JBJI Journal of Bone and Joint Infection JBJI J. Bone Joint Infect. 2206-3552 Ivyspring Göttingen, Germany 10.7150/jbji.30636 Association between Allogeneic Blood Transfusion and Wound Infection after Total Hip or Knee Arthroplasty: A Retrospective Case-Control Study Taneja Ashish 1 El-Bakoury Ahmed 1 2 Khong Hoa 3 Railton Pam 4 Sharma Rajrishi 1 5 Johnston Kelly Dean 1 Puloski Shannon 1 Smith Christopher 3 Powell James 1 Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada University of Alexandria, Egypt Alberta Bone and Joint Health Institute, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada Alberta Health Services, Calgary, Alberta, Canada McCaig Institute for Bone and Joint Health 20 04 2019 4 2 99 105 Copyright: © 2019 Ashish Taneja et al. 2019 This work is licensed under the Creative Commons Attribution 4.0 International License. To view a copy of this licence, visit https://creativecommons.org/licenses/by/4.0/ This article is available from https://jbji.copernicus.org/articles/4/99/2019/jbji-4-99-2019.html The full text article is available as a PDF file from https://jbji.copernicus.org/articles/4/99/2019/jbji-4-99-2019.pdf

<p class="p p-first" id="__p2"><strong>Background:</strong> To assess using a retrospective case control study, whether patients undergoing primary, elective total hip or knee arthroplasty who receive blood transfusion have a higher rate of post-operative infection compared to those who do not.</p><p id="__p3"><strong>Materials and Methods:</strong> Data on elective primary total hip or knee arthroplasty patients, including patient characteristics, co-morbidities, type and duration of surgery, blood transfusion, deep and superficial infection was extracted from the Alberta Bone and Joint Health Institute (ABJHI). Logistic regression analysis was used to compare deep infection and superficial infection in blood-transfused and non-transfused cohorts.</p><p id="__p4"><strong>Results:</strong> Of the 27892 patients identified, 3098 (11.1%) received blood transfusion (TKA 9.7%; THA 13.1%). Overall, the rate of superficial infection (SI) was 0.5% and deep infection (DI) was 1.1%. The infection rates in the transfused cohort were SI 1.0% and DI 1.6%, and in the non-transfused cohort were SI 0.5% and DI 1.0%. The transfused cohort had an increased risk of superficial infection (adjusted odds ratio (OR) 1.9 [95% CI 1.2-2.9, p-value 0.005]) as well as deep infection (adjusted OR 1.6 [95% CI 1.1-2.2, p-value 0.008]).</p><p class="p p-last" id="__p5"><strong>Conclusion:</strong> The odds of superficial and deep wound infection are significantly increased in primary, elective total hip and knee arthroplasty patients who receive blood transfusion compared to those who did not. This study can potentially help in reducing periprosthetic hip or knee infections.</p>

 References Kapadia BH, Banerjee S, Cherian JJ, Bozic KJ, Mont MA. The Economic Impact of Periprosthetic Infections After Total Hip Arthroplasty at a Specialized Tertiary-Care Center. J Arthroplasty. 2016;31(7):1422–1426. doi:10.1016/ j.arth.2016.01.021. Haddad FS, Ngu A, Negus JJ. Prosthetic Joint Infections and Cost Analysis? In: Springer, Cham; 2017. pp. 93–100. doi:10.1007/5584_2016_155. Matsen Ko L, Parvizi J. Diagnosis of periprosthetic infection: novel developments. Orthop Clin N Am. 2016;47:1–9. doi:10.1055/s-0034-1371768. Tissingh EK, Sudlow A, Jones A, Nolan JF. Orthopaedic surgical site infection surveillance in NHS England. Bone Joint J; 2017. p. 99. -B(2):171-174. doi:10.1302/0301-620X.99B2.BJJ-2016-0420.R1. Prasad N, Padmanabhan V, Mullaji A. Blood loss in total knee arthroplasty: An analysis of risk factors. Int Orthop. 2007;31(1):39–44. doi:10.1007/ s00264-006-0096-9. [PMC free article] Youssef LA, Spitalnik SL. Transfusion-related immunomodulation. Curr Opin Hematol. 2017;24(6):551–557. doi:10.1097/MOH.0000000000000376. [PMC free article] Kirkley S a, Cowles J, Pellegrini VD, Harris CM, Boyd a D, Blumberg N. Blood transfusion and total joint replacement surgery: T helper 2 (TH2) cytokine secretion and clinical outcome. Transfus Med. 1998;8(3):195–204. Friedman R, Homering M, Holberg G, Berkowitz SD. Allogeneic blood transfusions and postoperative infections after total hip or knee arthroplasty. J Bone Jt Surg - Am Vol. 2014;96(4):272–278. doi:10.2106/JBJS.L.01268. Helm AT, Karski MT, Parsons SJ, Sampath JS, Bale RS. A strategy for reducing blood-transfusion requirements in elective orthopaedic surgery. Audit of an algorithm for arthroplasty of the lower limb. J Bone Jt Surg. 2003;85(4):484–489. doi:10.1302/0301-620X.85B4.13615. Newman ET, Watters TS, Lewis JS. et al. Impact of perioperative allogeneic and autologous blood transfusion on acute wound infection following total knee and total hip arthroplasty. J Bone Jt Surg Am. 2014;96(4):279–284. doi:10.2106/JBJS.L.01041. Maempel JF, Wickramasinghe NR, Clement ND, Brenkel IJ, Walmsley PJ. The pre-operative levels of haemoglobin in the blood can be used to predict the risk of allogenic blood transfusion after total knee arthroplasty. Bone Jt J. 2016;98B(4):490–497. doi:10.1302/0301-620X.98B4.36245. Padegimas EM, Clyde CT, Zmistowski BM, Restrepo C, Williams GR, Namdari S. Risk factors for blood transfusion after shoulder arthroplasty. Bone Joint J; 2016. p. 98. -B(2):224-228. doi:10.1302/0301-620X.98B2.36068. Pedersen AB, Mehnert F, Overgaard S, Johnsen SP. Allogeneic blood transfusion and prognosis following total hip replacement: a population-based follow up study. BMCMusculoskeletDisord. 2009;10:167. doi:10.1186/1471-2474-10-167. [PMC free article] Bierbaum BE, Callaghan JJ, Galante JO, Rubash HE, Tooms RE, Welch RB. An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint Surg Am. 1999;81(1):2–10. http://www.ncbi.nlm. nih.gov/pubmed/9973048. Weber EW, Slappendel R, Prins MH, Van Der Schaaf DB, Durieux ME, Strümper D. Perioperative blood transfusions and delayed wound healing after hip replacement surgery: Effects on duration of hospitalization. Anesth Analg. 2005;100(5):1416–1421. doi:10.1213/01.ANE.0000150610.44631.9D. Rosencher N, Publique A, Marc C, Ostheo Investigation. 2013;(February) Innerhofer P, Klingler A, Klimmer C, Fries D, Nussbaumer W. Risk for postoperative infection after transfusion of white blood cell-filtered allogeneic or autologous blood components in orthopedic patients undergoing primary arthroplasty. Transfusion. 2005;45(1):103–110. doi:10.1111/j.1537-2995.2005. 04149.x. Kim JL, Park J-H, Han S-B, Cho IY, Jang K-M. Allogeneic Blood Transfusion Is a Significant Risk Factor for Surgical-Site Infection Following Total Hip and Knee Arthroplasty: A Meta-Analysis. J Arthroplasty. 2017;32(1):320–325. doi:10.1016/j.arth.2016.08.026. Hart A, Khalil JA, Carli A, Huk O, Zukor D, Antoniou J. Blood Transfusion in Primary Total Hip and Knee Arthroplasty. Incidence, Risk Factors, and Thirty-Day Complication Rates. J Bone Jt Surg. 2014;96(23):1945–1951. doi:10.2106/JBJS.N.00077. Rusk A, Bush K, Brandt M. et al. Improving Surveillance for Surgical Site Infections Following Total Hip and Knee Arthroplasty Using Diagnosis and Procedure Codes in a Provincial Surveillance Network. Infect Control Hosp Epidemiol. 2016;37(6):699–703. doi:10.1017/ice.2016.53. Marshall DA, Christiansen T, Smith C. et al. Continuous quality improvement program for hip and knee replacement. Am J Med Qual. 2015;30(5):425–431. doi:10.1177/1062860614540512. Cy Frank Doug Smith, Tracy Wasylak, Kathy Gooch, Ron Zernicke DD. The Alberta Bone and Joint Health Institute: Creating Sustainable Accountability through Collaboration, Relevant Measurement and Timely Feedback. Healthc Pap. 2006;7(1):34–39. http://www.longwoods.com/ product/18314. Richards J, Brown A, Homan C. The data quality study of the Canadian discharge abstract database. Proc Stat Canada …; 2001. pp. 1–10. http://www. icis.ca/cihiweb/en/downloads/quality_dadconfpaper_e.pdf%5Cnfile:///Users/fady/Dropbox/Papers 3/Library.papers3/Proceedings of Statistics Canada …/2001/RICHARDS/2001 RICHARDS.pdf%5Cnpapers3:// publication/uuid/FCAC8640-C0B9-4CEB-9FBC-6764E3A7. [Google Scholar] Canadian Institute for Health Information. National Ambulatory Care Reporting System Metadata (NACRS). https://www.cihi.ca/en/national- ambulatory-care-reporting-system-metadata. Published 2018. Accessed January 7; 2019. [Google Scholar] Berlinguet M, Preyra C, Dean S. Comparing the Value of Three Main Diagnostic-Based Risk-Adjustment Systems ( DBRAS ) Can Heal Serv Res Found. 2005;(March):7.. www.chrsf.ca) [Google Scholar] Centers for Disease Control and Prevention website. Surgical site infection (SSI) event. http://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent. pdf. Published 2015. Accessed January 7; 2019. [Google Scholar] Hanley AJ, McNeil JB. The Meaning and Use of the Area under a Receiver Operating Characteristic (ROC) Curve. Radiology. 1982;143:29–36. doi:10.1148/ radiology.143.1.7063747. Miller ME, Hui SL, Tierney WM. Validation techniques for logistic regression models. Stat Med. 1991;10(8):1213–1226. doi:10.1002/sim.4780100805. Zweig MH, Campbell G. Receiver-operating characteristic (ROC) plots: A fundamental evaluation tool in clinical medicine. Clin Chem. 1993;39(4):561–577. doi:ROC; Receiver-Operating Characteristic; SDT; Signal Detection Theory. Frisch NB, Wessell NM, Charters MA, Yu S, Jeffries JJ, Silverton CD. Predictors and complications of blood transfusion in total hip and knee arthroplasty. J Arthroplasty. 2014;29(9 SUPPL.):189–192. doi:10.1016/j.arth.2014.03.048. Yuan ZF, Yin H, Ma WP, Xing DL. The combined effect of administration of intravenous and topical tranexamic acid on blood loss and transfusion rate in total knee arthroplasty: Combined tranexamic acid for TKA. Bone Jt Res. 2016;5(8):353–361. doi:10.1302/2046-3758.58.BJR-2016-0001.R2. [PMC free article] Almustafa MA, Ewen AM, Deakin AH, Picard F, Clarke JV, Mahmood FF. Risk Factors for Surgical Site Infection Following Lower Limb Arthroplasty: A Retrospective Cohort Analysis of 3932 Lower Limb Arthroplasty Procedures in a High Volume Arthroplasty Unit. The Journal of arthroplasty. 2018;33(6):1861–7. Newman ET, Watters TS, Lewis JS, Jennings JM, Wellman SS, Attarian DE. et al. Impact of perioperative allogeneic and autologous blood transfusion on acute wound infection following total knee and total hip arthroplasty. The Journal of bone and joint surgery American volume. 2014;96(4):279–84. Friedman R, Homering M, Holberg G, Berkowitz SD. Allogeneic blood transfusions and postoperative infections after total hip or knee arthroplasty. The Journal of bone and joint surgery American volume. 2014;96(4):272–8. Everhart JS, Sojka JH, Mayerson JL, Glassman AH, Scharschmidt TJ. Perioperative Allogeneic Red Blood-Cell Transfusion Associated with Surgical Site Infection After Total Hip and Knee Arthroplasty. The Journal of bone and joint surgery American volume. 2018;100(4):288–94. Kim JL, Park JH, Han SB, Cho IY, Jang KM. Allogeneic Blood Transfusion Is a Significant Risk Factor for Surgical-Site Infection Following Total Hip and Knee Arthroplasty: A Meta-Analysis. The Journal of arthroplasty. 2017;32(1):320–5. Vallion R, Bonnefoy F, Daoui A. et al. Transforming growth factor-B released by apoptotic white blood cells during red blood cell storage promotes transfusion-induced alloimmunomodulation. Transfusion. 2015;55(7):1721–1735. doi:10.1111/trf.13031. Hebert PC, Yetisir E, Martin C. et al. Is a low transfusion threshold safe in critically ill patient with cardiovascular diseases? Crit Care Med. 2001;29(2):227–234. doi:10.1097/00003246-200109001-00007. Hebert P, Wells G, Blajchman M, A Multicenter, Randomized, Controlled Clinical Trial of Transfusion Requirements in Critical Care. 1999;340(6):409-417. doi:10.1056/NEJM199904013401322. [PubMed] Feagan BG, Wong CJ, Kirkley A. et al. Erythropoietin with iron supplementation to prevent allogeneic blood transfusion in total hip joint arthroplasty. A randomized, controlled trial. Ann Intern Med. 2000;133(11):845–854. http://www.ncbi.nlm.nih.gov/pubmed/11103054. Accessed September 29, 2017. Feagan BG, Wong CJ, Kirkley A. et al. Erythropoietin with Iron Supplementation To Prevent Allogeneic Blood Transfusion in Total Hip Joint Arthroplasty. Ann Intern Med. 2000;133(24):845–854.