Hypoalbuminemia Increases Mortality after Two-Stage Revision Total Joint Arthroplasty

Document Type : RESEARCH PAPER

Authors

Rush University Medical Center Department of Orthopedic Surgery, Chicago, IL, USA

Abstract

Objectives: This study aimed to evaluate the effect of hypoalbuminemia on failure rates and mortality
after a two-stage revision for PJI.
Methods: 199 Patients (130 knees and 69 hips) with a mean age of 64.7 ± 10.7 years who underwent a two-stage
exchange were retrospectively reviewed at a mean of 51.2 ± 39.7 months. Failure of treatment was defined as any
revision within the follow-up period, failure to undergo reimplantation, or death within one year of initiating treatment.
Results: There were 71 failures (35.7%), including 38 septic failures (19.1%). We found no differences between
successful revisions and failures regarding hypoalbuminemia (43% vs. 42% prior to stage 1, P=1 and 32% vs. 29%
prior to stage 2, P=0.856). There were also no differences in hypoalbuminemia rates between septic failures and
the rest of the cohort (42% vs. 43% prior to stage 1, P=1.0 and 34% vs. 30% prior to stage 2, P=0.674).
Hypoalbuminemia prior to stage 2 was a significant predictor of mortality based on multivariate analysis (odds ratio
5.40, CI 1.19-24.54, P=0.029). Hypoalbuminemia was independently associated with a greater length of stay by 2.2
days after stage 1 (P=0.002) and by 1.0 days after the second stage reimplantation (P=0.004).
Conclusion: Preoperative hypoalbuminemia is a significant predictor of mortality and increased length of stay
following two-stage revision but is not a predictor of failure of PJI treatment. Further study is required to understand
if hypoalbuminemia is a modifiable risk factor or a marker for poor outcomes.
Level of evidence: III

Keywords

Main Subjects

References

  1. Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J. Economic burden of periprosthetic joint infection in the United States. J Arthroplasty. 2012; 27(8 Suppl):61-5.e1. doi:10.1016/j.arth.2012.02.022
  2. Bozic KJ, Kamath AF, Ong K, et al. Comparative Epidemiology of Revision Arthroplasty: Failed THA Poses Greater Clinical and Economic Burdens Than Failed TKA. Clin Orthop Relat Res. 2015; 473(6):2131-8. doi:10.1007/s11999-014-4078-8
  3. Premkumar A, Kolin DA, Farley KX, et al. Projected Economic Burden of Periprosthetic Joint Infection of the Hip and Knee in the United States. J Arthroplasty. 2021; 36(5):1484-1489 e3. doi:10.1016/j.arth.2020.12.005
  4. Parvizi J, Adeli B, Zmistowski B, Restrepo C, Greenwald AS. Management of periprosthetic joint infection: the current knowledge: AAOS exhibit selection. J Bone Joint Surg Am. 2012; 94(14):e104. doi:10.2106/JBJS.K.01417
  5. Barton CB, Wang DL, An Q, Brown TS, Callaghan JJ, Otero JE. Two-Stage Exchange Arthroplasty for Periprosthetic Joint Infection Following Total Hip or Knee Arthroplasty Is Associated With High Attrition Rate and Mortality. J Arthroplasty. 2020; 35(5):1384-1389. doi:10.1016/j.arth.2019.12.005
  6. Petis SM, Abdel MP, Perry KI, Mabry TM, Hanssen AD, Berry DJ. Long-Term Results of a 2-Stage Exchange Protocol for Periprosthetic Joint Infection Following Total Hip Arthroplasty in 164 Hips. J Bone Joint Surg Am. 2019; 101(1):74-84. doi:10.2106/jbjs.17.01103
  7. Pelt CE, Grijalva R, Anderson L, Anderson MB, Erickson J, Peters CL. Two-Stage Revision TKA Is Associated with High Complication and Failure Rates. Adv Orthop. 2014;2014:659047. doi:10.1155/2014/659047
  8. Triantafyllopoulos GK, Memtsoudis SG, Zhang W, Ma Y, Sculco TP, Poultsides LA. Periprosthetic Infection Recurrence after 2-Stage Exchange Arthroplasty: Failure or Fate? J Arthroplasty. 2017; 32(2):526-531. doi:10.1016/j.arth.2016.08.002
  9. Wang Q, Goswami K, Kuo FC, Xu C, Tan TL, Parvizi J. Two-Stage Exchange Arthroplasty for Periprosthetic Joint Infection: The Rate and Reason for the Attrition After the First Stage. J Arthroplasty. 2019; 34(11):2749-2756. doi:10.1016/j.arth.2019.06.021
  10. He Y, Xiao J, Shi Z, He J, Li T. Supplementation of enteral nutritional powder decreases surgical site infection, prosthetic joint infection, and readmission after hip arthroplasty in geriatric femoral neck fracture with hypoalbuminemia. J Orthop Surg Res. 2019; 14(1):292. doi:10.1186/s13018-019-1343-2
  11. Jie B, Jiang ZM, Nolan MT, Zhu SN, Yu K, Kondrup J. Impact of preoperative nutritional support on clinical outcome in abdominal surgical patients at nutritional risk. Nutrition. 2012; 28(10):1022-7. doi:10.1016/j.nut.2012.01.017
  12. Martindale RG, McClave SA, Taylor B, Lawson CM. Perioperative nutrition: what is the current landscape? JPEN J Parenter Enteral Nutr. 2013;37(5 Suppl):5s-20s. doi:10.1177/0148607113496821
  13. Antonelli B, Chen AF. Reducing the risk of infection after total joint arthroplasty: preoperative optimization. Arthroplasty. 2019; 1(1):4.doi:10.1186/s42836-019-0003-7
  14. Pruzansky JS, Bronson MJ, Grelsamer RP, Strauss E, Moucha CS. Prevalence of modifiable surgical site infection risk factors in hip and knee joint arthroplasty patients at an urban academic hospital. J Arthroplasty. 2014; 29(2):272-6. doi:10.1016/j.arth.2013.06.019
  15. Yi PH, Frank RM, Vann E, Sonn KA, Moric M, Della Valle CJ. Is Potential Malnutrition Associated With Septic Failure and Acute Infection After Revision Total Joint Arthroplasty? Clin Orthop Relat Res.2015; 473(1):175-182. doi:10.1007/s11999-014-3685-8
  16. Cross MB, Yi PH, Thomas CF, Garcia J, Della Valle CJ. Evaluation of malnutrition in orthopaedic surgery. J Am Acad Orthop Surg. 2014; 22(3):193-9. doi:10.5435/jaaos-22-03-193.
  17. Mbagwu C, Sloan M, Neuwirth AL, et al. Preoperative Albumin, Transferrin, and Total Lymphocyte Count as Risk Markers for Postoperative Complications After Total Joint Arthroplasty: A Systematic Review. J Am Acad Orthop Surg Glob Res Rev. 2020; 4(9) doi: 10.5435/JAAOSGlobal-D-19-00057
  18. Man SL, Chau WW, Chung KY, Ho KKW. Hypoalbuminemia and obesity class II are reliable predictors of peri-prosthetic joint infection in patient undergoing elective total knee arthroplasty. Knee Surg Relat Res. 2020; 32(1):21. doi:10.1186/s43019-020-00040-9
  19. Yuwen P, Chen W, Lv H, et al. Albumin and surgical site infection risk in orthopaedics: a meta-analysis. BMC Surg. 2017; 17(1):7. doi:10.1186/s12893-016-0186-6
  20. Bohl DD, Shen MR, Kayupov E, Della Valle CJ. Hypoalbuminemia Independently Predicts Surgical Site Infection, Pneumonia, Length of Stay, and Readmission After Total Joint Arthroplasty. J Arthroplasty. 2016; 31(1):15-21. doi:10.1016/j.arth.2015.08.028
  21. Blevins K, Aalirezaie A, Shohat N, Parvizi J. Malnutrition and the Development of Periprosthetic Joint Infection in Patients Undergoing Primary Elective Total Joint Arthroplasty. J Arthroplasty. 2018; 33(9):2971-2975. doi:10.1016/j.arth.2018.04.027
  22. Walls JD, Abraham D, Nelson CL, Kamath AF, Elkassabany NM, Liu J. Hypoalbuminemia More Than Morbid Obesity is an Independent Predictor of Complications After Total Hip Arthroplasty. J Arthroplasty. 2015; 30(12):2290-5. doi:10.1016/j.arth.2015.06.003
  23. Hong CS, Ryan SP, Gabor JA, Bergen MA, Schwarzkopf R, Seyler TM. Predicting Success of Two-Stage Exchange for Prosthetic Joint Infection Using C-Reactive Protein/Albumin Ratio. Adv Orthop. 2019; 2019:6521941. doi:10.1155/2019/6521941
  24. Parvizi J, Zmistowski B, Berbari EF, et al. New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res. 2011; 469(11):2992-4. doi:10.1007/s11999-011-2102-9
  25. Fillingham YA, Della Valle CJ, Suleiman LI, et al. Definition of Successful Infection Management and Guidelines for Reporting of Outcomes After Surgical Treatment of Periprosthetic Joint Infection: From the Workgroup of the Musculoskeletal Infection Society (MSIS). J Bone Joint Surg Am. 2019; 101(14):e69. doi:10.2106/jbjs.19.00062
  26. Bohl DD, Shen MR, Kayupov E, Cvetanovich GL, Della Valle CJ. Is Hypoalbuminemia Associated With Septic Failure and Acute Infection After Revision Total Joint Arthroplasty? A Study of 4517 Patients from the National Surgical Quality Improvement Program. J Arthroplasty. 2016; 31(5):963-7. doi:10.1016/j.arth.2015.11.025
  27. Diaz-Ledezma C, Higuera CA, Parvizi J. Success after treatment of periprosthetic joint infection: a Delphi-based international multidisciplinary consensus. Clin Orthop Relat Res. 2013; 471(7):2374-82. doi:10.1007/s11999-013-2866-1
  28. Choi HR, Bedair H. Mortality following revision total knee arthroplasty: a matched cohort study of septic versus aseptic revisions. J Arthroplasty. 2014; 29(6):1216-8. doi:10.1016/j.arth.2013.11.026
  29. Yao JJ, Hevesi M, O'Byrne MM, Berry DJ, Lewallen DG, Maradit Kremers H. Long-Term Mortality Trends After Revision Total Knee Arthroplasty. J Arthroplasty. 2019; 34(3):542-548. doi:10.1016/j.arth.2018.11.031
  30. Fryhofer GW, Sloan M, Sheth NP. Hypoalbuminemia remains an independent predictor of complications following total joint arthroplasty. J Orthop. 2019; 16(6):552-558. doi:10.1016/j.jor.2019.04.019
  31. Kamath AF, Nelson CL, Elkassabany N, Guo Z, Liu J. Low Albumin Is a Risk Factor for Complications after Revision Total Knee Arthroplasty. J Knee Surg. 2017; 30(3):269-275. doi:10.1055/s-0036-1584575
  32. Black CS, Goltz DE, Ryan SP, et al. The Role of Malnutrition in Ninety-Day Outcomes after Total Joint Arthroplasty. J Arthroplasty. 2019; 34(11):2594-2600. doi:10.1016/j.arth.2019.05.060
  33. Rudasill SE, Ng A, Kamath AF. Preoperative Serum Albumin Levels Predict Treatment Cost in Total Hip and Knee Arthroplasty. Clin Orthop Surg. 2018; 10(4):398-406. doi:10.4055/cios.2018.10.4.398
  34. Botella-Carretero JI, Iglesias B, Balsa JA, Arrieta F, Zamarrón I, Vázquez C. Perioperative oral nutritional supplements in normally or mildly undernourished geriatric patients submitted to surgery for hip fracture: A randomized clinical trial. Clin Nutr. 2010; 29(5):574-579. doi:10.1016/j.clnu.2010.01.012
  35. Golladay GJ, Satpathy J, Jiranek WA. Patient Optimization-Strategies That Work: Malnutrition. J Arthroplasty. 2016; 31(8):1631-4. doi:10.1016/j.arth.2016.03.027
  36. Rao SS, Chaudhry YP, Solano MA, Sterling RS, Oni JK, Khanuja HS. Routine Preoperative Nutritional Screening in All Primary Total Joint Arthroplasty Patients Has Little Utility. J Arthroplasty. 2020; 35(12):3505-3511. doi:10.1016/j.arth.2020.06.073
  37.  White JV, Guenter P, Jensen G, Malone A, Schofield M. Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition). J Acad Nutr Diet. 2012; 112(5):730-738. doi:10.1016/j.jand.2012.03.012

 

 

 

 

 

 

 

 

  1. Botella-Carretero JI, Iglesias B, Balsa JA, Arrieta F, Zamarrón I, Vázquez C. Perioperative oral nutritional supplements in normally or mildly undernourished geriatric patients submitted to surgery for hip fracture: A randomized clinical trial. Clin Nutr. 2010; 29(5):574-579. doi:10.1016/j.clnu.2010.01.012
  2. Golladay GJ, Satpathy J, Jiranek WA. Patient Optimization-Strategies That Work: Malnutrition. J Arthroplasty. 2016; 31(8):1631-4. doi:10.1016/j.arth.2016.03.027
  3. Rao SS, Chaudhry YP, Solano MA, Sterling RS, Oni JK, Khanuja HS. Routine Preoperative Nutritional Screening in All Primary Total Joint Arthroplasty Patients Has Little Utility. J Arthroplasty. 2020; 35(12):3505-3511. doi:10.1016/j.arth.2020.06.073
  4. White JV, Guenter P, Jensen G, Malone A, Schofield M. Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition). J Acad Nutr Diet. 2012; 112(5):730-738. doi:10.1016/j.jand.2012.03.012

 

The Archives of Bone and Joint Surgery
Volume 11, Issue 3
March 2023
Pages 173-179

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History

  • Receive Date: 29 April 2022
  • Revise Date: 13 September 2022
  • Accept Date: 15 September 2022
  • First Publish Date: 25 February 2023

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