Colonoscopy Near Time of Joint Replacement Doesn't Increase Infection Risk

Colonoscopy performed within 6 months before or after total joint arthroplasty (TJA) did not increase the risk of periprosthetic joint infection (PJI), according to a retrospective cohort study.

In an analysis of a large military database, there was no association of colonoscopy with PJI risk when colonoscopy was performed within 6 months before total joint replacement (adjusted odds ratio [aOR] 1.10, 95% CI 0.98-1.23) or within 6 months after joint replacement (aOR 0.90, 95% CI 0.74-1.08), reported researchers led by Ashley Anderson, MD, of the Walter Reed National Military Medical Center in Bethesda, Maryland, in JAMA Network Open.

"On the basis of these results, we do not recommend delaying TJA after colonoscopy for patients with joint pain that is limiting function and quality of life," the authors wrote. "Similarly, we do not recommend delaying routine health screening procedures, such as a colonoscopy after TJA, because postoperative timing does not appear to increase the risk of PJI."

"Ultimately, when faced with scheduling colonoscopy for routine screening with either an existing or upcoming hip or knee arthroplasty, patients and their orthopedic surgeons must decide if there is an optimal time period within which to schedule these two generally elective procedures, and in which order," Anderson told MedPage Today in an email.

The study looked at PJI within 1 year after either total knee replacement and total hip replacement and within 1 year from the post-TJA index colonoscopy date.

Anderson and colleagues' study adds to the growing body of research trying to answer the question of whether perioperative colonoscopy increases risk of PJI in TJA, Jessica Seidelman, MD, MPH, of Duke University School of Medicine in Durham, North Carolina, commented to MedPage Today.

"The concern here is that PJIs are an incredibly morbid complication of total joint arthroplasty," Seidelman explained. "Colonoscopy can cause transient bacteremia, particularly if a biopsy is taken or a complication, such as a GI bleed or perforation, occurs."

"Analysis of both cohorts suggest that transient bacteremia from preoperative or postoperative colonoscopy does not increase the risk of PJI in TJA," Anderson and co-authors wrote.

In patients who underwent a colonoscopy in the 6 months before TJA, 2.8% developed a PJI within 1 year after TJA versus 2.4% of patients who did not have a colonoscopy before TJA.

Among patients who had a colonoscopy after TJA, 1.8% developed PJI within 1 year from the index colonoscopy date versus 2.1% in the group who did not have a colonoscopy after TJA.

Another recently published study found that colonoscopy with planned biopsy did not increase the risk of PJI in patients with pre-existing knee implants, Seidelman noted. Also, in that study, antibiotic prophylaxis in patients undergoing colonoscopy had no effect on PJI rates.

"While both of these studies provide some reassuring data, I think that there are still important considerations to take into account when an orthopedic surgeon is trying to give guidance to their individual patient," Seidelman emphasized. "The risk of potential PJI following a colonoscopy will also depend on the comorbidities and immunocompetency of that individual patient."

Of note, in the current study, researchers found a higher risk for PJI among people with several comorbidities -- cerebrovascular disease, cardiovascular disease, diabetes, kidney disease, and pulmonary disease -- who received a colonoscopy within 6 months before a TJA. Also, male sex was associated with higher PJI risk (aOR 1.30, 95% CI 1.23-1.37).

In the group that had a colonoscopy after TJA, male sex was once again associated with increased PJI risk (aOR 1.23, 95% CI 1.08-1.40), along with diabetes, kidney disease, and pulmonary disease.

The study included data from 243,671 patients in the Military Health System who were older than age 45 and who had a total hip replacement or total knee replacement from 2010 through 2016, as identified from Current Procedural Terminology codes in patient records. Approximately 60% of the study population were women and the mean age was 70 years.

Of patients included in the study, 4.7% received a colonoscopy within 6 months before TJA and 3% received a colonoscopy within 6 months after surgery. Researchers identified PJI and colonoscopy status using diagnostic and procedural codes. Comorbidities were identified in the Military Data Repository health risk files.

The authors acknowledged that retrospective studies of large databases can be limited by coding errors. Also, the expected low incidence of PJI precluded the researchers' ability to evaluate potential differences in patients who had invasive colonoscopies versus those who had surveillance colonoscopies.

Researchers could not characterize differences in risk with colonoscopy exposures less than 6 months preoperatively and postoperatively. "This limitation may obscure a potential elevated PJI risk associated with colonoscopy exposure defined as less than 1 to 2 months after TJA," they noted. Also, late PJI -- occurring more than 1 year after TJA or postsurgery colonoscopy -- was not evaluated in this study.

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