Accepted Manuscript

Risk Factors for Repeat Debridement, Spacer Retention, Amputation, Arthrodesis,

and Mortality after Removal of an Infected Total Knee Arthroplasty with Spacer
Placement

Jourdan M. Cancienne, MD, Victor A. Granadillo, MD, Kishan J. Patel, DO, Brian C.
Werner, MD, James A. Browne, MD
PII: S0883-5403(17)30760-X
DOI: 10.1016/j.arth.2017.08.037
Reference: YARTH 56067

To appear in: The Journal of Arthroplasty

Received Date: 7 May 2017

Revised Date: 29 July 2017
Accepted Date: 26 August 2017

Please cite this article as: Cancienne JM, Granadillo VA, Patel KJ, Werner BC, Browne JA, Risk Factors
for Repeat Debridement, Spacer Retention, Amputation, Arthrodesis, and Mortality after Removal of
an Infected Total Knee Arthroplasty with Spacer Placement, The Journal of Arthroplasty (2017), doi:
10.1016/j.arth.2017.08.037.

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 ACCEPTED MANUSCRIPT

Risk Factors for Repeat Debridement, Spacer Retention, Amputation, Arthrodesis, and Mortality

after Removal of an Infected Total Knee Arthroplasty with Spacer Placement

Jourdan M. Cancienne, MD1

Victor A. Granadillo, MD1

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Kishan J. Patel, DO2

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Brian C. Werner, MD1

James A. Browne, MD1

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1
Department of Orthopaedic Surgery
University of Virginia Health System

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Charlottesville, VA, 22903
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USA
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Department of Orthopaedic Surgery
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Larkin Community Hospital

South Miami, FL 33143
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USA
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Please address all correspondence to:

James A. Browne, MD
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Department of Orthopaedic Surgery

University of Virginia Health System
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400 Ray C Hunt Dr. #300

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Charlottesville, VA, 22903

Phone: (434) 243-5432
Fax: (434) 243-0290
Jab8hd@virginia.edu
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1 Risk Factors for Repeat Debridement, Spacer Retention, Amputation, Fusion, and

2 Mortality after Removal of an Infected Total Knee Arthroplasty with Spacer Placement

3 Abstract

4 Introduction

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5 Chronic periprosthetic infection (PJI) following total knee arthroplasty (TKA) is most commonly

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6 addressed with a two-stage exchange procedure. The purpose of this study is to examine the

7 natural history of patients who have undergone prosthesis removal and spacer placement and

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8 evaluate risk factors for outcomes other than reimplantation.

9 Methods

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Patients who underwent removal of an infected TKA and placement of an antibiotic spacer for
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11 PJI were identified in a Medicare database. Patients with a study outcome within one year were

12 then identified: 1) in hospital mortality, 2) knee arthrodesis, 3) amputation, 4) repeat debridement

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13 procedure without reimplantation, and 4) reimplantation. Independent risk factors for these
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14 outcomes was evaluated with a multivariate logistic regression analysis.

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15 Results

16 18,533 patients were included. Within 1 year postoperatively, 691 patients (3.7%) died in a
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17 hospital setting, 852 patients (4.5%) underwent a knee arthrodesis, 574 patients (3.1%)

18 underwent an amputation, 2,683 patients (14.5%) underwent a repeat debridement procedure

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19 without being reimplanted, 2,323 patients (12.5%) retained their spacer, and 11,420 patients
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20 (61.6%) patients underwent spacer removal and reimplantation within 1 year. Numerous

21 independent patient related risk factors for these outcomes were identified.

22 Conclusion

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23 A large number of patients (38.4%) do not undergo reimplantation within one year of prosthesis

24 removal and spacer placement. Outcomes following prosthesis removal and antibiotic spacer

25 placement are variable, and there are several independent risk factors for such outcomes that may

26 be utilized to develop and improve existing treatment strategies for patients presenting with

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27 chronic PJI following TKA.

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28 Keywords: infection; staged revision; spacer; mortality; debridement; arthrodesis

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29 Introduction

30 Total knee arthroplasty (TKA) is one of the most common orthopaedic procedures

31 performed in the United States, and its use is expected to increase 673% by the year 2030 [1].

32 While uncommon, periprosthetic joint infection (PJI) remains one of the most devastating,

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33 costly, and challenging complications following primary TKA for patients and surgeons alike

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34 [2–4]. The increasing number of TKAs in the near future will be accompanied by a rising

35 prevalence of PJI and the requirement of revision surgery due to deep infection [5–7]. The

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36 current standard of care in the United States for the treatment of a TKA complicated by chronic

37 PJI is two stage exchange arthroplasty [8–15]. The first stage involves the removal of the

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primary implants with the placement of an antibiotic spacer followed by treatment with organism
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39 specific parenteral antibiotics [16]. After completion of six weeks of antibiotics the patient is

40 then typically evaluated for spacer removal and reimplantation [17].

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41 The overall success rate of two stage exchange arthroplasty for PJI is variable, and has
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42 been reported to range from 72% to 100% [8–14,18–20]. However, the majority of these studies
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43 only include patients who were successfully reimplanted, and exclude patients those in the inter

44 stage period who may have undergone additional procedures or died prior to reimplantation
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45 [3,21]. Recent literature has questioned the definition of successful periprosthetic joint infection

46 treatment, and suggested that the exclusion of patients who do not undergo reimplantation might
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47 overestimate the reported success of two stage exchange arthroplasty [22–24]. Moreover, these
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48 studies have highlighted this subset of patients in the inter stage period, and have suggested that

49 the current literature could be neglecting nearly 20% of staged revision treatment failures for PJI

50 [22]. This literature has provided sobering data on the high morbidity, mortality, and bacterial

51 resistance in the inter stage period [22,25–27]. Given the low incidence of PJI following TKA,

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52 alongside the relatively high rate of reimplantation following two stage exchange, studies

53 examining patients following implant removal and spacer placement are often retrospective,

54 institutional studies that combine total hip and knee patients, making it difficult to investigate

55 outcomes other than reimplantation [8–11,14,16,22]. Furthermore, these small cohorts prohibit

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56 any statistically meaningful analysis of how patient related comorbidities and demographics

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57 might contribute to outcomes other than eventual reimplantation in this period.

58 The purpose of the present study was to investigate the clinical course and natural history

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59 of patients who underwent explantation and antibiotic spacer placement for PJI following

60 primary TKA on a national level. In addition, we sought to further this analysis by evaluating

61
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independent patient-related risk factors for outcomes other than reimplantation in the inter stage
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62 period.

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64 Materials and Methods

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65 The PearlDiver Patient Records Database (www.pearldiverinc.com, Fort Wayne, IN,

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66 U.S.A) was used for the present study. The database includes a Medicare dataset with

67 procedural volumes and patient demographics for patients with International Classification of
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68 Diseases, 9th Revision (ICD-9), diagnoses and procedures or Current Procedural Terminology

69 (CPT) codes. The data consists of de-identified patient records, and is therefore exempt from
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70 Institutional Review Board approval. The data for the present study was derived from the
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71 Medicare database within PearlDiver, which contains over 100 million individual patients

72 records from 2005-2012. The Medicare data contained within the database is the complete 100%

73 Medicare Standard Analytical File, indexed and reorganized to allow for patient tracking over

74 time.

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75 The goal study population were patients who underwent removal of a total knee

76 prosthesis and placement of an antibiotic cement spacer for a diagnosis of infection. The

77 database was first queried for all patients who fit this criteria using the CPT code 27488 (removal

78 of a total knee prosthesis) with the ICD-9 procedure code 80.06 (arthrotomy for removal of

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79 prosthesis without replacement, knee) coupled with ICD-9 procedure code 84.56 (insertion of

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80 cement spacer) during the same procedure. Only patients who had an associated infection ICD-9

81 diagnostic code, including codes for periprosthetic infection, septic total knee arthroplasty, or

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82 postoperative infection, were included in the study cohort. Patients without a study endpoint

83 within one year postoperatively, without at least one year of follow-up in the database, and

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patient’s aged less than 65 years were excluded.
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85 Six major study endpoints were evaluated within one year postoperatively to create six

86 mutually exclusive groups: 1) in hospital mortality, 2) repeat debridement without

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87 reimplantation, 3) amputation, 4) knee arthrodesis, 5) retained spacer, and 6) reimplantation of

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88 TKA. Reimplantation was defined as a subsequent total knee arthroplasty following the
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89 prosthesis removal procedure. Patients who died following reimplantation at any time point

90 were included in the reimplantation group. A repeat debridement procedure was characterized by
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91 a removal and reinsertion of a cement spacer and irrigation and debridement for infection (ICD-9

92 procedure codes 80.06 and 84.56 in the same operation) at a later date following the index
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93 prosthesis removal procedure. Any patients who underwent a repeat debridement and were
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94 subsequently reimplanted within 1 year were placed in the reimplantation group. Amputations

95 were identified using the CPT code 27590. Knee arthrodesis was identified using CPT code

96 27580. All remaining patients who were not coded as dead during the minimum one-year of

97 follow-up were considered to have retained cement spacers.

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98 A logistic regression analysis was then performed to evaluate independent risk factors for

99 each of five study endpoints: 1) death within 1 year postoperatively, 2) repeat stage I arthroplasty

100 without reimplantation within 1 year postoperatively 3) no replantation (spacer retention) within

101 1 year postoperatively, 4) amputation, and 5) knee arthrodesis. The same risk factor variables

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102 were entered into the regression model for each endpoint of interest: gender, age, obesity (BMI

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103 30-40 kg/m2), morbid obesity (BMI > 40 kg/m2), tobacco use, alcohol abuse, inflammatory

104 arthritis, depression, hypercoagulable state, diabetes mellitus, hyperlipidemia, hypertension,

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105 peripheral vascular disease, congestive heart failure, coronary artery disease, chronic kidney

106 disease, need for hemodialysis, lung disease and liver disease. For all significant variables, odds

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ratios and 95% confidence intervals were calculated. For all regression analyses, P < 0.05 was
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108 considered statistically significant. SPSS version 23 for Macintosh (IBM, Armonk, New York)

109 was used for all statistical calculations.

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110
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111 Results
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112 In total, 24,486 patients were identified who underwent removal of a total knee prosthesis

113 and placement of an antibiotic cement spacer for a diagnosis of infection. Of these, 5,953
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114 patients did not meet inclusion criteria and were excluded from the study, leaving 18,533 patients

115 for analysis. Within 1 year postoperatively, 691 patients (3.7%) died in a hospital setting, 852
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116 patients (4.5%) underwent a knee arthrodesis, 574 patients (3.1%) underwent an amputation,
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117 2,683 patients (14.5%) underwent a repeat debridement procedure without being reimplanted,

118 2,323 patients (12.5%) retained their spacer, and 11,420 patients (61.6%) patients underwent

119 spacer removal and reimplantation within 1 year. [Figure 1].

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120 Significant independent risk factors for death within 1 year included age greater than 70

121 years, with a rising odds of death with increasing age groups (70-74: O.R. 1.48, p < 0.0001; 75-

122 79: O.R. 1.62, p < 0.0001; 80-84: O.R. 2.06, p < 0.0001, and greater than 85: O.R. 3.01, p <

123 0.0001 ), diabetes (O.R. 1.33, p < 0.0001), alcohol abuse (O.R. 1.42, p = 0.001), congestive heart

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124 failure (O.R. 2.31, p < 0.0001), chronic lung disease (O.R. 1.23, p < 0.0001), chronic liver

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125 disease (O.R. 1.26, p = 0.014) and hemodialysis (O.R. 3.39, p < 0.0001) [Table 1].

126 Independent risk factors for repeat debridement without reimplantation within 1 year

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127 included male gender (O.R. 1.18, p < 0.0001), age 70-74 years (O.R. 1.08, p = 0.022), obesity

128 (O.R. 1.26, p < 0.0001) and morbid obesity (O.R. 1.43, p < 0.0001), tobacco use (O.R. 1.10, p =

129
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0.003), inflammatory arthritis (O.R. 1.29, p < 0.0001), depression (O.R. 1.40, p < 0.0001),
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130 hypercoagulable disorder (O.R. 1.23, p < 0.0001), hypertension (O.R. 1.20, p = 0.024),

131 peripheral vascular disease (O.R. 1.22, p < 0.0001), hyperlipidemia (O.R. 1.17, p < 0.0001),
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132 chronic liver disease (O.R. 1.24, p < 0.0001), and chronic kidney disease (O.R. 1.19, p <
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133 0.0001) [Table 1].

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134 Independent risk factors for no re-implantation (retained spacer) at 1 year included

135 female gender (O.R. 1.26, p < 0.0001), age 80-84 years and greater than 85 years (O.R. 1.15, p <
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136 0.0001; O.R. 1.59, p < 0.0001), depression (O.R. 1.14, p < 0.0001), alcohol abuse (O.R. 1.15, p =

137 0.002), peripheral vascular disease (O.R. 1.12, p < 0.0001), chronic lung disease (O.R. 1.06, p =
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138 0.013), hemodialysis (O.R. 1.15, p < 0.0001), and congestive heart failure (O.R. 1.20, p <
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139 0.0001) [Table 1].

140 Independent risk factors amputation included male gender (O.R. 1.45, p < 0.0001),

141 morbid obesity (O.R. 1.48, p = 0.018), tobacco use (O.R. 1.61, p < 0.0001), depression (O.R.

142 1.97, p < 0.0001), hypercoagulable disorder (O.R. 1.26, p = 0.001), diabetes mellitus (O.R.

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143 1.19, p = 0.004), peripheral vascular disease (O.R. 2.67, p < 0.0001), congestive heart failure

144 (O.R. 1.35, p < 0.0001), chronic kidney disease (O.R. 1.19, p = 0.003), and chronic liver disease

145 (O.R. 1.40, p < 0.0001) [Table 1].

146 Finally, independent risk factors for knee arthrodesis included morbid obesity (O.R. 1.50,

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147 p < 0.0001), alcohol abuse (O.R. 1.29, p = 0.01), depression (O.R. 1.58, p < 0.0001), diabetes

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148 mellitus (O.R. 1.28, p < 0.0001), hypertension (O.R. 1.60, p = 0.015), peripheral vascular

149 disease (O.R. 1.14, p < 0.0001), congestive heart failure (O.R. 1.30, p < 0.0001), hemodialysis

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150 (O.R. 1.42, p < 0.0001), and chronic kidney disease (O.R. 1.25, p < 0.0001) [Table 1].

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152 Discussion
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153 Despite an abundance of literature on the treatment and outcomes of staged revision for

154 the infected TKA, few studies have reported on the natural history of the patient who undergoes
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155 prosthesis removal and spacer placement for TKA PJI. A few recent studies have demonstrated
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156 that prosthesis removal for PJI is associated with significant morbidity and mortality and that
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157 many patients may not ultimately proceed to prosthesis reimplantation [25,28,29]. This literature

158 has called into question the definition of success for staged revision, and suggested that the
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159 current literature may overestimate such success by excluding patients who do not get

160 reimplanted [22,23]. As management strategies evolve for PJI following TKA, optimum
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161 treatment strategies will seek to identify patient factors that will impact and predict the likelihood
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162 of success and failure of ultimate infection eradication while minimizing patient morbidity and

163 mortality. The present study provides a platform for such research by giving a national

164 perspective on outcomes at one year following explantation and antibiotic spacer placement for

165 the infected TKA. We report that less than 60% of patients treated with implant removal and

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166 antibiotic spacer placement undergo reimplantation within one year, 14% undergo a repeat

167 debridement procedure without reimplantation within one year, nearly 5% undergo knee fusion,

168 less than 4% undergo amputation, and 18% retain their spacer for at least one year. In addition,

169 there are several independent, patient related risk factors for these outcomes.

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170 A recent study by Gomez et al. highlighted the variability in outcomes that is largely

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171 under reported in the current literature describing two stage revision for PJI following TKA [22].

172 The group reviewed their institutional database of 326 TKA treated with resection arthroplasty

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173 and spacer insertion for the treatment of PJI with a mean follow up of 59 months and reported an

174 reimplantation rate of 81%, a repeat debridement and spacer placement rate of 12.3%, a spacer

175
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retention rate of 11.7%, an amputation rate of 1.8%, a fusion rate of 1.2%, and a one-year
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176 mortality rate of 6.1%. Despite studying a national population that is more than 50 fold larger,

177 the incidence of amputation, fusion, repeat debridement and spacer placement, and one-year
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178 mortality in the present study are quite similar. The large difference seen in reimplantation rates
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179 can likely be attributed to a follow up period of one year in the present study as compared to
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180 nearly five years in the study by Gomez et al. However, given that the average duration of

181 spacers placed was 4.1 months in the study by Gomez et al, we believe that limiting our follow
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182 up to one year accurately depicts generalizable outcomes of this procedure. Therefore, the

183 present study adds to a growing body of evidence suggesting that outcomes of the inter stage
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184 period are variable at one year.

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185 As demonstrated, failure to be reimplanted following the first stage of a staged revision

186 may be due to several reasons, however, the most catastrophic is patient mortality. Gomez et al.

187 provided sobering data on the mortality associated with this procedure that often goes under

188 reported [22–24]. The group reported a one-year mortality rate of 6.1% compared to 3.9% in the

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189 present study. Our percentage likely underestimates the true incidence of mortality given that

190 only patient deaths in a hospital setting are captured in the PearlDiver database. It is likely that a

191 significant number of patients who die within 1 year of prosthesis removal do so outside the

192 hospital, and thus would not be coded as a death nor included in this study. Furthermore, many

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193 of the these patients have advanced age and multiple comorbidities, and the baseline risk of one

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194 year mortality in this patient population is not insignificant, even in the absence of PJI. Thus,

195 while staged revision and the placement of antibiotic spacers is associated with mortality, they

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196 are not necessarily a causative risk factor for mortality as this is likely multifactorial. Never the

197 less, these data adds to existing evidence that suggests revision for PJI is associated with a

198
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morality rate 5 times that of aseptic revision [25,28]. While there is a plethora of literature
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199 detailing the challenges of managing PJI following TKA and the associated loss of function these

200 patients experience, it is critical that patients and surgeons understand the treatment of this
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201 complication carries with it a substantial risk of mortality [9,19]. While failure to be reimplanted
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202 is often considered a failure of infection eradication, in certain low-demand patients, a well
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203 placed articulating spacer can serve as definitive management and may in fact be the desired

204 outcome [30]. Thus, while it is impossible to distinguish which patients this might be in the
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205 present study due to database limitations, there may be a subset of patients who were not

206 reimplanted within 1 year by choice rather than a failure of treatment.

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207 The current primary TKA literature contains an abundance of literature detailing patient-
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208 specific risk factors for PJI and their use for preoperative risk stratification [31]. Similar

209 analyses have yet to be conducted for patients who undergo staged revision for PJI and their risks

210 for outcomes other than reimplantation. This is largely due to overall infrequency of this

211 complication resulting in limited patient numbers even in the largest of institutional reviews

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212 [22,32]. In the present study we evaluated numerous demographics and comorbidities as

213 independent risk factors for the various outcomes studied following staged revision. Advanced

214 age has been cited as a risk factor for several complications including mortality in the primary

215 TKA literature [33]. In the present study, increasing age was strongly associated with both death

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216 within 1 year and retained spacer within 1 year. While a significant risk factor, the increased

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217 mortality and less likely chance of reimplantation may be more reflective of an overall decreased

218 life expectancy in this geriatric population. Nonetheless, older individuals should be counseled

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219 on the increased risk of mortality and higher likelihood of spacer retention for more than 1 year

220 post operatively. The presence of diabetes was a risk factor for all non reimplantation outcomes

221
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evaluated in the present study. Diabetes has been well established as a risk factor for numerous
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222 complications following primary TKA, including infection and mortality [34,35]. The present

223 study expands on this research and suggests that diabetics are at increased risk of death and a
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224 retained spacer within 1 year, in addition to above knee amputation, knee arthrodesis, and
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225 recurrent spacer infection requiring a subsequent procedure. Thus, diabetics presenting with an
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226 infected TKA should be counseled of an overall increased risk of successful reimplantation.

227 Similarly, peripheral vascular disease was a risk factor for several of the outcomes studied.
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228 Peripheral vascular disease has been shown to be a risk factor for delayed wound healing,

229 infection, and amputation following primary TKA [36]. Thus, we hypothesize that similar
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230 pathophysiology would place these patients at higher risk for persistent infection resulting in
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231 repeat debridements, retained spacers, above knee amputation, and ultimate knee fusion as

232 described in the present study. Patients with chronic kidney disease and those on dialysis

233 undergoing TKA are at increased risk of perioperative mortality, surgical site infection, wound

234 complications, and PJI [37]. The present study is the first to evaluate the impact of these disease

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235 states on outcomes following staged TKA revision for PJI. Similar to the primary TKA

236 literature, chronic kidney disease and hemodialysis are significant risk factors for poor outcomes

237 following implant removal and spacer placement. These patients should be counseled regarding

238 the exceedingly high mortality and morbidity of staged revision in addition to an increased

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239 likelihood of not being reimplanted when considering long term suppression compared to

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240 revision surgery. Other chronic disease states, such as lung, liver, and heart diseases, also

241 established in the primary literature as risk factors for poor outcomes, were statistically

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242 significant risk factors for the outcomes studied [38,39]. While no protective comorbidities or

243 demographics were identified in our analysis, the aforementioned variables identified placing

244
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patients at increased risk for negative outcomes and failed staged revision procedures should be
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245 used in risk stratification algorithms and the shared decision process between the surgeon and

246 patient when deciding to undergo staged revision and the possible outcomes.
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247 This data is of high clinical significance as the overall prevalence of PJI and staged
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248 revision is expected to drastically increase in the coming years, resulting in more surgeons and
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249 patients relying on evidenced based treatment algorithms to predict the likelihood of success and

250 guide surgical decision making [5–7]. Not dissimilar to a patient presenting for primary TKA,
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251 the risk factors detailed in the present study will help to balance both patient and surgeon

252 expectations for patients presenting with chronic PJI of a TKA. If a patient’s comorbidity profile
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253 and risk factors gives them little chance for a successful reimplantation, alternative surgical and
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254 non operative treatment strategies might be used [40]. While we recognize that this data must be

255 accepted within the context of the limitations of the study design, it should serve as a platform

256 for future multicenter, prospective studies evaluating the complex interplay or surgical and

257 patient factors that contribute to the outcomes examined in the present study.

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258 There are several limitations to this study, the majority of which are inherent to all studies

259 utilizing large databases [41,42]. The significance and impact of our conclusions is dependent

260 on the accuracy and quality of the data within the database, and miscoding and non-coding

261 represent potential sources for error. We acknowledge that there are several non-obtainable

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262 variables within the database that have been shown to impact the success of staged revision. The

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263 most significant of which is the infecting organism, which has been shown to substantially

264 influence additional procedures and outcomes other than successful reimplantation [22,43,44].

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265 However, by analyzing more than 17,000 cases of PJI following TKA, we expect to sample a

266 normal distribution of infecting organisms that is similar to smaller, institutional studies and

267
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representative of current PJI trends. As previously mentioned, our mortality rate likely
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268 underestimates the true incidence of death attributable to staged revision given that only patients

269 with an in hospital death were included in our analysis. In an effort to create a homogenous
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270 cohort and limit sampling bias, we limited follow up of the studied outcomes to one year. While
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271 patients who underwent reimplantation or additional procedures after a year would not be
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272 captured, average spacer duration in prior studies is substantially less than one year, and thus we

273 feel this cutoff is appropriate [22]. Finally, we are unable to evaluate and compare the functional
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274 outcomes associated with our studied endpoints. While it is beyond the scope of our study, other

275 studies have shown that certain patients might obtain a level of functional satisfaction with their
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276 spacer that they choose not to undergo reimplantation [40]. Thus, a retained spacer may not
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277 always be classified as a failure of treatment or a complication.

278 Recent literature has questioned the definition of successful periprosthetic joint infection

279 treatment, and suggested that the exclusion of patients who do not undergo reimplantation might

280 overestimate the reported success of two stage exchange arthroplasty [22–24]. The present

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281 study provides a population based perspective on the interstage outcomes a large subset of

282 medicare patients, and provides sobering data on the fate of these patients. To improve

283 outcomes, treatment strategies need to identify patient factors that will impact and predict the

284 likelihood of success and failure of ultimate infection eradication while minimizing patient

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285 morbidity and mortality. The present study provides a platform for such research by several

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286 independent, patient related risk factors for outcomes other than reimplantation at one year.

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363 Periprosthetic Infection Recurrence After 2-Stage Exchange Arthroplasty: Failure or Fate?

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Table 1. Summary of significant MANUSCRIPT
risk factors for study endpoints within 1 year postoperatively
Death within 1 year
Risk Factor Odds Ratio 95% CI P
Age 70 - 74 yrs 1.48 [1.25 - 1.74] < 0.0001
Age 75 - 79 yrs 1.62 [1.37 - 1.92] < 0.0001
Age 80 - 84 yrs 2.06 [1.73 - 2.46] < 0.0001
Age ≥ 85 yrs 3.01 [2.48 - 3.66] < 0.0001
Diabetes Mellitus 1.33 [1.19 - 1.49] < 0.0001
Alcohol abuse 1.42 [1.15 - 1.77] 0.001
Congestive Heart Failure 2.31 [2.04 - 2.62] < 0.0001
Chronic lung disease 1.23 [1.10 - 1.38] < 0.0001
Chronic Liver Disease 1.26 [1.05 - 1.51] 0.014

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Hemodialysis 3.39 [2.91 - 3.95] < 0.0001
No Replant
Risk Factor Odds Ratio 95% CI P
Female gender 1.26 [1.21 - 1.31] < 0.0001

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Age 80 - 84 yrs 1.15 [1.07 - 1.23] < 0.0001
Age ≥ 85 yrs 1.59 [1.45 - 1.73] < 0.0001
Depression 1.14 [1.09 - 1.19] < 0.0001

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Diabetes Mellitus 1.09 [1.04 - 1.14] < 0.0001
Peripheral Vascular Disease 1.12 [1.06 - 1.17] < 0.0001
Congestive Heart Failure 1.20 [1.14 - 1.25] < 0.0001
Chronic Lung Disease 1.06 [1.01 - 1.11] 0.013

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Hemodialysis 1.15 [1.07 - 1.24] < 0.0001
Repeat Stage I TKA
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Risk Factor Odds Ratio 95% CI P
Male gender 1.18 [1.13 - 1.25] < 0.0001
Age 70 - 74 yrs 1.08 [1.01 - 1.15] 0.022
BMI 30 - 40 1.26 [1.19 - 1.34] < 0.0001
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BMI 40 + 1.43 [1.34 - 1.52] < 0.0001

Inflammatory Arthritis 1.29 [1.21 - 1.37] < 0.0001
Depression 1.40 [1.34 - 1.48] < 0.0001
Hypercoagulable disorder 1.23 [1.15 - 1.32] < 0.0001
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Hyperlipidemia 1.17 [1.08 - 1.25] < 0.0001

Hypertension 1.20 [1.02 - 1.41] 0.024
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Peripheral Vascular Disease 1.22 [1.16 - 1.29] < 0.0001

Chronic Kidney Disease 1.19 [1.13 - 1.26] < 0.0001
Chronic Liver Disease 1.24 [1.14 - .135] < 0.0001
Above Knee Amputation
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Risk Factor Odds Ratio 95% CI P

Male gender 1.45 [1.30 - 1.62] < 0.0001
BMI 40+ 1.17 [1.03 - 1.33] 0.018
Tobacco Use 1.61 [1.42 - 1.83] < 0.0001
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Depression 1.97 [1.77 - 2.20] < 0.0001

Hypercoagulable disorder 1.26 [1.10 - 1.43] 0.001
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Diabetes Mellitus 1.19 [1.06 - 1.34] 0.004

Peripheral Vascular Disease 2.67 [2.39 - 2.97] < 0.0001
Congestive Heart Failure 1.35 [1.19 - 1.53] < 0.0001
Chronic Kidney Disease 1.19 [1.06 - 1.34] 0.003
Chronic Liver Disease 1.40 [1.20 - 1.63] < 0.0001
Fusion
Risk Factor Odds Ratio 95% CI P
BMI 40 + 1.50 [1.35 - 1.68] < 0.0001
Alcohol abuse 1.29 [1.06 - 1.56] 0.01
Depression 1.58 [1.44 - 1.74] < 0.0001
Diabetes Mellitus 1.28 [1.16 - 1.42] < 0.0001
Hypertension 1.60 [1.10 - 2.35] 0.015
Peripheral Vascular Disease 1.14 [1.03 - 1.26] 0.013
Congestive Heart Failure 1.30 [1.17 - 1.45] < 0.0001
Chronic Kidney Disease 1.25 [1.13 - 1.39] < 0.0001
Hemodialysis 1.42 [1.24 - 1.63] < 0.0001
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Figure Legends:
Figure 1. Flow chart depicting the fate of patients who underwent knee arthroplasty prosthesis
removal and cement spacer placement for infection

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