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The projected burden of complex surgical site infections following hip and knee arthroplasties in adults in the United States, 2020 through 2030

  • Hannah M. Wolford (a1), Kelly M. Hatfield (a1), Prabasaj Paul (a1), Sarah H. Yi (a1) and Rachel B. Slayton (a1)...

As the US population ages, the number of hip and knee arthroplasties is expected to increase. Because surgical site infections (SSIs) following these procedures contribute substantial morbidity, mortality, and costs, we projected SSIs expected to occur from 2020 through 2030.


We used a stochastic Poisson process to project the number of primary and revision arthroplasties and SSIs. Primary arthroplasty rates were calculated using annual estimates of hip and knee arthroplasty stratified by age and gender from the 2012–2014 Nationwide Inpatient Sample and standardized by census population data. Revision rates, dependent on time from primary procedure, were obtained from published literature and were uniformly applied for all ages and genders. Stratified complex SSI rates for arthroplasties were obtained from 2012–2015 National Healthcare Safety Network data. To evaluate the possible impact of prevention measures, we recalculated the projections with an SSI rate reduced by 30%, the national target established by the US Department of Health and Human Services (HHS).


Without a reduction in SSI rates, we projected an increase in complex SSIs following hip and knee arthroplasty of 14% between 2020 and 2030. We projected a total burden of 77,653 SSIs; however, meeting the 30% rate reduction could prevent 23,297 of these SSIs.


Given current SSI rates, we project that complex SSI burden for primary and revision arthroplasty may increase due to an aging population. Reducing the SSI rate to the national HHS target could prevent 23,000 SSIs and reduce subsequent morbidity, mortality, and Medicare costs.

Corresponding author
Author for correspondence: Hannah Wolford, 1600 Clifton Road MS A-16, Atlanta, GA 30329. E-mail:
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1. Lovald, ST, Ong, KL, Lau, EC, Schmier, JK, Bozic, KJ, Kurtz, SM. Mortality, cost, and downstream disease of total hip arthroplasty patients in the medicare population. J Arthroplasty 2014;29:242246.
2. Lovald, ST, Ong, KL, Lau, EC, Schmier, JK, Bozic, KJ, Kurtz, SM. Mortality, cost, and health outcomes of total knee arthroplasty in Medicare patients. J Arthroplasty 2013;28:449454.
3. Kurtz, SM, Ong, KL, Lau, E, Bozic, KJ. Impact of the economic downturn on total joint replacement demand in the United States: updated projections to 2021. J Bone Joint Surg Am 2014;96:624630.
4. Kurtz, SM, Ong, KL, Schmier, J, et al. Future clinical and economic impact of revision total hip and knee arthroplasty. J Bone Joint Surg Am 2007;89 Suppl 3:144151.
5. Pollock, M, Somerville, L, Firth, A, Lanting, B. Outpatient total hip arthroplasty, total knee arthroplasty, and unicompartmental knee arthroplasty: a systematic review of the literature. JBJS Rev 2016;4.
6. Bozic, KJ, Lau, E, Kurtz, S, et al. Patient-related risk factors for periprosthetic joint infection and postoperative mortality following total hip arthroplasty in Medicare patients. J Bone Joint Surg Am 2012;94:794800.
7. Bozic, KJ, Ward, DT, Lau, EC, et al. Risk factors for periprosthetic joint infection following primary total hip arthroplasty: a case control study. J Arthroplasty 2014;29:154156.
8. Lee, QJ, Mak, WP, Wong, YC. Risk factors for periprosthetic joint infection in total knee arthroplasty. J Orthop Surg (Hong Kong) 2015;23:282286.
9. Peter, WF, Dekker, J, Tilbury, C, et al. The association between comorbidities and pain, physical function and quality of life following hip and knee arthroplasty. Rheumatol Int 2015;35:12331241.
10. Singh, JA, Vessely, MB, Harmsen, WS, et al. A population-based study of trends in the use of total hip and total knee arthroplasty, 1969–2008. Mayo Clin Proc 2010;85:898904.
11. Berrios-Torres, SI, Yi, SH, Bratzler, DW, et al. Activity of commonly used antimicrobial prophylaxis regimens against pathogens causing coronary artery bypass graft and arthroplasty surgical site infections in the United States, 2006–2009. Infect Control Hosp Epidemiol 2014;35:231239.
12. Poultsides, LA, Ma, Y, Della Valle, AG, Chiu, YL, Sculco, TP, Memtsoudis, SG. In-hospital surgical site infections after primary hip and knee arthroplasty—incidence and risk factors. J Arthroplasty 2013;28:385389.
13. National targets and metrics. Office of Disease Prevention and Health Promotion website. Published 2017. Accessed October 12, 2017.
14. Yi, SH, Baggs, J, Culler, SD, Berrios-Torres, SI, Jernigan, JA. Medicare reimbursement attributable to periprosthetic joint infection following primary hip and knee arthroplasty. J Arthroplasty 2015;30:931938.
15. Soe, MM, Gould, CV, Pollock, D, Edwards, J. Targeted assessment for prevention of healthcare-associated infections: a new prioritization metric. Infect Control Hosp Epidemiol 2015;36:13791384.
16. Policies for Eliminating Healthcare-Associated Infections: Lessons Learned From State Stakeholder Engagement. The Association of State and Territorial Health Officials and the Centers for Disease Control; 2012.
17. Baker, AW, Dicks, KV, Durkin, MJ, et al. Epidemiology of surgical site infection in a community hospital network. Infect Control Hosp Epidemiol 2016;37:519526.
18. 2014 National Population Projections. US Census; 2014.
19. Sher, A, Keswani, A, Yao, DH, Anderson, M, Koenig, K, Moucha, CS. Predictors of same-day discharge in primary total joint arthroplasty patients and risk factors for post-discharge complications. J Arthroplasty 2017;32 Suppl 9:S150S156.
20. Aynardi, M, Post, Z, Ong, A, Orozco, F, Sukin, DC. Outpatient surgery as a means of cost reduction in total hip arthroplasty: a case-control study. HSS J 2014;10:252255.
21. Procedure-associated module SSI. National Healthcare Safety Network. Centers for Disease Control and Prevention website. Published 2017. Accessed July 30, 2018.
22. Katz, JN, Wright, EA, Wright, J, et al. Twelve-year risk of revision after primary total hip replacement in the US Medicare population. J Bone Joint Surg Am 2012;94: 18251832.
23. Duffy, GP, Crowder, AR, Trousdale, RR, Berry, DJ. Cemented total knee arthroplasty using a modern prosthesis in young patients with osteoarthritis. J Arthroplasty 2007;22:6770.
24. Guo, L, Yang, L, Briard, JL, Duan, XJ, Wang, FY. Long-term survival analysis of posterior cruciate-retaining total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2012;20:17601765.
25. Kearns, SR, Jamal, B, Rorabeck, CH, Bourne, RB. Factors affecting survival of uncemented total hip arthroplasty in patients 50 years or younger. Clin Orthop Relat Res 2006;453:103109.
26. Ong, KL, Lau, E, Suggs, J, Kurtz, SM, Manley, MT. Risk of subsequent revision after primary and revision total joint arthroplasty. Clin Orthop Relat Res 2010;468:30703076.
27. Finkelstein, EA, Khavjou, OA, Thompson, H, et al. Obesity and severe obesity forecasts through 2030. Am J Prev Med 2012;42:563570.
28. Kurtz, SM, Lau, E, Watson, H, Schmier, JK, Parvizi, J. Economic burden of periprosthetic joint infection in the United States. J Arthroplasty 2012;27:6165.
29. Berrios-Torres, SI, Umscheid, CA, Bratzler, DW, et al. Centers for disease control and prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg 2017;152: 784791.
30. Magill, SS, Edwards, JR, Bamberg, W, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med 2014; 370:11981208.
31. Scott RD. The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention. Centers for Disease Control and Prevention website. Published 2009. Accessed July 30, 2018.
32. National inpatient sample. Centers for Disease Control and Prevention website. Updated 2018. Accessed July 30, 2018.
33. Bovonratwet, P, Webb, ML, Ondeck, NT, et al. Definitional differences of ‘outpatient’ versus ‘inpatient’ THA and TKA can affect study outcomes. Clin Orthop Relat Res 2017;475:29172925.
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Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
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