Relação entre desnutrição e infecção precoce pós artroplastia total de joelho

Abstract

Objetivo: A artroplastia total de joelho (ATJ) e o procedimento de escolha para o tratamento da osteoartrite (OA) avancada e sintomatica. A despeito dos avancos tecnologicos, a infeccao permanece como a complicacao pos-operatoria mais associada a falha precoce e a necessidade de revisao cirurgica. Diversos fatores pre-operatorios, intraoperatorios e pos-operatorios vem sendo estudados visando a reducao do risco de infeccao pos ATJ. O estado nutricional tem ganhado destaque como um fator de risco potencialmente modificavel para a reducao de complicacoes infeciosas. O objetivo deste estudo foi avaliar a associacao entre a desnutricao e o risco de infeccao periprotetica precoce pos ATJ. Realizamos um estudo de coorte, com analise de banco de dados dos pacientes submetidos a ATJ no Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad (INTO) entre janeiro de 2014 e dezembro de 2016. A desnutricao foi definida por pelo menos um dos seguintes critérios laboratoriais: albumina serica menor que 3,5 g/dL, transferrina serica menor que 200 mg/dL e linfocitos no sangue menor que 1.500 celulas/mm3. Foram incluidos no estudo 2.080 pacientes submetidos a ATJs, apresentando mediana de idade de 68 anos, sendo 1.530 mulheres e 550 homens. A taxa de infeccao foi de 2,06%. Não foram encontradas diferencas em relacao a distribuicao por sexo, idade, classificacao de risco anestesico, indice de massa corporal (IMC), hemoglobina preoperatoria e volume de hemotransfusao entre os pacientes que evoluiram para infeccao e os pacientes nao-infectados. A prevalencia de comorbidades preoperatorias entre os grupos tambem foi investigada, demonstrando distribuição simetrica para hipertensao, diabetes, cardiopatia, dislipidemia e artrite reumatoide. A prevalencia encontrada para desnutricao baseada nos valores sericos de albumina, transferrina e contagem de linfocitos foi de 2,1%, 7,3% e 10,3%. Nenhum dos três marcadores se mostrou preditor de complicacao infecciosa pos artroplastia. A prevalencia de desnutricao, definida como a alteracao de pelo menos um marcador, foi de 17,7%. O risco relativo para infeccao em pacientes com desnutricao, em comparacao aos pacientes nao desnutridos, foi de 0,93 [95% IC: 0,27 – 3,18] (p=0,905). A analise por categoria de IMC demonstrou infeccao em 12,5% dos pacientes com baixo peso, 4,1% dos pacientes com peso normal, 1,5% dos pacientes com sobrepeso, 1,3% dos pacientes obesos e 2,7% dos obesos morbidos. O risco de infeccao dos pacientes baixo peso e peso normal foram significativamente maiores do que o dos obesos (p<0,05). Foi identificada a associacao positiva entre desnutricao e anemia pre operatoria (p=0,01), assim como a necessidade de transfusao sanguinea (p=0,02). Ja a HAS e DM se mostraram significativamente menos prevalentes nos denutridos, com p de 0,04 e 0,001 respectivamente. A desnutricao diagnosticada por criterios laboratoriais nao se mostrou como fator de risco para infeccao articular precoce pos ATJ.

Objective: Total knee arthroplasty (TKA) is the gold standard treatment for advanced and symptomatic osteoarthritis (OA). Despite technological advances, infection remains the most frequent postoperative complication leading to early TKA failure and the need for surgical revision. Several preoperative, intraoperative and postoperative factors have been studied aiming to reduce the risk of infection after TKA.The nutritional status has gained importance as a potential modifiable risk factor for the reduction of infectious complications, being serum nutritional markers such as albumin, transferrin and lymphocytes counting the most comum used criteria. The aim of this study was to evaluate the association between malnutrition and the risk of early periprosthetic infection after TKA. We performed a cohort study with database analysis of the TKA performed at the National Institute of Traumatology and Orthopedic Jamil Haddad (INTO) between 2014 and 2016. Malnutrition was defined by at least one of the following laboratory criteria : serum albumin <3,5 g / dL, sérum transferrin <200 mg/dl and blood lymphocytes <1500 cells/mm3. A total of 2,080 patients undergoing TKA were included in the study, with a median age of 68 years, of which 1,530 were women and 550 were men. The infection rate was 2.06%. No differences were found regarding the distribution by gender, age, anesthetic risk classification, body mass index (BMI), preoperative hemoglobin and blood transfusion volume between patients who developed infection and the non-infected patients. The prevalence of preoperative comorbidities between the groups was also investigated, showing symmetrical distribution for hypertension, diabetes, heart disease, dyslipidemia and rheumatoid arthritis. The prevalence found for malnutrition based on serum albumin, transferrin and lymphocyte counts was 2.1%, 7.3% and b10.3%. None of the three markers proved to be a predictor of infectious complication after arthroplasty. The prevalence of malnutrition, defined as the change in at least one marker, was 17.7%. The relative risk for infection in malnourished patients compared to non-malnourished patients was 0.93 (95% CI: 0.27-3.18) (p = 0.905). The BMI category analysis showed infection in 12.5% of patients underweight, 4.1% of patients with normal weight, 1.5% of overweight patients, 1.3% of obese patients and 2.7% of the morbidly obese. The risk of infection of patients underweight and normal weight were significantly higher than that of obese patients (p<0,05). The positive association between malnutrition and preoperative anemia (p = 0.01) was identified, as well as the need for blood transfusion (p = 0.02). On the other hand, hypertension and DM were significantly less prevalent in denutrans, with p of 0.04 and 0.001 respectively. Malnutrition diagnosed by laboratory criteria was not shown to be a risk factor for early joint infection after TKA.