Morbid obesity: a significant risk factor for failure of two-stage revision total knee arthroplasty for infection.

BACKGROUND Obese patients have a higher risk of complications following primary total knee arthroplasty, including periprosthetic joint infection. However, there is a paucity of data concerning the efficacy of two-stage revision arthroplasty in obese patients. METHODS We performed a two-to-one matched cohort study to compare the outcomes of thirty-seven morbidly obese patients (those with a body mass index of ≥ 40 kg/m(2)) who underwent two-stage revision total knee arthroplasty for periprosthetic joint infection following primary total knee arthroplasty with the outcomes of seventy-four non-obese patients (those with a body mass index of <30 kg/m(2)). Groups were matched by sex, age, and date of reimplantation. Outcomes included subsequent revision, reinfection, reoperation, and Knee Society pain and function scores. The minimum follow-up time was five years. RESULTS Morbidly obese patients had a significantly increased risk for revision surgery (32% compared with 11%; p < 0.01), reinfection (22% compared with 4%; p < 0.01), and reoperation (51% compared with 16%; p < 0.01). Implant survival rates were 80% for the morbidly obese group and 97% for the non-obese group at five years and 55% for the morbidly obese group and 82% for the non-obese group at ten years. Knee Society pain scores improved significantly following surgery in both groups; the mean scores (and standard deviation) were 50 ± 5 points for the morbidly obese group and 55 ± 2 points for the non-obese group (p = 0.06) preoperatively, 74 ± 5 points for the morbidly obese group and 89 ± 2 points for the non-obese group (p < 0.0001) at two years, 72 ± 6 points for the morbidly obese group and 88 ± 3 points for the non-obese group (p < 0.0001) at five years, and 56 ± 9 points for the morbidly obese group and 84 ± 3 points for the non-obese group (p = 0.01) at ten years. CONCLUSIONS Morbid obesity significantly increased the risk of subsequent revision, reoperation, and reinfection following two-stage revision total knee arthroplasty for infection. In addition, these patients had worse pain relief and overall function at intermediate-term clinical follow-up. Although two-stage revision should remain a standard treatment for chronic periprosthetic joint infection in morbidly obese patients, increased failure rates and poorer outcomes should be anticipated.

[1]  S. Kurtz,et al.  Risk Factors for Early Revision After Primary TKA in Medicare Patients , 2014, Clinical orthopaedics and related research.

[2]  S. Berkowitz,et al.  Complication Rates After Hip or Knee Arthroplasty in Morbidly Obese Patients , 2013, Clinical orthopaedics and related research.

[3]  D. Dahm,et al.  The Influence of Obesity on the Complication Rate and Outcome of Total Knee Arthroplasty , 2012 .

[4]  P. Baker,et al.  The association between body mass index and the outcomes of total knee arthroplasty. , 2012, The Journal of bone and joint surgery. American volume.

[5]  A. Eskelinen,et al.  Obesity, diabetes, and preoperative hyperglycemia as predictors of periprosthetic joint infection: a single-center analysis of 7181 primary hip and knee replacements for osteoarthritis. , 2012, The Journal of bone and joint surgery. American volume.

[6]  D. Naudie,et al.  Assessing the Gold Standard: A Review of 253 Two-Stage Revisions for Infected TKA , 2012, Clinical orthopaedics and related research.

[7]  M. Beck,et al.  Micronutrients, immunology and inflammation The impact of obesity on the immune response to infection , 2016 .

[8]  S. Kurtz,et al.  Patient-related Risk Factors for Postoperative Mortality and Periprosthetic Joint Infection in Medicare Patients Undergoing TKA , 2012, Clinical orthopaedics and related research.

[9]  Javad Parvizi,et al.  Failure following revision total knee arthroplasty: infection is the major cause , 2011, International Orthopaedics.

[10]  S. Odum,et al.  The Chitranjan Ranawat Award: Fate of Two-stage Reimplantation After Failed Irrigation and Débridement for Periprosthetic Knee Infection , 2011, Clinical orthopaedics and related research.

[11]  M. Ritter,et al.  Morbidly obese, diabetic, younger, and unilateral joint arthroplasty patients have elevated total joint arthroplasty infection rates. , 2009, The Journal of arthroplasty.

[12]  Javad Parvizi,et al.  Periprosthetic Infection Due to Resistant Staphylococci: Serious Problems on the Horizon , 2009, Clinical orthopaedics and related research.

[13]  S. Kurtz,et al.  Infection burden for hip and knee arthroplasty in the United States. , 2008, The Journal of arthroplasty.

[14]  C. Salgado,et al.  Higher Risk of Failure of Methicillin-resistant Staphylococcus aureus Prosthetic Joint Infections , 2007, Clinical orthopaedics and related research.

[15]  S. Kurtz,et al.  Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. , 2007, The Journal of bone and joint surgery. American volume.

[16]  M. Colonna,et al.  Impaired mononuclear cell immune function in extreme obesity is corrected by weight loss. , 2007, Rejuvenation research.

[17]  P. Ernsberger,et al.  The epidemiology of overweight and obesity: public health crisis or moral panic? , 2006, International journal of epidemiology.

[18]  S. Olshansky,et al.  A potential decline in life expectancy in the United States in the 21st century. , 2005, The New England journal of medicine.

[19]  D. Berry,et al.  Mid-Term to Long-Term Followup of Two-stage Reimplantation for Infected Total Knee Arthroplasty , 2004, Clinical orthopaedics and related research.

[20]  HusamGhanim,et al.  Circulating Mononuclear Cells in the Obese Are in a Proinflammatory State , 2004 .

[21]  R. Laskin,et al.  Infection in Total Knee Replacement: A Retrospective Review of 6489 Total Knee Replacements , 2001, Clinical orthopaedics and related research.

[22]  J. Parvizi,et al.  Total joint arthroplasty in patients surgically treated for morbid obesity. , 2000, The Journal of arthroplasty.

[23]  Hermann Brenner,et al.  Obesity, overweight and patterns of osteoarthritis: the Ulm Osteoarthritis Study. , 2000, Journal of clinical epidemiology.

[24]  A. Utter,et al.  Influence of obesity on immune function. , 1999, Journal of the American Dietetic Association.

[25]  T S Thornhill,et al.  Infection as a complication of total knee-replacement arthroplasty. Risk factors and treatment in sixty-seven cases. , 1990, The Journal of bone and joint surgery. American volume.

[26]  F. Dorey,et al.  Deep sepsis following total knee arthroplasty. Ten-year experience at the University of California at Los Angeles Medical Center. , 1986, The Journal of bone and joint surgery. American volume.

[27]  A. Hanssen,et al.  Reinfection after two-stage revision for periprosthetic infection of total knee arthroplasty , 2011, International Orthopaedics.

[28]  A. Hanssen,et al.  Infection after total knee arthroplasty. , 2001, Instructional course lectures.

[29]  B. Morrey,et al.  Correlation of patient questionnaire responses and physician history in grading clinical outcome following hip and knee arthroplasty. A prospective study of 201 joint arthroplasties. , 1996, The Journal of arthroplasty.