Gut-Joint Axis: History of Clostridium Difficile Infection Increases the Risk of Periprosthetic Joint Infection After Total Knee Arthroplasty.

Abstract

Introduction: Increasing evidence suggests that the gut microbiome is important in immune system function and influences the risk of periprosthetic joint infection (PJI) after total knee arthroplasty (TKA). A C. difficile infection (CDI) is an indicator of poor gut microbiome health. However, no prior studies have evaluated the independent risk of CDI on the rates of PJI after TKA.

Methods: Patients undergoing TKA from 2010 to 2021 were identified in a patient claims database (n = 1,416,362). Patients who had a history of CDI within two years prior to TKA (n = 5,170) were propensity-matched on a 1:4 basis to those who did not have a diagnosis of CDI. The exposed CDI cohort was also stratified into four groups by time of CDI before TKA (zero to three months, three to six months, six to 12 months, and one to two years). The risk of PJI within two years following TKA was compared between the exposed and control cohorts. Logistic regression was used to evaluate the association of CDI occurring in each time interval prior to TKA and PJI after TKA.

Results: A CDI within two years prior to TKA was independently associated with higher odds of PJI (OR [odds ratio], 2.1; 95% CI [confidence interval], 1.91 to 2.36). In addition, we observed a stepwise increase in the risk of PJI by the timing of preoperative CDI infection, with patients who had a diagnosis of CDI within three months of their primary TKA exhibiting the highest odds of developing PJI (OR, 4.19; 95% CI, 3.51 to 5.02). Additionally, patients who had a diagnosis of CDI within two years of undergoing primary TKA were significantly more likely to experience a subsequent episode of CDI at the latest follow-up (OR, 25.9; 95% CI, 22.3 to 30.1).

Conclusion: A CDI prior to TKA is an independent risk factor for PJI. Closer proximity of CDI to surgery is associated with a "dose-dependent" increased PJI risk. Surgeons should consider delaying TKA until a minimum of one year after a diagnosis of CDI.