosisand classifica-tionofinfectionusedinthestudywerethoserecommended bytheCentersforDiseaseControlandPrevention11_andthe NationalHealthSurveillanceAgencyoftheBrazilianMinistry ofHealth.2,4

Basedondocumentalsources,thefollowingdatawere col-lectedandenteredintoaMicrosoftExcel2007spreadsheet: patient’sregister andname,age, gender,medicaldiagnosis thatmotivatedthesurgery, dateofhospitaladmissionand discharge(discharge ordeath),typeofarthroplasty surgery (primaryorsecondary),siteoftheprocedure(THAorTKA), unilateral or simultaneousbilateral procedure, time ofthe startandend ofsurgeryandpatientoutcomes.Ofpatients who developed SSI, information was also collected about performedculturesandisolatedmicroorganisms, character-ization of infection (superficial, deep, of organ or space), readmission,reoperationandclinicaloutcome.

DatawereanalyzedusingtheStatisticalPackageforSocial Sciences v. 20.0 and the results obtained from quantita-tivevariables were described asmean,standard deviation, minimumandmaximumvalues.Qualitative variableswere expressed as frequencies and percentages such as those relatedtogender,numberofsurgeries perpatient,baseline medicaldiagnosis,descriptionandtypeofsurgeryand evolu-tionornottoinfection.Fisher’sexacttestwasusedtoassess the association betweentwo dichotomous qualitative vari-ables. The comparison ofgroups defined by infection (yes orno), inrelationtoage, wascarriedout usingStudent’st testforindependentsamples;andcomparisonbetween sur-gerieswithandwithoutinfection,inrelationtothetimeof surgical procedure was carried out using the nonparamet-ric Mann–Whitney test. The nonparametric Wilcoxon test was usedcompare the preoperative time withthe time of postoperativehospitalizationamongcasesofsurgeriesthat developedanddidnotdevelopinfection.Thep-values<0.05 wereconsideredstatisticallysignificant.

Results

During the study period,421 total arthroplastieswere per-formedin346patients,ofwhich213(50.59%)wereTHAand 208(49.41%)TKA;146(42.2%)wereperformedinmalepatients and200(57.8%)infemales.Thepatients’agesrangedfrom13 to92yearswithameanageof59.17(SD=14.7);276(79.8%) weresubmittedtoonlyonesurgery,65(18.8%)totwosurgeries andfive(1.4%)tothreearthroplasties.

Allpatientsreceived1gofcefazolininthefirstsurgery,up to30minpriortosurgicalincisionandthisprophylactic antibi-oticwasmaintainedforupto24haftersurgery,accordingto

Table1–Medicaldiagnosisofpatientsundergoingtotal hipandkneearthroplasty,2010to2012.

Diagnosis N %

Primarycoxarthrosis,bilateral 105 24.94

Primarygonarthrosis,bilateral 99 23.5

Primarygonarthrosis,unilateral 36 8.6

Othertypesofrheumatoidarthritis 27 6.4

Fixationdevicecomplication 25 5.93

Unspecifiedgonarthrosis 21 5.0

Primarycoxarthrosis 19 4.5

Unspecifiedcoxarthrosis 13 3.1

RheumatoidArthritis 9 2.13

Others 67 15.9

TOTAL 421 100

Table2–Infectionratesintheperformedprimaryand revisionarthroplastysurgeries,2010to2012.

Infection Primarysurgery,N(%) Revisionsurgery,N(%)

No 361(95.5) 42(97.67)

Yes 17(4.5) 1(2.33)

Total 378 43

theinstitutionalprotocolfororthopedicsurgerywith prosthe-sis.Inreoperationsduetoinfection,treatmentwasspecificfor eachcase.Amongthebaselinediagnosisforsurgical indica-tion,therewasaprevalenceofcoxarthrosisandgonarthrosis (Table1).

Regardingthetypeofsurgery,378(89.8%)wereprimary(199 THAand179TKA)and43(10.2%)wererevisionsurgeries.Of these,14wereTHAand29wereTKArevisions(Table2).The prevalenceofSSIinprimaryTHAwas3%,whereasinprimary TKAitwas6.14%;inTKArevision,itwas3.45%.After apply-ingFisher’sexacttest,nosignificantdifferencewasidentified inthe occurrenceofinfection amongprimary andrevision surgeries(p=0.707).

There were 18 cases of infection in 18 patients, which resultedinaprevalencerateof4.3%;allpatientswere readmit-tedfortreatment,15(83.33%)werereoperatedandtwo(11.1%) diedduetotheinfection.Theprevalencerateofinfectionin THA was2.8%(sixcases)and inTKAwas5.78%(12cases). Infectionsclassifiedasorgan/space(77.78%,n=14)werethe mostprevalent,withfivecasesinTHAandnineinTKA, fol-lowedbydeepinfections(22.22%,n=4),oneinTHAandthree inTKA.

Themeansurgicaltimeinpatientsthatdevelopedanddid not developinfection is shown inFig. 1. The null hypoth-esis that the surgical time was equal in both groups was tested,versustheoptionalhypothesisofdifferenttimes,using Mann–Whitney test;theresultindicatedatrendthattimes weredifferent(p=0.067).

Table3–Associationbetweenthepre-andpostoperativeperiodsandinfectionafterperformedtotalhipandknee arthroplastysurgeries,2010to2012.

Infection N Mean Median Minimum Maximum Standarddeviation p-Value

Preoperativehospitalstay No 403 1.25 1 0 27 1.94 0.258

Yes 18 1.72 1 0 8 2.02

Postoperativehospitalstay No 403 4.47 3 1 56 4.66 0.225

Yes 18 8 3 2 63 14.02

Mean time in minutes

Cases without infection Cases with

infection All surgeries

150

126.6

138.6

126 140

130

120

110

Fig.1–Timeinminutesofperformedhipandknee arthroplastysurgeries,2010–2012.

testshowedthatthemeanagewasnotdifferentbetweenthe groups(p=0.265).

Consideringallsurgeries(n=421),themeanhospitallength ofstaywas5.9days(SD=6.2),withaminimumoftwoand maximum of69 days; the mean hospitallength ofstay in readmission was 24.1 days, with a minimum of five and maximumof57days(SD16.9).Regardingthepre-and postop-erativehospitallengthofstay,wetestedthenullhypothesis of equal mean hospital length of stay between the group thatdevelopedinfectionandthegroupthatdidnotdevelop infection, using the nonparametric test of Mann–Whitney. There was no significant difference in the preoperative timeofhospitalization betweengroups(p=0.258);orinthe timeofpostoperativehospitalization(p=0.225)asshownin Table3.

Amongthe18casesofinfection,17hadmaterialcollected for culture; Staphylococcus aureus was the most commonly identifiedmicroorganism(Table4).

Table4–Cultureresultsamongcasesofinfectionof performedtotalhipandkneereplacements,2010to 2012.

Results N %

Positiveculture 14 82.4

Staphylococcusaureus 7 41.2

KlebsiellapneumoniaeESBL 2 11.8

Enterococcusfaecalis 1 5.9

EnterococcusfaeciumandAcinetobacterbaumannii 1 5.9

Escherichiacoli 1 5.9

Streptococcusagalactiae 1 5.9

Coagulase-negativestaphylococciandCitrobacter 1 5.9

Negativeculture 3 17.6

Total 17 100.0

Discussion

Theclinicalandepidemiologicalprofileofpatientssubmitted toarthroplastysurgeryduringthestudyperiodis character-izedbypatientswithpredominantdiagnosesofcoxarthrosis and gonarthrosis,withamedianof59.17yearsand under-going primary surgery. There was a higher frequency of womenundergoingsurgery,whichcorroboratesareviewstudy onfactorsassociatedwithkneeosteoarthritisperformedby ZhangandJordan12_{in2010,whichindicatedthatfemalesare} most oftenaffected by osteoarthritisafter menopause due to hormonalchanges; regardingthe development of infec-tion, therewasno significant differencebetween menand women.

The mean age of patients submitted to THA and TKA reportedbytheresearchersrangedfrom63to75years,7,12,13 older than what was observed in this study, which was 59 years.Thejointdiseases thatmostoften affect individ-uals submittedtoTHAand TKAarethe osteoarthrites.5,6,13 Piano,Golmia and Scheinbergcarriedout a study inBrazil and demonstrated that the diagnostic profile of patients reached92.4%onlyforosteoarthritisand2%forinflammatory arthritis.14_{Inthisstudy,althoughthediagnosticclassification} ismorespecific,ingeneraltheresultsaresimilar,butwitha higherprevalenceofarthritis.

AnotherstudycarriedoutinaBrazilianhospitalbyLenza et al.13 _{described the epidemiological characteristics and} adverse eventsofpatientssubmitted toTHAand TKA;the prevalenceofsuperficialSSIwas1.45%inTHAand1.2%ofin TKA,whichrequiredantimicrobialtreatment,butnot reopera-tion.Insimilarstudies,theSSIratewas6.42%in592patients submittedtoprimaryTKA15_{and inTKArevisions,itvaried} from9%16_to25.2%.17_{Inthisstudy,theincidenceofdeepand} organ/spaceinfectioninTHAwas2.8%and5.78%inTKAand allpatientsweresubmittedtoantibiotictherapyand reopera-tion.

Deepinfections result inadhesion,colonization, biofilm formationandbacterialadhesiontotheimplantedmaterial,in additiontobecomingabarrierthatpreventsantibioticaction; as the bacterial dissemination over the biomaterialmakes theinfection chronicand resistant,thechoiceoftreatment isimplantremoval.18_{Whitsideetal.}19_{consideredasthegold} standardforthetreatmentofTKAinfection,implantremoval andnewsurgicalinterventionforrevisionintwostages,with the intravenousadministration ofantibioticsforsixweeks andfillingthejointcavitywithantibiotic-loadedbonecement spacer.

foritsseveritypotential,obviousinfluenceonpatient morbid-ityandmortality,butalsoduetothehighcostsforpatientsand thehealthcaresystem.9,18_{Aretrospectivestudycarriedoutin} BrazilbyDal-Pazetal.20_{estimatedanadditionalcostofUS$} 91,843.75for34patientsundergoingTKAandthatdeveloped infection.

Themultidisciplinaryteamcanusedatafrom evidence-basedstudies toimprove theuse ofresourcesand prevent unnecessary costs12_{; among the actions to prevent these} infections, reduce costs and improve the use of hospital resources,itisessentialtohaveprofessionalswithdifferent backgrounds,includingatthefinancialandhumanresource departments, to share information, evaluate routines and makechangeswhennecessary.13

Consideringallsurgeriesinthisstudy,themeanhospital lengthofstaywas5.9days(SD=6.2),withaminimumoftwo andmaximumof69days.Theincreaseinthepatient’s hospi-talstayisavariablethatisdirectlyrelatedtotheoccurrence ofinfectionandthefinancialcosts.Prolongedhospitalization periodsandreadmissions,increasehospitalcosts,inaddition totriggeringmorbiditiesassociatedwithhospitalization.

Ideally,themeanhospitallengthofstayshouldnotexceed fivedaysinordernottobecomeariskfactorforthepatient21_; consideringall analyzedsurgeries,the meanlengthofstay exceeded the suggested time and was significantly higher among patients who developed infection, which may also incurinhigherfinancialcosts.

Asforthedurationoftheprocedure,Ercoleetal.22_showed thatamongthe infection cases,79.4% occurredinpatients submittedtoorthopedicsurgerylastingmorethan120min.In thisstudythemeansurgicaltimeforpatientsthatdeveloped infectionwas138.6minand126inthosewhodidnotdevelop it.Althoughnotstatisticallysignificant,the resultindicates atrendthattimesaredifferent(p=0.067)andreinforcesthis factorasariskforthedevelopmentofSSI.

ThepredominanceofStaphylococcusaureusinthecultures supportsthe literaturedata10,23 _{and although most ofthe} surgerieswereprimaryones,secondarysurgeriesshowedno evidenceofbeingassociatedwithinfection,aswellasgender andage.

Conclusion

There was equivalence between THA and TKA, with a prevalenceofbilateralcoxarthrosisandgonarthrosisand pri-maryarthroplasties. Infections inprimary TKA were more prevalentand riskfactors withstatisticalsignificancewere not identified; surgical time showed a tendency toward beinganassociatedriskfactor.There wasapredominance of Staphylococcus aureus as the etiological infectious agent, emphasizing the importance of surgical preparation, as well as the improvement ofsurgical time, as a preventive measure.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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