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Risk Factors for Periprosthetic Ankle Joint Infection: A Case-Control Study
Bernhard Kessler, MD1; Parham Sendi, MD1; Peter Graber, MD1; Markus Knupp, MD2; Lukas Zwicky, MSc2; Beat Hintermann, MD2; Werner Zimmerli, MD1
1 Unit of Infectious Diseases, Basel University Medical Clinic, Liestal, Rheinstrasse 26, CH-4410 Liestal, Switzerland. E-mail address for P. Sendi: sendi-pa@magnet.ch. E-mail address for W. Zimmerli: werner.zimmerli@ksli.ch
2 Clinic of Orthopaedic Surgery, Cantonal Hospital, Rheinstrasse 26, CH-4410 Liestal, Switzerland
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Investigation performed at the Interdisciplinary Unit for Orthopaedic Infections, Kantonsspital, Liestal, Switzerland

A commentary by Jason H. Calhoun, MD, is linked to the online version of this article at jbjs.org.

Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Oct 17;94(20):1871-1876. doi: 10.2106/JBJS.K.00593
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Periprosthetic ankle joint infection is a feared complication of total ankle arthroplasty because the implant fails in the majority of cases. However, risk factors for developing these infections are unknown.


We aimed to determine risk factors for infection in a matched case-control study that included twenty-six patients with periprosthetic ankle joint infection and two control groups, each consisting of fifty-two patients.


The prevalence of periprosthetic ankle joint infection within our cohort was 4.7%. Four infections (15%) had a hematogenous origin and twenty-two (85%), an exogenous origin. Staphylococcus aureus was the most common pathogen, followed by coagulase-negative staphylococci. Preoperative predisposing factors associated with infection included prior surgery at the site of infection (odds ratio [OR] = 4.56, 95% confidence interval [CI] = 0.98 to 21.35, and OR = 4.78, 95% CI = 1.53 to 14.91, in comparison with the two control groups) and a low American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score (35.8 versus 49.8 and 47.6 in the two control groups, p ≤ 0.02). The mean duration of the index surgery was significantly longer in the case group than in both control groups (119 versus eighty-four and ninety-three minutes, p ≤ 0.02). After surgery, persistent wound dehiscence (OR = 15.38, 95% CI = 2.91 to 81.34, p = 0.01, in comparison with both control groups) and secondary wound drainage (OR = 7.00, 95% CI = 1.45 to 33.70, and OR = 5.31, 95% CI = 1.01 to 26.78, in comparison with the two control groups, p ≤ 0.04) were associated with the development of a periprosthetic ankle joint infection.


Patients at risk for periprosthetic ankle joint infection following total ankle arthroplasty include those with a history of surgery on the ankle, a low preoperative AOFAS hindfoot score, and a long operative time. Postoperatively, patients with a prolonged wound dehiscence or a secondary wound-healing problem are also at risk for infection.

Level of Evidence: 

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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