Prevalence and potential influencing factors of non-superficial surgical site infection in patients with total hip arthroplasty: A systematic review and meta-analysis

doi:10.21203/rs.3.rs-1593410/v1

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Prevalence and potential influencing factors of non-superficial surgical site infection in patients with total hip arthroplasty: A systematic review and meta-analysis

https://doi.org/10.21203/rs.3.rs-1593410/v1

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Objective To assess the prevalence of non-superficial surgical site infection (NSSSI) in patients with total hip arthroplasty (THA) and the influencing factors.

Method The PubMed, the Cochrane Library, EMBASE, China National Knowledge Infrastructure (CNKI), Weipu database and Wanfang database were systematically searched from 2016 to 2021. The data were collected from the included studies that met the inclusion criteria. For exploring the prevalence of NSSSI with THA, the pooled prevalence and its 95% confidence intervals (CI) were calculated. Publication bias was assessed. In the study of the association between potential influencing factors and infection, the odds ratio and its 95% CI were calculated.

Results In all, 57 studies involving 2075304 patients were included. The number of patients receiving THA ranged from 87 to 623253, and the prevalence of patients with NSSSI after THA ranged from 0.05% to 9.13%. The meta-analysis results showed that the prevalence of patients with NSSSI after THA was 1.0% (95% CI: 0.8%, 1.1%). No publication bias was found under Begg’s test (z=0.28, p>0.05) or Egger's test (t=1.65, p>0.05). When stratified by data scale, pooled prevalence of studies with large-scale data and that of studies with normal-scale data were similar (large-scale: 0.9% (95%CI: 0.6%-1.3%); normal-scale: 1.1% (95%CI: 0.9%-1.2%), respectively). When stratified by country, the prevalence of different countries was of various. Individual results showed that the prevalence of Netherlands was the highest (9.5%) and that of New Zealand was the lowest (0.1%). Pooled results showed that China had the highest prevalence of 2.2% (95%CI: 1.8%-2.7%), and UK had the lowest prevalence of 0.3% (95%CI: 0.0%-0.6%). Ten influencing factors of NSSSI in patients with THA were recognized (p<0.05), including male, tobacco smoker, body mass index, diabetes mellitus, American Society of Anesthesiologists grade III or IV or V, serum albumin <3.5 g/dL, immunosuppressive agent user, universal anesthesia, non-vancomycin powder user, and duration of drain >48h.

Conclusion The pooled prevalence of NSSSI in patients after THA was 1.0% and 10 potential factors were associated with the prevalence. We provide clinical guidance to prevent NSSSI after THA.

Total hip arthroplasty

Non-superficial surgical site infection

Prevalence

Influencing factors

Systematic review

As one of the most commonly orthopedics, total hip arthroplasty (THA) is estimated to increase in future, owing to the aging of the boomers, higher rates of diagnosis and treatment for advanced arthritis, or growing demand for improved mobility and quality of life.^[1] After THA, bacteria may form bacterial biofilms after colonization on the prosthesis. These biofilms are formed by causative pathogens surrounded by extracellular matrix and relatively dormant cells, resulting in a barrier against the host immune system and antibiotics. They not only contribute to the pathogenesis of infection but also result in diagnostic challenges, antibiotic resistance, and infection treatment failure. ^[2–4]

Surgical site infection (SSI) can be divided into superficial SSI (SSSI, involving skin incision site) and non-superficial SSI (NSSSI). The NSSSI involves deep incision sites including fascia and /or muscular layers, or involves other organs/spaces sere opened or manipulated during operation procedure. Compared with SSSI, NSSSI brings more pain and burden on patients with THA.^[5]

According to a previous literature, the prevalence of NSSSI after THA ranged from 0.69–9%, ^[6] which was quite heterogenous due to different statuses of patients.^[7] Surgeons need to adjust every patient to an ideal state when preparing for surgery operation^[8] Some preoperative indicators were shown to have impacts on the prevalence, but the results were not definitely conclusive as other studies presented contradictive conclusion.^[9–12] And during perioperative period and intraoperative operation, every action and instruction of doctors and even surrounding environment may have important impact on the prevalence of SSI after surgery.^[13–18]

The current study firstly assessed the prevalence of NSSSI in patients with THA and identified potential influencing factors by systematic review and meta-analysis. We expect to provide clinical guidance to prevent NSSSI after THA.

Search strategy

The PubMed, Cochrane Library, EMBASE, CNKI (China National Knowledge Infrastructure), Wanfang database and Weipu database were systematically searched, from January 2016 to April 2021. The search terms were93. The manual searches were performed through checking the reference lists of key studies and review articles, to identify additional studies.

Study selection

The overall literature searches were performed and potential studies were screened independently by two reviewers. Initially, all the related titles and abstracts were reviewed and irrelevant studies were excluded. Secondly, full texts of studies selected from the first phase were further reviewed. Finally, the studies which were suitable for data extraction were included in the systematic review and meta-analysis. Disagreements between the two reviewers are resolved by a third reviewer via discussion and consensus.

Inclusion criteria

Studies were included if they met the following criteria: published in either English or Chinese language; having available data of NASSI after THA; research target being human; patients at the age of ≥18; numbers of enrolled patients being more than 10.

Exclusion criteria

The exclusion criteria of included studies were as follows: insufficient information; duplicate publication; return visit time less than 3 months; treatment for THA after hip infection; hip revision surgery.

Data extraction

Relevant data were extracted independently by two reviewers. Each of the following information was filled in a pre-designed form: first author’s name, publication year, basic information of patients (unhealthy habits, basic diseases, history of medication), causes of hip disorders, operative information, number of all patients receiving THA, and number of patients with NASSI after THA. The information of potential influencing factors were exacted for comparison analyses, including age, gender, tobacco smoking, body mass index (BMI), diabetes mellitus (DM), American Society of Anesthesiologists (ASA) grade, serum albumin, immunosuppressive agent, causes of hip disorders, fixation technique, surgical approach, type of anesthesia, duration of surgery, vancomycin powder, drain and duration of drain. Disagreements between the two reviewers were resolved by a third reviewer via discussion and consensus.

Data analysis

Stata software (v12.0, Stata Corp, College Station, TX, USA) was utilized to assess all statistical analyses. For exploring the prevalence of NSSSI with THA, the pooled prevalence and its 95% confidence intervals (CI) were calculated by using a random-effect model (p<0.05, I²>50%) or a fixed‐effect model (p>0.05, I²<50%). Publication bias was assessed using Begg’s test and Egger’s test. In the study of the association between potential influencing factors and infection, the odds ratio (OR) and its 95% CI were calculated. A p<0.05 was considered statistically significant.

Characteristics of included studies

A total of 2063 studies (1562 English and 501 Chinese) were identified in the first phage. Following selection process (figure 1), 57 studies involving 2075304 patients were included, including 38 studies written in English and 19 studies in Chinese. The studies were conducted in China, USA, Canada, Switzerland, UK, Brazil, Germany, New Zealand, Spanish or Netherlands, respectively. The number of patients receiving THA ranged from 87 to 623253, and the prevalence of patients with NSSSI after THA ranged from 0.05% to 9.13%. The basic information of patients receiving THA in all included studies were listed in table 1.

Of the 57 studies, the information of 7 studies were derived from one large-scale database, i.e., National Surgery Quality Improvement Program (NSQIP) of the American College of Surgeons (marked with # on table 1). The data of another 5 studies originated from other 5 large-scale databases (marked with * on table 1), i.e., Nationwide Inpatient Sample in China between 2005 and 2014^[27], Taiwan National Health Insurance Research Database between 1996 and 2013^[28], administrative databases in Ontario^[35], The Nationwide Inpatient Sample in the United States in 2014^[43], New Zealand Joint Registry data between 2000 and 2014.^[65]

Analysis results of prevalence of NSSSI after THA

The data of 6 studies with large-scale data (1 study with the largest number of patients from NSQIP^[51] and 5 studies from other 5 large-scale databases), and 45 studies with normal-scale data, were used for meta-analysis. Pooled results of above 51 studies showed that the prevalence of patients with NSSSI after THA was 1.0% (95% CI: 0.8%, 1.1%), using random-effects method (figure 2, table 2). No publication bias was found under Begg’s test (z=0.28, p>0.05) or Egger's test (t=1.65, p>0.05) (figure 3).

When stratified by data scale (table 2), pooled prevalence of 6 studies with large-scale data (figure 4) and that of 45 studies with normal-scale data (figure 5) were similar (large-scale: 0.9% (95%CI: 0.6%-1.3%); normal-scale: 1.1% (95%CI: 0.9%-1.2%), respectively). When stratified by country (table 2), the prevalence of different countries was of various (table 2). Netherlands was the highest (9.5%), next was Brazil (3.9%) and Germany (2.7%), and New Zealand was the lowest (0.1%). However, each of above result came from individual study. Pooled results of 5 countries showed that China had the highest prevalence of 2.2% (95%CI: 1.8%-2.7%), and UK had the lowest prevalence of 0.3% (95%CI: 0.0%-0.6%).

Potential influencing factors of NSSSI after THA

The potential influencing factors of NSSSI after THA were screened from all included 57 studies. The prevalence of NSSSI after THA stratified by 16 potential influencing factors were listed in table 2. And the comparison results of the potential influencing factors were listed in table 3. In the following comparisons of influencing factors, each of the former prevalence of NSSSI after THA was significantly higher than the latter one (p<0.05), i.e., male (3.1%) vs. female (2.3%), tobacco smoker (2.5%) vs. non-smoking (1.4%), BMI >25 (3.9%) vs. BMI <25 (1.7%), DM (5.9%) vs. non-DM (1.7%), BMI >30 (1.7%) vs. BMI <30 (0.4%), BMI >35 (3.1%) vs. BMI <35 (0.9%), ASA grade III or IV or V or VI (0.5%) vs. ASA grade I or II (0.5%), serum albumin <3.5g/dL (5.2%) vs. serum albumin <3.5g/dL (4.6%), immunosuppressive agents (13.2%) vs. none immunosuppressive agents (3.1%), universal anesthesia (2.3%) vs. regional anesthesia (0.3%), non-vancomycin powder (4.9%) vs. vancomycin powder (1.3%), duration of drain >48h (6.0%) vs. <48h (3.8%). No significant difference was found between other comparisons (p>0.05).

To our knowledge, this is the first systematic review and meta-analysis about NSSSI after THA. Since the included studies were confined to publications in recent five years, the results are closer to current state of the art. This meta-analysis showed that the prevalence of NSSSI after THA was 1.0%. Studies with large-scale data and studies with normal-scale data were further analyzed separately and showed similar results of the two kinds of data, indicating data scale did not arouse bias of the pooled prevalence.

The prevalence in different countries was in a variety. The highest prevalence was 9.5% in Netherlands, and the lowest prevalence was 0.1% in New Zealand. However, because only single study was conducted in each of these counties, the credibility is not high. Meta-analysis of counties with more than one relevant studies showed that the highest prevalence was 2.2% in China and the lowest one was 0.3% in the UK. Besides, in the neighboring countries sharing common boundaries and similar ethnic distribution, the prevalence was not definitely the same, for example, 1.4% in Canada while 0.7% in United States. These results demonstrated that different regions and ethnic groups as well as other potential factors influence the prevalence of NSSSI after THA.

Among the 16 influencing factors, it is surprisingly to see that age was not a clear factor that affects the prevalence of NSSSI after THA. In fact, the included studies set stratified age at 60 or 65 years old, but most of the patients receiving THA were middle-aged and elderly patients over 50 years old.^[76] Thus the present systematic review cannot give an absolute conclusion that NSSSI after THA has no relationship with age. In future studies, researchers should set more reasonable stratified age to further clarify the effects of age on NSSSI. Male patients or tobacco smokers have higher prevalence of NSSSI than female patients or non-tobacco smokers. This reminds us the smoking habits may lead to the increased prevalence of NSSSI after THA in male population.

In 2019, Aidan T Morrell et al. reported that the prevalence of NSSSI in patients who met the preoperative screening criteria was significantly decreased. The preoperative screening criteria included no smoking, BMI ≤ 40 kg/m2, hemoglobin A1c ≤ 7.5%, hemoglobin ≥ 12 g /dL, and albumin ≥ 3.5 g/dL within 30 days prior to surgery.^[77] Consistently, our systematic review identified some important preoperative factors, including BMI, diabetes mellitus, ASA grade (assessment of the situation of systemic disease), serum albumin, immunosuppressive agents, that influence the prevalence of NSSSI after THA. These results suggests that good basic conditions are important adjustable factors in reducing NSSSI after THA for patients undergoing elective surgery. For example, diabetes is considered to be one of the important factors of NSSSI, owing to the effects of hyperglycemia on phagocytosis of white blood cells^[78] or destruction of blood vessels^[79]. Surgeons should guide diabetes patients to control BMI and glyx`cemia to avoid the risk of NSSSI after THA.

The surgical approach has always been the focus of discussion in the academic community. The DAA is welcomed because of its less or even no damage to the nerve plane.^[80] However, some studies demonstrated that the prevalence of SSSI was more obvious in obese patients with DAA approach, comparing to non-DAA.^[81–83] Besides, a previous study showed that patients receiving DAA present higher prevalence of NSSSI than patients receiving non-DAA.[84] While our pooled results, using the meta-analysis method, convincingly demonstrated that there was no significant difference in the NSSSI rate between DAA and non-DAA approaches. As such, DAA can be especially recommended owing to its relatively better safety profile.

Postoperative indwelling drainage was ever thought to be a beneficial and necessary method to reduce possible SSI.^{[85, 86]} However, the current results found that the prevalence of NSSSI was same with indwelling drains and no drains, and that indwelling drains for more than 48 hours increased the prevalence of NSSSI. Many studies believed that indwelling drainage tube will cause increased postoperative blood loss and high blood transfusion rate.^[87] And blood transfusion will reduce the level of immune response in patients, which is mainly due to the influence of leukocytes or leukocyte products of allogeneic blood.^[88] Thus, traditional viewpoint that postoperative indwelling drainage reduce the NSSSI rate was challenged. Indwelling drain after THA is no longer a necessary operation.

In addition to the 16 influencing factors explored in our review, other influencing factors were also be concerned recently. For example, patients undergoing THA in winter were more likely to have NSSSI, some NSSSI after THA may be related to oral bacteria and it is necessary to maintain oral hygiene during the perioperative period of THA, et al .^[89–92]

The current systematic review and meta-analysis has limitations due to the following reasons. Firstly, some studies mixed the information of THA and total knee arthroplasty together. We cannot obtain the sole data of THA and thus these studies were excluded. ^{[93, 94]} Secondly, some included studies mixed short-term NSSSI and long-term NSSSI together. However, studies that only described long-term NSSSI after THA were excluded.^[95] Thirdly, the extracted data of included studies were from multiple large-scale databases or individual hospitals, and there may be situations that multiple data were used interchangeably.

In summary, the pooled prevalence of NSSSI in patients with THA was 1.0% and 10 potential influencing factors were found to be associated with the prevalence. Controlling the risk factors may decrease the prevalence of NSSSI after THA. We provide clinical guidance to prevent NSSSI after THA.

NSSSI: non-superficial surgical site infection

THA: total hip arthroplasty

CNKI: China National Knowledge Infrastructure

CI: confidence intervals

SSI: Surgical site infection

BMI: body mass index

DM: diabetes mellitus

ASA: American Society of Anesthesiologists

OR: odds ratio

NSQIP: National Surgery Quality Improvement Program

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Table 1 The basic information of all included studies comprising NSSSI after THA

Author	Year	Country	Number of NSSSI	Total THA	Prevalence
Shohat N, et al^[61]	2021	USA	111	10201	1.09%
A Hernández-Aceituno, et al^[6]	2021	Spanish	8	563	1.42%
Morton JS, et al^#[48]	2020	USA	297	98391	0.30%
Sherman AE, et al^#[59]	2020	USA	15	1731	0.87%
Aali Rezaie A, et al^[1]	2020	USA	6	293	2.05%
Hartford JM, et al^[31]	2020	USA	8	1808	0.44%
Siljander MP, et al^[64]	2020	USA	12	5353	0.22%
Buchalter DB, et al^[14]	2020	USA	84	12549	0.67%
Yang Q, et al *^[88]	2020	China	1180	590122	0.20%
Chen CH, et al *^[19]	2020	China	31	650	4.77%
Shi XJ, et al^[60]	2020	China	1	1547	0.06%
Huang ZH, et al^[32]	2020	China	26	2444	1.06%
Wang CG, et al^[77]	2020	China	5	140	3.57%
Liu XY, et al^[41]	2020	China	6	87	6.90%
Li YL, et al^[42]	2020	China	24	426	5.63%
Bian RP, et al^[9]	2020	China	21	516	4.07%
MAC, et al *^[45]	2020	Canada	1450	100674	1.44%
Pincus D, et al^[50]	2020	Canada	47	5986	0.79%
Matar HE, et al^[43]	2020	Canada	126	55681	0.23%
Ferro FP, et al^[29]	2020	Brazil	16	426	3.76%
Wills BW, et al^#[79]	2019	USA	540	98896	0.55%
Debbi EM, et al ^#[23]	2019	USA	148	317230	0.05%
Aggarwal VK, et al^[3]	2019	USA	50	6086	0.82%
Triantafyllopoulos GK, et al^[75]	2019	USA	62	19235	0.32%
Dugdale EM, et al *^[27]	2019	USA	534	44658	1.20%
Thacher RR, et al^[73]	2019	USA	3	591	0.51%
Zhou PM, et al^[88]	2019	China	28	604	4.64%
Yang YP, et al^[85]	2019	China	31	994	3.12%
Yang YZ, et al^[86]	2019	China	4	253	1.58%
Taneja A, et al^72]	2019	Canada	159	11507	1.38%
Ravi B, et al^[55]	2019	Canada	821	29121	2.82%
Bongers J, et al^[12]	2019	Netherlands	42	486	8.64%
Wills BW, et al ^# *^[80]	2018	USA	1047	103044	1.02%
DeMik DE, et al ^#[24]	2018	USA	300	64648	0.46%
Bedard NA, et al ^#[8]	2018	USA	172	8237	2.09%
Sutphen SA, et al^[69]	2018	USA	28	5702	0.49%
Dial BL, et al^[25]	2018	USA	8	265	3.02%
Purcell RL, et al^[51]	2018	USA	28	4651	0.60%
Winkler C, et al^[82]	2018	USA	18	343	5.25%
Ma KM, et al^[44]	2018	China	36	611	5.89%
Feng EY, et al^[28]	2018	China	1	197	0.51%
Wu YG, et al^[84]	2018	China	16	334	4.79%
Lenguerrand E, et al^[39]	2018	UK	2705	623253	0.43%
Burn E, et al^[15]	2018	UK	14	10961	0.13%
Antoniadis A, et al^[5]	2018	Switzerland	4	254	1.57%
Tissot C, et al^[74]	2018	Switzerland	12	1195	1.00%
Smith JO, et al *^[66]	2018	New Zealand	137	92305	0.15%
Cao H, et al^[17]	2017	China	7	300	2.33%
Zhao M, et al^[87]	2017	China	1	120	0.83%
Triantafyllopoulos GK, et al^[76]	2016	USA	28	6650	0.42%
Brimmo O, et al^[11]	2016	USA	2	278	0.72%
Purcell RL, et al^[52]	2016	USA	10	1621	0.62%
Zhan SA, et al^[89]	2016	China	5	147	3.40%
Liu J, et al^[40]	2016	China	20	219	9.13%
Pu CC, et al^[53]	2016	China	13	1021	1.27%
Radtke K, et al^[54]	2016	Germany	13	498	2.61%
Ilchmann T, et al^[33]	2016	Switzerland	23	1104	2.08%
Note: # From National Surgery Quality Improvement Program (NSQIP) database of the American College of Surgeons; * From other large-scale databases; NSSSI: Non-superficial surgical site infection; THA: Total hip arthroplasty.

Table 2 The pooled results and subgroup analysis of the prevalence of NSSSI after THA

		Number of study	N	n	Prevalence rate			Heterogeneity		Model
		Number of study	N	n	effect size	lower limit	upper limit	I²	p	Model
Total		51	2075304	9220	1.0%	0.8%	1.1%	98.70%	<0.01	random
Data scale
	large-scale	45	826621	4693	1.1%	0.9%	1.2%	96.60%	<0.01	random
	normal-scale	6	931453	4379	0.9%	0.6%	1.3%	99.80%	<0.01	random
Country
	China	19	600732	1456	2.2%	1.8%	2.7%	93.40%	<0.001	random
	USA	18	540558	2187	0.7%	0.5%	1.0%	99.10%	<0.001	random
	Canada	5	202969	2603	1.4%	0.5%	2.2%	99.70%	<0.001	random
	Switzerland	4	2553	39	1.4%	0.9%	1.8%	56.80%	0.099	fix
	UK	2	634214	2719	0.3%	0.0%	0.6%	98.70%	<0.001	random
	Brazil	1	426	16	3.9%	-	-	-	-	-
	Germany	1	498	13	2.7%	-	-	-	-	-
	New Zealand	1	92305	137	0.1%	-	-	-	-	-
	Spanish	1	563	8	1.4%	-	-	-	-	-
	Netherlands	1	486	42	9.5%	-	-	-	-	-
Inflencing factors
1.Age (year)
	>65	3	39684	96	1.3%	0.1%	2.4%	95.40%	<0.01	random
	<65	3	59168	127	0.6%	0	1.6%	95.40%	<0.01	random
	>60	3	321123	2003	3.5%	0.0%	7.1%	93.70%	<0.01	random
	<60	3	132628	761	1.9%	0.2%	3.6%	86.60%	0.01	random
2.Gender
	male	16	303375	1727	1.2%	0.9%	1.5%	95.90%	<0.01	random
	female	16	432154	1444	0.6%	0.4%	0.8%	94.30%	<0.01	random
3.Tobacco smoking
	yes	5	67860	144	2.5%	0.6%	4.4%	94.50%	<0.01	random
	no	5	265163	175	1.4%	0.5%	2.3%	98.00%	<0.01	random
4.Body mass index
	>25	5	72707	300	3.9%	1.0%	6.7%	89.10%	<0.01	random
	<25	5	259808	1564	1.7%	0.4%	3.0%	81.70%	<0.01	random
	>30	4	130844	1032	1.7%	0.6%	2.7%	92.30%	<0.01	random
	<30	4	264040	1102	0.4%	0.3%	0.5	86.20%	<0.01	random
	>35	5	1738	49	3.1%	1.4%	4.8%	75.40%	0.003	fix
	<35	5	27136	119	0.9%	0.3%	1.4%	93.30%	<0.01	random
5.Diabetes mellitus
	yes	10	43516	312	5.9%	3.5%	8.3%	86.60%	<0.01	random
	no	10	462132	2260	1.7%	1.1%	2.2%	89.50%	<0.01	random
6.ASA grade ^[1]
	III, IV, V	5	106419	518	0.5%	0.2%	0.7%	98.40%	<0.01	random
	I, II	5	584093	2346	0.5%	0.2%	0.8%	87.90%	<0.01	random
7.Serum albumin (g/dL)
	< 3.5	2	878	28	5.2%	0.0%	12.5%	91.60%	0.001	fix
	>3.5	2	720	37	4.6%	1.1%	8.2%	79.40%	0.028	fix
8.Immunosuppressive gents
	yes	5	837	65	13.2%	6.4%	20.0%	85.80%	<0.001	random
	no	5	2073	63	3.1%	1.6%	4.7%	76.40%	0.002	random
9.Causes of hip disorders
	fracture	6	17675	83	0.5%	0.1%	0.9%	88.30%	<0.01	random
	primary osteoarthrosis or non-traumatic AVN ^[2]	6	700117	2770	0.4%	0.2%	0.6%	98.80%	<0.01	random
	inflammatory arthritis	4	11223	50	0.4%	0.3%	0.6%	0.00%	<0.01	random
10.Fixation technique
	cementless	3	1067	47	5.5%	2.0%	8.9%	81.70%	0.004	random
	cement	3	777	21	2.4%	1.3%	3.4%	43.00%	0.173	fix
11.Surgical approach
	DAA ^[3]	13	26028	193	0.7%	0.4%	1.0%	86.50%	<0.001	random
	non-DAA	13	48148	274	0.7%	0.4%	1.0%	87.60%	<0.001	random

12.Type of anesthesia
	universal	3	300427	1399	0.3%	0.0%	0.7%	83.80%	<0.01	random
	regional	3	324707	1323	2.3%	0.0%	6.3%	89.70%	<0.01	random

13.Duration of surgery (minute)
	>120	4	1768	47	3.5%	0.8%	6.3%	89.80%	<0.001	random
	<120	4	5689	79	5.6%	0.8%	10.4%	90.60%	<0.001	random
	>180	2	664	22	6.3%	0.0%	15.5%	89.00%	0.003	random
	<180	2	944	37	4.0%	2.8%	5.3%	0.00%	0.343	fix

14.Vancomycin powder
	no	3	419	23	1.3%	0.1%	2.6%	65.40%	0.089	fix
	yes	3	446	7	4.9%	2.8%	6.9%	56.60%	0.1	fix

15.Drain
	yes	2	568	26	4.3%	2.7%	6.0%	67.90%	0.078	fix
	no	2	282	11	3.4%	1.3%	5.5%	55.20%	0.135	fix

16. Duration of drain (hour)
	>48	3	716	43	6.0%	4.3%	7.8%	40.40%	0.187	fix
	<48	3	1465	52	3.8%	1.8%	5.9%	75.80%	0.016	fix
Note: [1] ASA grade: American Society of Anesthesiologists grade. I No organic, physiologic, biocemical or psychiatric disturbance. II A patient with mild systemic disease that results in no functional limitation. III A patient with severe systemic disease that results in functional impairment. IV Severe systemic disease that is a constant to life. V Moribund condition in a patient who is not expected to servive with or without the operation. VI Declared brain death patient whose organs are being harvested for transplantation. [2] AVN: Avascular necrosis; [3] DAA: Direct anterior approach;

Table 3 The comparison results stratified by 16 influencing factors

		Study	Comparison results				Heterogeneity		Model
		Study	p	OR ^[1]	lower limit	upper limit	I²	p	Model
1.Age (year)	<65 vs. >65	3	0.25	0.677	0.349	1.316	77.60%	0.012	random
	<60 vs. >60	3	0.163	0.72	0.454	1.142	55.00%	0.108	fix
2.Gender	male vs. female	16	<0.001	1.68	1.566	1.803	10.20%	0.337	fix
3.Tobacco smoking	yes vs. no	5	<0.001	2.368	1.915	2.929	70.70%	0.009	random
4.Body mass index	>25 vs. <25	5	<0.001	1.574	1.388	1.784	0.00%	0.503	fix
	>30 vs. <30	4	0.003	2.622	1.383	4.972	92.50%	<0.001	random
	>35 vs. <35	5	0.004	3.489	1.498	8.125	79.90%	0.001	random
5.Diabetes mellitus	yes vs. no	10	<0.001	2.358	1.592	3.492	59.90%	0.008	random
6.ASA grade^[2]	III, IV, V vs. I, II	5	0.006	2.246	1.268	3.979	82.80%	<0.001	random
7.Serum albumin (g/dL)	<3.5 vs. >3.5	2	<0.001	3.405	2.002	5.793	0.00%	0.725	fix
8.Immunosuppressive agents	yes vs. no	5	<0.001	4.203	2.688	6.571	41.10%	0.147	fix
6.Causes of hip disorders ^[3]	a vs. b	5	0.27	1.135	0.096	1.422	0.00%	0.696	fix
	a vs. c	5	0.729	1.066	0.743	1.529	59.50%	0.085	fix
	b vs. c	5	0.441	0.894	0.673	1.188	48.60%	0.12	fix
10.Fixation technique	cementless vs. cement	3	0.334	2.061	0.476	8.927	86.00%	0.001	random
11.Surgical approach	DAA ^[4]vs. non-DAA	11	0.458	1.077	0.885	1.310	75.70%	<0.001	random
12.Type of anesthesia	universal vs. regional	3	0.001	1.137	1.054	1.226	0.00%	0.613	fix
13.Duration of surgery (minute)	>120 vs. <120	4	0.055	1.453	0.993	2.128	0.00%	0.436	fix
	>180 vs. <180	2	0.885	1.161	0.155	8.705	92.70%	<0.001	random
14.Vancomycin powder	yes vs. no	3	0.002	3.828	1.642	8.924	0.00%	0.548	random
15.Drain	drain vs. no drain	2	0.562	1.234	0.607	2.508	79.60%	0.027	random
16.Duration of drain (hour)	>48 vs. <48	3	0.007	1.768	1.166	2.679	17.30%	0.298	fix
Note:[1] OR: Odds ratio; [2] ASA grade: American Society of Anesthesiologists grade. I No organic, physiologic, biocemical or psychiatric disturbance. II A patient with mild systemic disease that results in no functional limitation. III A patient with severe systemic disease that results in functional impairment. IV Severe systemic disease that is a constant to life. V Moribund condition in a patient who is not expected to servive with or without the operation. VI Declared brain death patient whose organs are being harvested for transplantation; [3] a: fracture, b: primary osteoarthrosis or non-traumatic avascular necrosis, c: inflammatory arthritis; [4] DAA: Direct anterior approach;

No competing interests reported.

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Prevalence and potential influencing factors of non-superficial surgical site infection in patients with total hip arthroplasty: A systematic review and meta-analysis

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