Evaluation of Risk Factors for Periprosthetic Joint Infection Following Reverse Shoulder Arthroplasty: A Multivariate Analysis Study

doi:10.21203/rs.3.rs-4831168/v1

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Evaluation of Risk Factors for Periprosthetic Joint Infection Following Reverse Shoulder Arthroplasty: A Multivariate Analysis Study

https://doi.org/10.21203/rs.3.rs-4831168/v1

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Background

Reverse shoulder arthroplasty (RSA) has been widely used for treatment of shoulder pathologies, particularly rotator cuff tear arthropathy. Currently, it is also increasingly performed for different indications. Like in any arthroplasty procedure, periprosthetic joint infection (PJI) is one of the most concerning complications and may have devastating outcomes. This study aimed to identify risk factors for PJI following RSA.

Methods

This retrospective case-control study was conducted with patients who underwent RSA during study period. Based on PJI occurence during follow-up period, patients were divided into two groups: Group I (no infection) and Group II (infection). The relationship between numerous clinical variables and PJI was tested. All variables were initially evaluated through univariate analysis between the two groups, and variables showing significant differences between the two study groups were subjected to multivariate logistic regression analysis to determine independent risk factors.

Results

The study included 302 patients, with a mean age of 69.6 ± 10.1 years and a mean follow-up duration of 59.8 ± 24.7 months. During follow-up period, PJI was not detected in 289 patients (95.7%) (Group I), while 13 patients (4.3%) developed PJI (Group II). Univariate analysis revealed a significant association for preoperative C-reactive protein (CRP) value (p = 0.001) and preoperative diabetes history (p = 0.007) with PJI. Multivariate logistic regression analysis including these two variables showed that diabetes was an independent risk factor for PJI development (p = 0.01, odds ratio = 4.85). Preoperative CRP elevation was not observed as an independent risk factor.

Conclusions

This study demonstrated a significant association between high preoperative CRP levels and diabetes with PJI. Additionally, the presence of diabetes was identified as an independent risk factor for infection, with a 4.85-fold higher risk of PJI development in patients with a history of diabetes.

Reverse shoulder arthroplasy

periprosthetic joint infection

infection

diabetes mellitus

C-reactive protein

Since its first introduction for treatment of cuff tear arthropathy (CTA), reverse shoulder arthroplasty (RSA) has shown successful and reliable outcomes [1]. In the following decades, indications for RSA have expanded including proximal humeral fractures, fracture sequelae, glenohumeral osteoarthritis (OA), failed prior rotator cuff repair, avascular necrosis (AVN) of humeral head, revision of failed prior shoulder arthroplasty etc. [2] Even though clinical outcomes have been promising for these various pathological conditions [1, 3]; high complication rates have been attributed with RSA including periprosthetic joint infection (PJI), instability, fracture, scapular notching, aseptic loosening or neurological injury [4].

As in all arthroplasty procedures, PJI is a major concern following RSA which may require multiple additional surgeries and long-duration antibiotics treatment. In previous reports, PJI incidence following primary RSA ranges from 0.5 to 6.7%, but most commonly between 3 to 4% [5–7]. The current knowledge regarding PJIs is mainly based on studies about lower limb arthroplasty. Due to increasing demand for RSA and growing concerns for subsequent PJIs, determination of risk factors related to PJIs is essential. However, there is a paucity of evidence in the literature regarding patient and procedure related risk factors on PJIs following RSA; and most of the available data is confined to certain factors without controlling for confounding variables [3, 8–10]. This brings out the need for further investigation with large series of patients and with multiple variable analysis in order to confirm independent risk factors for PJIs. The purpose of this study is to evaluate patient and procedure related factors that may be related to PJIs and to identfy independent risk factors for PJIs following RSA.

This study was a retropsective analysis of prospectively collected data of patients who underwent RSA surgery between April 2014 and May 2022 and was conducted in a tertiary university hospital clinic. All included patients were informed about the use of their medical records data for publication and written informed consents were obtained.

INCLUSION AND EXCLUSION CRITERIA

Records of patients who underwent RSA surgery during study period were assessed from a prospectively collected institutional shoulder arthroplasty database. All interventions were performed by a single surgeon, who is a fellowship-trained experienced shoulder surgoen. Patients who had history of any kind of infection (septic arthritis, osteomyelitis) in the operative shoulder, patients who underwent RSA procedure as a revision of a prior failed shoulder arthroplasty (RSA, total anatomic shoulder arthroplasty or hemiarthroplasty), patients with history of any rheumatoid condition or immunodeficiency and patients who received immunosuppresive treatment during follow-up period were excluded. Included patients were sub-grouped per diagnosis for RSA indication in order to assess the influence of diagnosis on PJI and five different diagnoses were identified: CTA, proximal humeral fracture (PHF), glenohumeral OA, sequelae of previously operated PHFs (malunion or nonunion), AVN of humeral head and failed prior arthroscopic rotator cuff repair (fARCR).

SURGICAL TECHNIQUE

All patients were operated under general anesthesia with pre-operative interscalene nerve block, on beach-chair position. The skin preparation was performed using povidone-iodine paint solution combined with isopropyl alcohol. The operative field was covered with Ioban 2 surgical drapes (3M, St Paul, MN, USA) and no surgical helmets were used during intervention.

Standard deltopectoral approach was preferred and uncemented humeral stems were used for all interventions. Suction drains or medical prophlyaxis for deep venous thrombosis were not routinely used. Deep venous thrombosis prophylaxis was performed using compressive stockings.

POSTOPERATIVE REHABILITATION

Immobilisation using an abduction sling with shoulder in neutral rotation and 30 degrres of abduction was performed for all patients for 4 weeks. Passive and active elbow and wrist motions were encouraged immediately after surgery. At 4th postoperative week, passive shoulder range of motion (ROM) exercises were initiated and continued until full passive ROM was achieved combined with active assissted ROM exercises. At 6th to 8th postoperative week, active ROM, deltoid strengthening and shoulder proprioception exercises were initiated. Return to full phsyical activity was allowed considering the recovery level of each patient starting from 3rd to 6th postoperative month.

INFECTION PROPHYLAXIS PROTOCOL

All patients were screened preoperatively for possible urinary tract infection (UTI) with urinalysis and further urine cultures were obtained if results of urinalysis were consistent with UTI. These patients were consulted to infectious disease department for appropriate treatment and surgeries were delayed considering their counselling.

At the operative day, 2g of intravenous (IV) cefazolin was administered 30 minutes before incision for all patients and additional 4 doses of 1g IV cefazolin were continued every 6 hours of first postoperative 24 hours. In 2020, antibiotic protocol has been changed and an additional local administration of 2g of teicoplanin in powder format into the surgical area before wound closure was performed routinely for all patients.

CLINICAL EVALUATION

All indications for RSA were given by the senior surgeon following preoperative clinical and radiological assessment. All demographic and clinical data of patients were prospectively collected in a shoulder arthroplasty database. Postoperative clinical evaluations were performed at 2nd week, 4th week, 3 months, 6 months, 12 months posteoperatively and each following postoperative year. All intraoperative and postoperative complications were noted.

All patients with suspicious clinical findings for PJI during follow-up period underwent an infection workup. The findings that cause an infection suspicion include new on set of pain or persistent postoperative pain without other explanation, a sinus tract around the surgical wound, persistent erythema and/or fluctuance around the surgical wound and persistent wound drainage. Criteria described by the International Consensus Meeting (ICM) for shoulder PJI [11] were used for diagnosis (Table-1). Presence of a major criteria (definite PJI) or probable PJI according to minor criteria were considered as PJI. Patients that were classifed as possible PJI were followed up until resolution of the clinical findings or diagnosed as PJI if it was confirmed by intraoperative findings and intraoperatively obtained cultures.

Patients without a PJI diagnosis constituted group I and patients with PJI diagnosis constituted group II. Demographic and clinical variables were compared between two study groups with a univariate analysis in order to find out which variables were associated with PJIs. A multivariate analysis was then conducted with the significant variables of the univarate analysis in order to confirm which variables were independent risk factors for PJI.

STATISTICAL ANALYSIS

Mean, median, standard deviation, range, percentage and frequency were determined as descriptive statistical methods in order to analyse study data. Distribution of normality of continious data was tested using Shapiro-Wilk test, Kolmogorov-Smirnov test and histograms. The univariate analysis was conducted using unpaired t test for continious variables and chi-square or Fisher’s exact test for categorical variables. Comparison of non-normally distributed continious data was performed using Mann-Whitney U test.

A multivariate logistic regression analysis was then conducted with statistically significant variables observed in the univariate analysis in order to determine independent risk factors and to estimate odds ratios (ORs) for PJI. All analyses were performed using SPSS Statistics for Windows (Version 26.0.0, Armonk NY, USA) and significance level was set at p = 0.05.

302 patients were included to study with a mean age of 69.9 ± 10.1 years and with a mean follow-up duration of 59.8 ± 24.7 months. There were 232 (76.8%) female and 70 (23.2%) male patients. During study period, 13 (4.3%) patients were diagnosed with PJI and constituted group II. No PJI was observed in 289 (95.7%) patients (group I). Distribution of patients according to preoperative diagnosis for RSA surgery was as follows: 137 (45.4%) patients with CTA, 75 (24.8%) patients with PHF, 37 (12.3%) patients with glenohumeral OA, 13 (4.3%) patients with fracture sequelea, 18 (6.0%) patients with AVN and 22 (7.3%) patients with fARCR.

Identified pathogens for PJI in group II were Cutibacterium acnes in 3 patients, methicillin-sensitive S.aureus in 3 patients, methicillin-resistant S.aureus in 3 patients, Pseudomonas spp. in one patient and multibacterial infection (Morganella morganii + enterobacteriaceae spp) in one patient. No pathogens could be identified in two patients despite obvious infection findings and apparent intraoperative purulence.

Comparison of two study groups according to tested variables in the univaraite analysis revealed that preoperative C-reactive protein (CRP) levels and history of diabetes were significantly associated with PJI (p < 0.05). Mean preoperative CRP level was 5.19 ± 13.9 mg/L in group I and 10.3 ± 10.4 mg/L in group II (p = 0.001). While there were 217 (75.1%) patients without diabetes history and 72 (24.9%) patients with diabetes history in group I; group II was consisted of 5 (38.5%) patients without diabetes history and 8 (61.5%) patients with diabetes history (p = 0.007). No significant difference was observed between the two study groups for other tested variables (p > 0.05). Data of univariate analysis between two study groups were resumed in (table-2).

A subsequent multivariate logistic regression analysis was then performed with these two variables (Area under the curve, AUC = 0.795, 95% confidence interval = 0.677 to 0.914). Results of this analysis revealed that diabetes mellitus was the only independent risk factor for PJI with 4.85 fold increased risk (p = 0.007). (Table-3)

Number of positive observations (PJI) is 13 in this logistic regression model with 2 independent variables. Therefore, “events per variable” (EPV) value is 6.5 (13/2) which is, according to the most recent statistical knowledge[12], inside the acceptable limits for EPV and which confirms that necessary sample size was achieved to conduct a logistic regression analysis.

The findings of this study showed that high preoperative CRP levels and history of diabetes were associated with PJI following RSA. Secondly, with an almost 5-fold increased risk, diabetes was found to be an independent risk factor for PJI.

In previous studies, PJI rates after RSA surgery were reported to be between 0.5 and 6.7%; but most commonly ranging from 3 to 4% [5–7]. In our series, overall PJI rate was 4.3% which was consistent with previous reports. The majority of current evidence suggests that there is an increased risk for PJI in males and in patients aged under 65 [5, 13, 14]. From a causative aspect, this is most likely multifactorial. However; it has been shown that burden of C.acnes around shoulder area was considerably higher in males, which might contribute to higher PJI rates in males [15]. Unlike these previous evidence, gender and age were not significantly associated with PJI in our series.

Diabetes is considered as a major contributor for infection and impairment of wound healing following arthroplasty procedures; but this knowledge relies mainly on reports about lower extremity arthroplasty. Current knowledge regarding the influence of diabetes on PJI following RSA surgery is rather limited and controversial. Moreover, most of the available data is confined to univariate analyses or retrospective database studies with low evidence level. In a recent study, Rao et al.[16] reported a significant association between preoperative diabetes diagnosis and postoperative infection following shoulder arthroplasty. Additionally, they showed that while there was a significant association between elevated first postoperative glucose measurement and infection; second and third glucose level measurements were not found to be associated with infection. The authors stated that early postoperative glucose measurements represent the patient’s baseline glycemic control level more accurately and they also concluded that strict postoperative glucose level control in diabetic patients might play a crucial role for infection prevention. Another retrospective database study reported that patients with an increased hemoglobin A1c level (> 8mg/dl) had higher risk for wound complications and for deep infection [17]. In contrast to these findings, there are numerous studies reporting no correlation between diabetes and PJI after shoulder arthroplasty [5, 6, 18, 19]. However; the findings of present study also suggests a significant association between preoperative diabetes history and PJI. Moreover, diabetes was found to be the sole independent risk factor for PJI (odds ratio: 4.85) among the tested variables.

Inflammatory markers such as CRP and erythrocyte sedimentation rate (ESR) are traditionnally used for infection work up in clinicial practice. These markers are not only considered as primary diagnostic tools for PJI detection and included in diagnostic criteria described by ICM [11]; but they are also used for preoperative screening for any underlying infectious condition before arthroplasty procedures. An increased preoperative level of these inflamatory markers is usually considered as a relative contrindication for surgery and cause delay of intervention. Current knowledge regarding accurate thresholds for CRP and ESR in order to enhance the sensitivity and specifity of these markers are based on previous reports studying hip or knee arthroplasties [20]; and a significant paucity of evidence exist concerning role and efficacy of inflammatory markers in shoulder PJIs. Low-virulent, indolent pathogens such as C.acnes constitute a considerable portion (38.9%) [21] of shoulder PJIs and these infections might be a possible reason for reduced sensitivity and specifity of these markers for shoulder PJI detection. An increased CRP or ESR level may also be due to other scenerios such as reduced clearance of markers, an occult autoimmune condition or another infectious condition (UTI, upper respiratory system infection, etc.). Besides, patient-related factors including female gender and older age, which constitutes a large portion of population who underwent RSA surgery, were reported to be associated with increased ESR levels in healty general population [22]. Considering all of these conditions, use of preoperative inflammatory markers and their influence on risk assessment of shoulder PJI needs to be precisely clarified. A previous study by Kopechek et al. [23] examined risk factors for elevated preoperative CRP and ESR levels prior shoulder arthroplasty surgery. Their findings showed that a considerable amount of patients undergoing shoulder arthroplasty surgery with a diagnosis of primary glenohumeral OA had elevated preoeprative CRP (25.5% of patients) and ESR (29.8% of patients) levels. Unsurprisingly, they found out that active PJIs and acute PHFs caused significant increase of preoperative CRP and ESR values compared to patients who underwent shoulder arthroplasty due to glenohumeral OA. The authors concluded that increased inflammatory marker levels were possible even without the presence of an underlying infection and elevated preoperative ESR and CRP levels might not be considered as a relative contrindication for shoulder arthroplasty surgery. However, we think that current data is limited to support this implication and more evidence is needed to draw such a conclusion. In contrast to these findings; our results showed that even though an increased preoperative CRP level was not independent risk factor for PJI development, a significant association was present between preoperative CRP levels and PJI. These findings imply that surgeons should still be cautious about PJI development and meticulous risk assessment with patient counselling is needed in case of an increased preoperative CRP level.

According to available knowledge, revision arthroplasty surgery due to a failed prior shoulder arthroplasty is a known risk factor for PJI with reported infection rates reaching up to 15.4% [8]. In current study, revision RSA procedures were excluded and we tried to focus on evaluating the influence of other diagnoses for RSA indication on PJI development. In previous reports, history of previous non-arthroplasty shoulder surgery [9, 24] and RSA surgery for PHF or its sequelae have been showed to have higher risk for PJI [5, 7, 25]. However, there are also some reports suggesting that arthroplasty for trauma did not have any association or increased risk with infection [10, 26]. In our series, we did not observe any influence of different indications on PJI. However, we still think that PJI might be more likely especially when there is a history of previous shoulder surgery (prior rotator cuff repair or osteosynthesis of a PHF). Our study probably was unable to reveal these factors due to low number of events. Therefore future studies with larger cohorts are needed to clarify this issue.

Recently, interest in the intraoperative admission of antibiotics into the surgical wound for infection prevention have raised. However, most of the available data on this issue is based on reports studying lower extremity arthroplasty or spine surgery and evidence is quite limited for shoulder arthroplasty. A recent study by Iorio et al.[27] reported effects of a “vanco-povidone” protocol for patients with high risk for infection following hip or knee arthroplasty. The protocol included lavage of the joint with a povidone-iodine solution after implantation followed by 2g vancomycin administration in powder form into the surgical wound before wound closure. They reported 27.8% decrease in PJI rates in patients who received this protocol. In the 2018 ICM, it was suggested that intraoperative vancomycin powder administration might possibly have a role for infection prevention but there that there was no available data of its use in shoulder arthroplasty. Subsequently, it was recommended with limited evidence in high risk patients for PJI [28]. In our study, intraoperative teicoplanin powder was evaluated and we could not reveal any significant positive effect for PJI prevention; therefore, we were unable to give any recommendation in favor of its use.

There are several limitations of the present study that should be noted. Retrospective nature of this study is the first limitation due to possibility of selection bias or other unanticipated factors which may have distorted the results. However, prospectively collected informationvfrom an arthroplasty database was used which could minimize this risk. Second drawback that needs to be mentioned is that type of diabetes and level of glycemic control could not be evaluated since these data were not available. History of diabetes diagnosis was the only available information in our database which was tested in the analysis. Severity of diabetes and level of glycemic control would probably have an important effect of PJI, therefore this limitaion may also have distorted our results.

There are also some strengths related to this study that needs to be mentioned. To our knowledge, this is the second study evaluating risk factors for PJI, specifically after RSA surgery and controlling for potential confounders using a multivariate analysis. Therefore, the present study aims to fulfill an important gap in the available literature. Secondly, the present study has a considerably longer follow-up duration compared to the mentioned study [19]; thus, mid- to long-term results have been reported. Moreover, the present study also has a relatively larger cohort compared to the majority of previous studies on this topic. As it has already been mentioned, necessary sample size was reached in this study to conduct regression analysis. Same standard surgical technique was performed by a single surgeon and all patients were followed-up by the same protocol, which can also be mentioned as another strength of the study.

PJI is one of the major concerns following RSA which may cause devastating outcomes, but current knowledge is markedly limited and mostly relies on evidence derived from studies about hip and knee arthroplasty. Present study fulfills this gap and guide shoulder surgeons for accurate preoperative risk assessment and patient management. Our findings showed that increased preoperative CRP levels and diabetes were associated with PJI following RSA surgery. Secondly, history of diabetes was found to be an independent risk factor for PJI development, with an almost 5-fold increased risk. Further research ,specific to RSA, with high evidence level are still needed to comprehensively elicit risk factors related to PJI following RSA.

RSA: Reverse shoulder arthroplasty

PJI: Periprosthetic joint infection

CRP: C-reactive protein

CTA: Cuff tear arthropathy

OA: Osteoarthritis

AVN: Avascular necrosis

PHF: Rroximal humeral fracture

fARCR: Failed arthroscopic rotator cuff repair

ROM: Range of motion

UTI: Urinary tract infection

IV: Intravenous

ICM: International Consensus Meeting

ESR: Eryhtrocyte sedimentation rate

Ethichs approval and consent to participate

This study was performed in line with the principles of the Declaration of Helsinki. This is an observational retrospective study. The Institutional Review Board (IRB) of Bezmialem Vakif University has confirmed that no ethical approval is required. The study was approved by the same IRB (IRB ID: E-45446446-020-143420).

Informed consent was obtained from all individual participants included in the study.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests

Funding

No funding was received to conduct the present study

Authors’s contributions

KŞ – study conception and design, material preparation, data collection and analysis, drafting the manuscript

HBK – study conception and design, material preparation, data collection

CBK - study conception and design, material preparation, data collection

NZ – study conception and design, critical revision of the manuscript

KB - study conception and design, critical revision of the manuscript

MK - study conception and design, critical revision of the manuscript

All authors read and approved the final manuscript

Acknowledgements

Not applicable

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Table 1: Diagnostic criteria described in 2018 by International Consensus Meeting on Orthopedic Infections for periprosthetic joint infection (PJI).

Major criteria (Definite PJI):
Presence of a sinus tract to the prosthetic implant
Presence of gross intra-articular pus
Two positive tissue cultures for identical virulent organisms
Minor criteria	Points
Unexpected wound drainage	4
Single positive tissue culture wityh virulent organism	3
Single positive tissue culture with low-virulence organism	1
Second positive tissue culture (identical low-virulence organism)	3
Humeral loosening	3
Positive frozen section (5 PMN in ≥5 high-power fields)	3
Positive preoperative aspirate culture (low or high virulence)	3
Elevated synovial neutrophil percentage (>80%)^a	2
Elevated ESR (>30mm/h)^a	2
Elevated CRP level (>10mg/L)^a	2
Elevated synovial α-defensin level	2
Cloudy aspiration fluid	2
Minor criteria evaluation
≥6 points with identified organism	Probable PJI
≥6 points without identified organism	Possible PJI
<6 points and
Single positive culture with virulent organism	Possible PJI
2 positive cultures with low-virulence organism	Possible PJI
Negative culture or single positive culture with low-virulence organism	Unlikely PJI

(^a: Avaliable at 6^th week after most recent surgery, PMN: polymorphonuclear leokucyte, ESR: erythrocyte sedimentation rate, CRP: C-reactive protein)

Table 2: Univariate analysis of demographic and clinical data.

Variable	Group I (n=289)	Group II (n=13)	P value
Age (years)	70.0±9.8	68.0±15.8	0.585^a
Follow-up duration (months)	60.2±24.7	52.3±25.0	0.204^a
Sex	224 (77.5%) female, 65 (22.5%) male	8 (61.5%) female, 5 (38.5%) male	0.188^b
BMI (kg/m²)	29.0±4.0	28.6±2.6	0.852^a
Duration of hospital stay (days)	2.7±1.1	3.2±1.2	0.155^a
Duration of surgery (minutes)	128.2±26.9	134.0±28.9	0.489^c
Preoperative hemogloblin level (g/dL)	12.4±1.7	12.0±1.6	0.321^a
Preoperative hematocrit level (%)	38.1±4.4	37.5±5.6	0.690^c
Preoperative CRP level (mg/L)	5.2±13.9	10.3±10.4	0.001^{a *}
Preoperative ESR (mm/h)	16.8±15.8	21.7±20.5	0.545^a
Daignosis for RSA surgery (%)			0.963^d
CTA	132 (45.7%)	5 (38.5%)
PHF	71 (24.6%)	4 (30.8%)
Glenohumeral OA	36 (12.5%)	1 (7.7%)
Fracture sequelae	12 (4.2%)	1 (7.7%)
AVN	17 (5.9%)	1 (7.7%)
fARCR	21 (7.3%)	1 (7.7%)
Intraoperative local teicoplanin powder	no 174 (60.2%), yes 115 (39.8%)	no 6 (46.2%), yes 7 (53.8%)	0.389^b
Preoperative UTI	no 239 (82.7%), yes 50 (17.3%)	no 12 (92.3%), yes 1 (7.7%)	0.703^b
Tobacca use	no 250 (86.5%), yes 39 (13.5%)	no 12 (92.3%), yes 1 (7.7%)	0.546^d
COPD history	no 282 (97.6%), yes 7 (2.4%)	no 12 (92.3%), yes 1 (7.7%)	0.247^d
Diabetes history	no 217 (75.1%), yes 72 (24.9%)	no 5 (38.5%), yes 8 (61.5%)	0.007^{b *}
Hypertension	no 162 (56.1%), yes 237 (43.9%)	no 5 (38.5%), yes 8 (61.5%)	0.259^b
Coronary artery disease	no 255 (88.2%), yes 34 (11.8%)	no 9 (69.2%), yes 4 (30.8%)	0.066^b

(Data presented as mean±standard deviation or n(%). p values marked with “*” indicate statistical significance. BMI: body mass index, CRP: C-reactive protein, ESR: eryhtrocyte sedimentation rate, RSA: reverse shoulder arthroplasty, CTA: cuff tear arthropathy, PHF: proximal humeral fracture, OA: osteoarthritis, AVN: avascular necrosis, fARCR: failed previous arthroscopic rotator cuff repair, UTI: urinary tract infection, COPD: chronic obstructive pulmonary disease, ^a: Mann-Whitney U test, ^b: Fisher’s exact test, ^c: Unpaired samples t test, ^d: Chi square test)

Table 3: Multivariate logistic regression analysis to detect independent risk factors for periprosthetic joint infection

Variable	Odds Ratio	95%CI	P value
Preoperative CRP level (mg/L)	1.016	0.98 to 1.04	0.219
Diabetes history	4.852	1.56 to 16.6	0.007*

(p values marked with “*” indicate statistical significance. CRP: C-reactive protein, CI: confidence interval)

No competing interests reported.

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Evaluation of Risk Factors for Periprosthetic Joint Infection Following Reverse Shoulder Arthroplasty: A Multivariate Analysis Study

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Abstract

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BACKGROUND

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POSTOPERATIVE REHABILITATION

INFECTION PROPHYLAXIS PROTOCOL

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