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J Am Acad Orthop Surg Glob Res Rev
J Am Acad Orthop Surg Glob Res Rev
JAAOS Glob Res Rev
JAAOS Glob Res Rev
JAAOS Global Research & Reviews
2474-7661
Wolters Kluwer Philadelphia, PA

39288290
JAAOSGlobal-D-24-00180
10.5435/JAAOSGlobal-D-24-00180
00009
3
004
Research Article
Outcomes of Regional Block in Revision Total Joint Arthroplasty for Prosthetic Joint Infection
https://orcid.org/0000-0002-1334-0042
Treanor Ashley BS
Shimizu Michelle BSc mshimizu@luc.edu

Barrett Athena BS abarrett@luc.edu

Byram Scott MD sbyram@lumc.edu

Schmitt Daniel MD daniel.schmitt@luhs.org

Brown Nicholas MD nicholas.brown002@lumc.edu

From the Loyola University Chicago Stritch School of Medicine, Maywood, IL (Ms. Treanor, Ms. Shimizu, and Ms. Barrett); the Department of Anesthesiology and Perioperative Medicine, Loyola University Medical Center, Maywood, IL (Dr. Byram); and the Department of Orthopaedic Surgery, Loyola University Medical Center, Maywood, IL (Dr. Schmitt and Dr. Brown).
Correspondence to Treanor: atreanor@luc.edu
9 2024
17 9 2024
8 9 e24.0018008 5 2024
06 7 2024
Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.
2024
American Academy of Orthopaedic Surgeons
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article distributed under the Creative Commons Attribution-NoDerivatives License 4.0 (CC BY-ND) which allows for redistribution, commercial and non-commercial, as long as it is passed along unchanged and in whole, with credit to the author

Introduction:

Infection is among the most common reasons for revision after a total joint arthroplasty (TJA) and is associated with notable morbidity and mortality rates. As the demand for TJA increases, a concurrent increase in the prevalence of periprosthetic joint infection (PJI) is also expected to rise. While previous studies have explored differences in postoperative outcomes between general and spinal anesthesia, there is limited data on the use of regional blocks in patients undergoing revision joint arthroplasty for PJI. This study evaluated the postoperative outcomes of patients undergoing revision TJA for PJI using regional blocks.

Methods:

Data from 518 patients were retrospectively collected. Patients included in the study had undergone revision TJA for PJI from January 2004 to January 2023 at a single institution. Patients undergoing same-day bilateral revisions, above-knee amputations, and aseptic revisions were excluded. Postoperative complications investigated included local complications, postoperative transfusion, wound complication, readmission, sepsis, systemic infection, spinal infection, death, persistent PJI, periprosthetic fracture, and unplanned revision surgery. Chi-square analysis was used to compare postoperative complications between procedures that used spinal or general anesthesia with regional blocks and those with spinal or general anesthesia without regional blocks.

Results:

Of the 518 patients who underwent revision TJA, 63 (12.2%) used a regional block. After surgery, 12.7% (n = 8) of patients with regional block and 23.5% (n = 107) of patients without regional block experienced persistent PJI (P = 0.076). No significant differences in wound complication (P = 0.333), readmission (P = 0.998), revision surgery (P = 0.783), and death (P = 0.588) were found between those with and without regional block use. Sepsis (P = 0.224), systemic infection (P = 0.220), and spinal infection (P = 0.998) rates within 1 year after revision TJA for PJI surgery were comparable between the two groups. No local infections were observed at the block site. A subanalysis comparing spinal and general anesthesia demonstrated comparable persistent PJI postoperatively and complication rates; however, spinal anesthesia use was associated with shorter length of stay (P = 0.003) and lower transfusion rates (P = 0.002).

Conclusion:

The results of this study suggest that the use of regional block is not associated with an increased probability of postoperative persistent PJI, local wound complication, readmission, spinal/systemic/other infections, death, or revision surgery. Surgeons can comfortably choose regional block as a safe option for revision surgery for PJI. Consistent with previous research, patients who received spinal anesthesia had shorter hospital stays and lower transfusion rates when compared with those who received general anesthesia.

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pmcProsthetic joint infection (PJI) is the most common reason for revision after total knee arthroplasty (TKA) and the third most common reason for revision after total hip arthroplasty (THA).1-4 Previous studies have explored differences in postoperative outcomes between general and spinal anesthesia for total joint arthroplasty (TJA) revisions for PJI, with most studies showing spinal anesthesia with improved patient outcomes and reduced complications.5,6 Tirumala et al6 demonstrated that patients who received spinal anesthesia for revision THA for PJI exhibited a notable reduction in surgical time, perioperative blood loss, and complications compared with patients who received general anesthesia. Similarly, Wilson et al7 noted decreased rates of deep surgical site infection, length of stay, readmission, and postoperative transfusions in patients undergoing TKA revision using spinal anesthesia compared with patients undergoing the same procedure with general anesthesia; however, PJI cases were excluded from the study for ease of interpretation. In addition, spinal anesthesia in both primary and revision TJAs has been associated with a shorter length of hospital stay.8

While many studies have compared spinal and general anesthesia in both primary and revision TJAs, the current data on the efficacy and safety of regional blocks in the setting of a prosthetic joint infection is limited. A systematic review by Memtsoudis et al9 found that there were reduced odds for cardiac complications, pulmonary complications, respiratory failure, any infectious complications, surgical site infections, thromboembolic events, and blood transfusions when regional blocks were used in primary TJA. A recent study by Wei et al10 found that the use of regional anesthesia was associated with decreased odds of several postoperative complications, transfusion, and extended length of stay after revision TJA; however, PJI cases were excluded from the study to create a more homogeneous cohort. Gritsenko et al demonstrated that the incidence of central nervous system (CNS) infection was exceedingly low when spinal anesthesia and regional blocks were used for patients undergoing revision surgery for PJI. However, of their 474-patient cohort, there was one patient who experienced a psoas abscess and one who developed an epidural hematoma, demonstrating rare but major complications that can arise.11 Similarly, Rasouli et al noted that use of spinal anesthesia was associated with low risk of CNS infection and found that there was lower risk of systemic infection in patients who underwent revision for PJI compared with general anesthesia.5

The purpose of this study was to compare the postoperative complication rates between patients who have undergone revision hip or knee TJA for PJI using spinal or general anesthesia with a regional block and those without a regional block. The secondary outcome was to explore the outcomes of patients with spinal versus general anesthesia.

Methods

Patient Data

After obtaining institutional review board approval, electronic databases were manually reviewed to identify patients who underwent a revision hip or knee TJA for a PJI at a single tertiary center between 2007 and 2021. Patients were initially identified using the International Classification of Diseases (ICD) codes for PJI (996.66, 996.67). Patients with an indication other than PJI, a surgical treatment outside a revision TJA, a history of revision TJA, or missing or insufficient perioperative data were excluded from this study (n = 496).

Patient Variables

Variables associated with demographics (age, sex, body mass index [BMI], race, ethnicity), comorbidities (American Society of Anesthesiologists [ASA] score, Charlson Comorbidity Index [CCI],12 smoking, alcohol use, drug use, HIV, hepatitis C, end-stage renal disease [ESRD], diabetes, immunocompromised), surgery (laterality, blood loss, surgical time, anesthesia type), and hospital stay (preoperative methicillin-resistant Staphylococcus aureus (MRSA) nasal swab results, hospital length of stay, discharge disposition) were collected. Age, BMI, ASA score, CCI, blood loss, surgical time, and hospital length of stay were collected as quantitative variables. The type of anesthesia (spinal versus general) and whether a regional block was used were recorded. The type of anesthesia used for the revision surgery was primarily based on surgeon and anesthesiologist preference. The aforementioned intraoperative variables were extracted from surgical and anesthesia notes. Primary postoperative outcomes included the need for transfusion, wound complications, block site complications, sepsis, spinal infection, systemic infection, death, fracture, and unplanned revision surgeries, all within a year of the index surgery. Recurrence or persistence of PJI, positive blood culture results, and unplanned readmission within 90 days of the surgery were also recorded.13

Statistical Analysis

Baseline characteristics in both cohorts were presented as a mean with a standard deviation (SD) and counts and percentages. Differences in characteristics between patients with regional block and those with another type of anesthesia were analyzed using t-tests or chi-square analysis for quantitative and categorical variables. Similar analysis comparing those who underwent revision TJA with regional and general anesthesia was also conducted. P-values less than 0.05 were considered significant. All analyses were conducted using Python (version 3.9).

Results

Patient Demographics

A total of 518 patients who underwent a revision TJA for PJI were identified in this study, of which 63 patients (12.2%) were included in the regional block cohort. 84.0% of patients had general and 16.0% spinal anesthesia. The baseline demographic characteristics of the two groups are summarized in Table 1. The cohorts were statistically similar in sex and BMI. The most prevalent race was Caucasian (regional block: 79.4%; no regional block: 78.9%) while the most prevalent comorbidity in both cohorts was diabetes (regional block: 46.0%; no regional block: 37.4%; P = 0.282). Patients with a positive preoperative MRSA nasal swab made up 6.3% and 9.9% of the regional block and nonregional block cohorts, respectively (P = 0.748). A significant difference was observed in the proportion of patients who had a record of drug use at the time of surgery (regional block: 9.5%; no regional block: 2.4%; P = 0.041) and a current diagnosis of end-stage renal disease (regional block: 31.7%; no regional block 16.3%; P = 0.005). Patients who had a regional block were also significantly older (69.06 ± 10.67 versus no regional block: 64.31 ± 11.43; P = 0.0019), had a higher ASA score (3.4 ± 0.65 versus no regional block: 3.19 ± 0.73; P = 0.043), and had a higher CCI score (5.83 ± 3.40 versus no regional block: 4.39 ± 3.25; P = 0.001) compared with the cohort without regional block.

Table 1 Baseline Patient Characteristics of Regional Block Versus No Regional Block Cohorts

Patient Characteristics	Regional Block (n = 63; 12.2%)	No Regional Block (n = 455; 87.8%)	P	
Age, year	69.06 ± 10.67	64.31 ± 11.43	0.0019	
Sex, male (%)	29 (46.0%)	243 (53.4%)	0.335	
BMI, kg/m2	31.84 ± 7.10	33.53 ± 8.56	0.139	
Operation			0.123	
 THA	20 (31.7%)	195 (42.9%)		
 TKA	43 (68.3%)	260 (57.1%)		
Laterality, right (%)	33 (52.4%)	241 (53.0%)	0.999	
Race (%)			0.759	
 Caucasian	50 (79.4%)	359 (78.9%)		
 Black	10 (15.9%)	64 (14.1%)		
 Other	3 (4.8%)	32 (7.0%)		
Ethnicity, Hispanic (%)	10 (15.9%)	64 (14.1%)	0.787	
ASA score	3.4 ± 0.65	3.19 ± 0.73	0.043	
CCI	5.83 ± 3.40	4.39 ± 3.25	0.001	
Comorbidities (%)	
 Smoking	5 (7.9%)	63 (13.8%)	0.216	
 Alcohol use	22 (34.9%)	108 (23.7%)	0.074	
 Drug use	6 (9.5%)	11 (2.4%)	0.041	
 HIV	0	1 (0.2%)	0.999	
 Hepatitis C	1 (1.6%)	8 (1.8%)	0.997	
 ESRD	20 (31.7%)	74 (16.3%)	0.005	
 Diabetes	29 (46.0%)	170 (37.4%)	0.282	
 Immunocompromised	9 (14.3%)	69 (15.2%)	0.993	
 Preoperative MRSA, positive (%)	4 (6.3%)	45 (9.9%)	0.748	
ASA = American Society of Anesthesiologists, BMI = body mass index, CCI = Charlson Comorbidity Index, ESRD = end-stage renal disease, MRSA = methicillin-resistant Staphylococcus aureus, THA = Total hip arthroplasty, TKA = Total knee arthroplasty

Bold indicates statistically significant P values (P < 0.05).

Perioperative and Postoperative Outcomes

No statistically significant differences were observed in operation time, intraoperative blood loss, and postoperative length of stay between patients who have undergone revision TJA for an infection using regional block compared with those without (Table 2). 44.4% of patients who used regional block were discharged home while half of the nonregional block cohort (51.0%) went home after surgery (P = 0.419). The incidence of postoperative transfusion (P = 0.350), wound complications (P = 0.333), fractures (P = 0.811), and persistent PJI (P = 0.076) was similar in both cohorts. No patients had an infection or other local complications resulting from the administration of regional anesthesia. The readmission rate within 90 days of surgery was comparable in patients with (n = 181; 39.8%) and without (n = 25; 39.7%) regional block (P = 0.998). No spinal infections were recorded in patients who underwent surgery with a regional block. The occurrence of sepsis (P = 0.224), spinal infection (P = 0.998), and systemic infection (P = 0.220) was low in both cohorts. Both cohorts had comparable rates of unplanned revision surgery within a year of the revision TJA (P = 0.783) and positive blood cultures (P = 0.667). Persistent postoperative PJI was higher in patients that did not receive regional block (n = 107; 23.5%) compared with those who did receive regional block (n = 8; 12.7%); however, this difference was not statistically significant (P = 0.076).

Table 2 Perioperative and Postoperative Outcomes of Regional and General/Spinal Anesthesia Cohorts

Patient Characteristics	Regional Block (n = 63; 12.2%)	No Regional Block (n = 455; 87.8%)	P	
Operation time, minutes	158.21 ± 55.49	170.93 ± 76.83	0.209	
Intraoperative blood loss, mL	474.19 ± 439.70	520.19 ± 626.28	0.576	
Length of stay, days	6.86 ± 6.41	7.52 ± 6.37	0.438	
Discharge disposition, home (%)	28 (44.4%)	232 (51.0%)	0.419	
Transfusion (%)	21 (33.3%)	189 (41.5%)	0.350	
Wound complication (%)	7 (11.1%)	31 (6.8%)	0.333	
Unplanned readmission < 90 days (%)	25 (39.7%)	181 (39.8%)	0.998	
Sepsis<1 year (%)	5 (7.9%)	17 (3.7%)	0.224	
Spinal infection <1 year (%)	0	4 (0.9%)	0.998	
Systemic infection < 1 year (%)	2 (3.2%)	3 (0.7%)	0.220	
Deaths < 1 year (%)	3 (4.8%)	12 (2.6%)	0.588	
Fracture (%)	1 (1.6%)	2 (0.4%)	0.811	
Persistent PJI (%)	8 (12.7%)	107 (23.5%)	0.076	
Unplanned revision surgery < 1 year (%)	25 (39.7%)	193 (42.4%)	0.783	
(+) Blood culture (%)	3 (4.8%)	13 (2.9%)	0.667	
PJI = periprosthetic joint infection

Spinal Versus General Anesthesia Use

Of the patients included in this study, 83 received spinal anesthesia and 435 received general anesthesia. Of those who received either spinal (n = 83; 16.0%) or general (n = 435; 84%), 6 (7.2%) and 28 (6.4%) patients received regional block anesthesia, respectively (P < 0.001). A greater proportion of those who had spinal anesthesia were male (n = 53; 63.9%) while men made up half (50.3%) of the cohort that used general anesthesia (P = 0.032; Table 3). A significant difference in length of stay (P = 0.003) and transfusion rates (P = 0.002) postoperatively was noted between the two cohorts, with the spinal anesthesia cohort having a shorter length of stay (5.52 ± 4.22) and lower transfusion rates (24.1%) compared with the general anesthesia cohort (7.81 ± 6.65; 42.7%). No difference was observed in the persistence of infection in the spinal anesthesia cohort (20.5%) versus general anesthesia cohort (22.5%) (P = 0.789; Table 4). No cases of spinal or systemic infection were observed in patients who received spinal anesthesia.

Table 3 Baseline Patient Characteristics of Spinal Versus General Anesthesia Cohorts

Patient Characteristics	Spinal (n = 83)	General (n = 435)	P	
Age, year	66.35 ± 9.91	64.61 ± 11.70	0.205	
Sex, male (%)	53 (63.86%)	219 (50.34%)	0.032	
BMI, kg/m2	33.14 ± 7.69	33.35 ± 8.55	0.835	
Operation (%)			0.091	
 THA	27 (32.53%)	188 (43.22%)		
 TKA	56 (67.47%)	247 (56.78%)		
Combined with regional (%)	6 (7.23%)	28 (6.44%)	<0.001	
Laterality, right (%)	40 (48.19%)	234 (53.79%)	0.414	
Race (%)			0.114	
 Caucasian	72 (86.75%)	337 (77.47%)		
 Black	9 (10.84%)	65 (14.94%)		
 Other	2 (2.41%)	33 (7.59%)		
Ethnicity, Hispanic (%)	9 (10.84%)	41 (9.43%)	0.848	
ASA score	3.30 ± 0.74	3.19 ± 0.73	0.21	
CCI	4.82 ± 3.19	4.52 ± 3.32	0.448	
Comorbidities (%)	
 Smoking	9 (10.84%)	59 (13.56%)	0.550	
 Alcohol use	27 (32.53%)	103 (23.68%)	0.095	
 Drug use	2 (2.41%)	15 (3.45%)	0.780	
 HIV	0	1 (0.23%)	0.998	
 Hepatitis C	0	9 (2.07%)	0.392	
 ESRD	19 (22.89%)	75 (17.24%)	0.285	
 Diabetes	37 (44.58%)	162 (37.24%)	0.239	
 Immunocompromised	15 (18.07%)	63 (14.48%)	0.479	
 Preoperative MRSA, positive (%)	5 (6.02%)	44 (10.11%)	0.432	
CCI = Charlson Comorbidity Index, MRSA = methicillin-resistant Staphylococcus aureus, THA = Total hip arthroplasty, TKA = Total knee arthroplasty

Bold indicates statistically significant P values (P < 0.05).

Table 4 Perioperative and Postoperative Outcomes of Spinal Versus General Anesthesia Cohorts

Patient characteristics	Spinal (n = 83)	General (n = 435)	P	
Operation time, minutes	161.62 ± 66.69	170.85 ± 76.00	0.302	
Intraoperative blood loss, mL	453.09 ± 332.26	526.18 ± 318.20	0.058	
Length of stay, days	5.52 ± 4.22	7.81 ± 6.65	0.003	
Discharge disposition, home (%)	50 (60.24%)	210 (48.28%)	0.058	
Transfusion (%)	20 (24.10%)	190 (43.68%)	0.002	
Wound complication (%)	4 (4.82%)	34 (7.82%)	0.465	
Unplanned readmission < 90 days (%)	37 (44.58%)	169 (38.85%)	0.393	
Sepsis<1 year (%)	4 (4.82%)	18 (4.14%)	0.998	
Spinal infection <1 year (%)	0	4 (0.92%)	0.847	
Systemic infection < 1 year (%)	0	5 (1.15%)	0.712	
Deaths < 1 year (%)	2 (2.41%)	13 (2.99%)	0.999	
Fracture (%)	1 (1.20%)	2 (0.46%)	0.976	
Persistent PJI (%)	17 (20.48%)	98 (22.53%)	0.789	
Unplanned revision surgery < 1 year (%)	36 (43.37%)	182 (41.84%)	0.890	
(+) Blood culture (%)	2 (2.41%)	14 (3.22%)	0.965	
PJI = periprosthetic joint infection

Bold indicates statistically significant P values (P < 0.05).

Discussion

Complication Rates Using Regional Block Anesthesia

Our study found no statistical difference in postoperative complications between patients who had an additional regional block and those who did not. Although including a regional block did not increase the risk of postoperative complications, previous studies have demonstrated neuraxial anesthesia to have better postoperative benefits when compared with general anesthesia. Analysis of the ACS-NSQIP database by Serino et al14 showed neuraxial anesthesia to be associated with a lower 30-day risk of any adverse event when compared with general anesthesia in revision surgery for PJI. A meta-analysis conducted by Hu et al15 found that regional anesthesia helps reduce the duration of surgery, the need for transfusion, and the incidence of thromboembolic disease in TJA. In our study, adding a regional block to spinal or general anesthesia did not increase the risk of systemic infection. While those who used either spinal or general anesthesia with a regional block had higher rates of sepsis within a year of the index surgery, this was only seen in 5 patients and not statistically significant. Studies that have evaluated neuraxial anesthesia for surgical treatment of PJI in the hip or knee found neuraxial anesthesia to have lower risk of CNS infection when compared with general anesthesia.5,11 Hebl et al16 reported no new or worsening symptoms for patients with preexisting CNS infections after surgery using neuraxial anesthesia. Serino et al14 demonstrated neuraxial anesthesia to have a lower rate of sepsis when compared with general anesthesia after surgery for PJI. These studies conclude that after the administration of antibiotics, neuraxial anesthesia is safe to use in the setting of infection.5,11,14 We also conclude the addition of regional block to be safe in the setting of infection.

Infection Rates in Regional Block Anesthesia

In this study, none of the infectious postoperative outcome rates between anesthesia cohorts were statistically different. In addition, patients with regional anesthesia did not have any local complications at the block site. Thus, adding a regional block is not associated with increased complication rates in patients who undergo a revision TJA secondary to PJI. The option to incorporate regional anesthesia in these surgeries without exacerbating complication rates may allow the surgeon and anesthesiologist the flexibility to decide which anesthesia is better suited for a patient based on factors beyond the setting of infection. Hebl et al16 determined that neuraxial anesthesia should not be an absolute contraindication for patients with CNS infections. Serino et al14 concluded that infection should be re-evaluated as a contraindication for neuraxial anesthesia based on their finding that neuraxial anesthesia for revision surgery for PJI had a low risk of adverse events. Similarly, we conclude that infection should be re-evaluated as a contraindication for regional anesthesia based on our finding that adding a regional block for revision surgery for PJI had a low risk of postoperative infection.

Patient Comorbidities and Regional Block

Patients who received regional block had statistically higher CCI, ASA scores, and comorbidities, including older age, drug use, and ESRD. The addition of regional anesthesia for patients with comorbidities may be preferred, given the lower rates of complications associated with intubation, ventilation, respiratory depression, and systemic medications, all of which are commonly discussed as complications associated with general anesthesia use.17 Regional block has been used in patients with a history of intravenous drug use undergoing TJA because of their ability to mitigate postoperative pain.18 Regional anesthesia has the notable advantage of focusing, adjusting, and sustaining pain inhibition to the CNS.17,18 Better pain control reduces opioid consumption and opioid-related adverse effects of nausea and vomiting that can extend hospital stay.19 The higher incidence of patients with ESRD in the regional block cohort could be explained by several observations. Given the contraindication of nonsteroidal anti-inflammatory drugs in patients with renal disease, the addition of regional blocks could enhance postoperative pain control for these patients.20 In addition, a previous study by Liu et al21 compared anesthesia type and postoperative complications after hemiarthroplasty secondary to femoral neck fractures and found no statistical difference in the incidence of renal injury after surgery between patients who received general anesthesia with and without peripheral nerve blocks. This finding could suggest the benefit of regional block use for pain management for this patient population while preventing additional kidney damage. Surgeons and anesthesiologists should consider the benefits of regional block in patients with comorbidities when selecting the best anesthesia for revision TJA for PJI.

Postoperative Complications in Spinal Versus General Anesthesia

A greater length of stay and higher rates of postoperative transfusion were seen in patients who underwent revision TJA for PJI using general anesthesia. This is in concordance with previous studies that found general anesthesia to be associated with an extended length of stay and higher transfusion rates in patients undergoing revision TKA for any indication.7 Between spinal and general anesthesia, our data found no statistical difference in surgical time or perioperative blood loss. While the perioperative blood loss difference is minimal, the occurrence of transfusion rates is statistically reduced in spinal anesthesia. Similarly, previous studies found that spinal anesthesia in revision THA was associated with reduced surgical time and perioperative blood loss compared with general anesthesia.6 This study also found no statistical difference in revision surgery rates between the two cohorts. This is in contrast to the findings by Qvistgaard et al,22 who found that patients receiving general anesthesia in revision THA for PJI experienced a higher risk of revision surgery compared with those who received spinal anesthesia. Our study found no additional statistical differences in postoperative complications between spinal and general anesthesia. This differs from previous studies that concluded spinal anesthesia to have statistically reduced postoperative complications and mortality.6,7,22 Differences in our findings on revision surgery and postoperative complications could be attributed to our study's broader inclusion criteria of both THA and TKA revision surgeries with or without regional block. In addition, most studies focused on a single institution; therefore, the patient population, preferred surgical technique, and implant type used are not controlled between studies. We conclude that general and spinal anesthesia are comparable options for revision TJA for PJI.

Limitations

First, our data were collected from a single institution with a limited sample size.5 Second, patients with improperly labeled ICD-9, ICD-10, and CPT codes could influence the true population size. To minimize the effect of coding errors in patient information, we manually cross-checked the data to exclude patients mistakenly coded to have undergone a revision TJA surgery for PJI. It is also likely that errors are equally distributed between the 2 groups with and without regional blocks.2,5,14 Third, while a wide variety of factors were considered and recorded through manual review, there may be other influences on perioperative outcomes and infection, including implant types and surgical technique.19,23 However, the sample size of the regional block cohort was too small to control for these potentially confounding factors. In addition, there may be more subtle differences between these techniques with outcomes such as pain, nausea, mobilization, and patient satisfaction that were not captured in this data set. There may be selection bias among anesthesia choice that also influenced the results. Regarding spinal versus general anesthesia groups, the lack of a power analysis and small sample sizes limit the detection differences of rare complications such as respiratory failure or cardiac events. Finally, while there were typically not large demographic or comorbidity differences between the cohorts, our low event rate and sample size precluded the use of multivariate models to fully control for potential confounding variables.

Conclusion

The results of our study suggest that the use of regional block is not associated with an increased probability of postoperative persistent PJI, local wound complication, readmission, spinal/systemic/other infections, death, or revision surgery. Surgeons can comfortably choose regional block as a safe option for revision surgeries for PJI. Consistent with previous research, patients who received spinal anesthesia had shorter hospital stays and lower transfusion rates when compared with those who received general anesthesia.

None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Treanor, Shimizu, Barrett, Dr. Byram, Dr. Schmitt and Dr. Brown
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