Articles | Volume 11, issue 6
https://doi.org/10.5194/jbji-11-705-2026
https://doi.org/10.5194/jbji-11-705-2026
Original full-length article
 | 
11 Nov 2026
Original full-length article |  | 11 Nov 2026

A pre-specified surgical-complexity index is associated with a graded increase in periprosthetic joint infection after total knee arthroplasty: a competing-risks analysis using coronal alignment as a negative control

Wayne Hoskins, Charles Gusho, Kenrick Rosser, Matthew Lim, Kate Dunstall, and Kelly G. Vince

Cited articles

Anneberg, M., Troelsen, A., Gundtoft, P., Sørensen, H. T., and Pedersen, A. B.: Temporal trends in revision rate due to knee periprosthetic joint infection: a study of 115,120 cases from the Danish Knee Arthroplasty Register, Acta Orthop., 94, 616–624, https://doi.org/10.2340/17453674.2023.33294, 2023. 
Anneberg, M., Kristiansen, E. B., Troelsen, A., Gundtoft, P., Sørensen, H. T., and Pedersen, A. B.: Enhancing the data capture of periprosthetic joint infections in the Danish Knee Arthroplasty Registry: validity assessment and incidence estimation, Acta Orthop., 95, 166–173, https://doi.org/10.2340/17453674.2024.40358, 2024. 
Bagheri, A., Sharifi Niknafs, A., Farhadi, B., Mazhari, S. A., Karimian, P., Hekmati Pour, N., Hojjati, H., Nosratabadi, I., Emami, A., and Salehi, R.: Incidence and risk factors of surgical site infection after knee arthroplasty; a systematic review and meta-analysis, Arch. Acad. Emerg. Med., 13, e28, https://doi.org/10.22037/aaemj.v13i1.2543, 2025. 
Berbari, E. F., Osmon, D. R., Lahr, B., Eckel-Passow, J. E., Tsaras, G., Hanssen, A. D., Mabry, T., Steckelberg, J., and Thompson, R.: The Mayo prosthetic joint infection risk score: implication for surgical site infection reporting and risk stratification, Infect. Control Hosp. Epidemiol., 33, 774–781, https://doi.org/10.1086/666641, 2012. 
Chong, Y. Y., Lau, C. M. L., Jiang, T., Wen, C., Zhang, J., Cheung, A., Luk, M. H., Leung, K. C. T., Cheung, M. H., Fu, H., Chiu, K. Y., and Chan, P. K.: Predicting periprosthetic joint infection in primary total knee arthroplasty: a machine learning model integrating preoperative and perioperative risk factors, BMC Musculoskelet. Disord., 26, 241, https://doi.org/10.1186/s12891-025-08296-6, 2025. 
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Short summary

Infection after knee replacement is usually blamed on the patient. We asked whether the operation itself matters. In 2920 knee replacements from one New Zealand hospital, each added feature of a complex operation, such as a previous implant, a bone deformity or a larger, stemmed implant, raised the risk of later infection by about 60 %. Leg alignment, which affects wear and loosening, did not change infection risk. Surgeons should weigh how complex the operation will be when judging this risk.

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