The Journal of Arthroplasty xxx (2023) 1e8

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The Journal of Arthroplasty

journal homepage: www.arthroplastyjournal.org

Positive Preoperative Colonization With Methicillin Resistant

Staphylococcus Aureus Is Associated With Inferior Postoperative
Outcomes in Patients Undergoing Total Joint Arthroplasty
Itay Ashkenazi, MD a, b, *, Jeremiah Thomas a, Kyle W. Lawrence a,
Joshua C. Rozell, MD a, Claudette M. Lajam, MD a, Ran Schwarzkopf, MD, MSc a
a
Department of Orthopaedic Surgery, NYU Langone Health, New York, New York
b
Division of Orthopaedic Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel

a r t i c l e i n f o a b s t r a c t

Article history: Background: The impact of preoperative nasal colonization with methicillin resistant staphylococcus
Received 14 December 2022 aureus (MRSA) on total joint arthroplasty (TJA) outcomes is not well understood. This study aimed to
Received in revised form evaluate complications following TJA based on patients’ preoperative staphylococcal colonization status.
20 February 2023
Methods: We retrospectively analyzed all patients undergoing primary TJA between 2011 and 2022 who
Accepted 21 February 2023
Available online xxx
completed a preoperative nasal culture swab for staphylococcal colonization. Patients were 1:1:1 pro-
pensity matched using baseline characteristics, and stratified into 3 groups based on their colonization
status: MRSA positive (MRSAþ), methicillin sensitive staphylococcus aureus positive (MSSAþ), and
Keywords:
total joint arthroplasty
MSSA/MRSA negative (MSSA/MRSA). All MRSAþ and MSSA þ underwent decolonization with 5%
complications povidone iodine, with the addition of intravenous vancomycin for MRSA þ patients. Surgical outcomes
methicillin resistant staphylococcus aureus were compared between groups. Of the 33,854 patients evaluated, 711 were included in final matched
MRSA analysis (237 per group).
decolonization Results: The MRSA þ TJA patients had longer hospital lengths of stay (P ¼ .008), were less likely to
discharge home (P ¼ .003), and had higher 30-day (P ¼ .030) and 90-day (P ¼ .033) readmission rates
compared to MSSAþ and MSSA/MRSA-patients, though 90-day major and minor complications were
comparable across groups. MRSA þ patients had higher rates of all-cause (P ¼ .020), aseptic (P ¼ .025)
and septic revisions (P ¼ .049) compared to the other cohorts. These findings held true for both total knee
and total hip arthroplasty patients when analyzed separately.
Conclusion: Despite targeted perioperative decolonization, MRSA þ patients undergoing TJA have longer
lengths of stay, higher readmission rates, and higher septic and aseptic revision rates. Surgeons should
consider patients’ preoperative MRSA colonization status when counseling on the risks of TJA.
© 2023 Elsevier Inc. All rights reserved.

Evaluating complication risk for patients undergoing total joint
arthroplasty (TJA) is critical for adequate preoperative patient
counseling and improvement in clinical outcomes for surgical
candidates [1]. Perioperative optimization to minimize the risk of
infectious complications has become an area of increased focus, as
One or more of the authors of this paper have disclosed potential or pertinent
conflicts of interest, which may include receipt of payment, either direct or indirect,
institutional support, or association with an entity in the biomedical field which
may be perceived to have potential conflict of interest with this work. For full
disclosure statements refer to https://doi.org/10.1016/j.arth.2023.02.065.
* Address correspondence to: Itay Ashkenazi, MD, Division of Adult Recon-
struction, Department of Orthopaedic Surgery, NYU Langone Orthopaedic Hospital,
Hospital of Joint Diseases, 301 East 17th Street, New York, NY 10003.
infection portends increased patient morbidity, worse functional
status, and increased healthcare costs [2].
Preoperative nasal colonization screening for methicillin sen-
sitive staphylococcus aureus (MSSA) and methicillin resistant
staphylococcus aureus (MRSA) as well as decolonization protocols
have been widely adopted to minimize surgical risk in colonized
patients [3]. Decolonization programs utilizing nasal iodine and
vancomycin have been demonstrated as cost-effective and may
partially reduce postoperative infection risk [4,5]. However, a
considerable percentage of patients undergoing decolonization
remain colonized with MRSA at the time of surgery [6], and
previous reports have shown that an increased risk of infection
remains even after successful MRSA eradication [7]. Furthermore,
data on the association between MRSA colonization and

https://doi.org/10.1016/j.arth.2023.02.065
0883-5403/© 2023 Elsevier Inc. All rights reserved.
2 I. Ashkenazi et al. / The Journal of Arthroplasty xxx (2023) 1e8
complications after TJA have been limited by small sample sizes
and inadequate control for confounding variables [7e10]. Addi-
tionally, the relationship between MRSA colonization status and
risk of revision surgery has not been investigated. Despite this,
prior analyses have justified decolonization protocols based on
proposed reductions in revision rates and subsequent reductions
in healthcare cost [11,12].
This study aimed to examine readmission, complication, as well
as septic and aseptic revision rates following TJA based on patients’
MSSA and MRSA colonization status. We hypothesized that MRSA
colonization would be associated with a higher risk of post-
operative complications compared to MSSA colonization and
negative colonization, including prosthetic joint infection (PJI),
surgical site infection (SSI), and septic revision.
Methods
Study Design
After receiving approval for this study from our Institutional Re-
view Board, we retrospectively reviewed all patients undergoing
primary, elective total hip arthroplasty and total knee arthroplasty
(THA and TKA) at a single, urban academic center between June 1st
2011, and May 31st 2022. Patients were identified using current
procedural terminology codes 27130 and 27447. Patients undergoing
primary, elective TKA or THA during the study period who had a
recorded, preoperative nasal colonization swab were included for
analyses. Patients were excluded if they did not have an available
preoperative nasal swab or if their surgical indication was for fracture
or cancer. We stratified patients into groups based whether their
preoperative staphylococcal colonization study was positive for
MRSA (MRSAþ), positive for MSSA (MSSAþ), or MRSA/MSSA negative
(MRSA/MSSA). Subanalyses of clinical outcomes by procedure type
(THA or TKA) were performed. Propensity matching was conducted to
control for differences in baseline characteristics between groups.
Surgery
All patients regardless of colonization status used chlorhexidine
gluconate wipes on their bodies the night prior to and on the day of
surgery. The MRSAþ and MSSAþ patients also underwent day of
surgery decolonization consisting of 5% povidone iodine solution
(3M Nasal Antiseptic, 3M health care, St. Paul, Minnesota) nasal
swabs in both nostrils while in the preoperative holding area.
Perioperatively, all patients receive 3 weight-based doses of cefa-
zolin (1 gram [g] for patient weight <60 kilograms [kg], 2 g for
patient weight between 60 and 120 kg, and 3 g for patient weight
over 120 kg). Additionally, our institution added 1 perioperative
weight-based dose of gentamicin (5 mg/kg) to this antibiotic
protocoleregardless of colonization statusefor THA patients
beginning in July 1st, 2012, and for TKA patients beginning June 1st,
2021. The first dose of cefazolin was given within 30 minutes of
incision with a single gentamicin dose, and 2 additional cefazolin
doses were administered during the first 24 hours postoperatively.
MRSAþ patients received weight-based vancomycin (15 mg/kg)
with the first dose of cefazolin and then subsequently for 24 hours
following surgery. For patients who have an anaphylactic or life-
threatening reaction to penicillin or cephalosporins, cefazolin was
replaced with weight-based vancomycin (15 mg/kg). No patients
received extended oral antibiotic prophylaxis.
Data Collection and Outcome Measures
Patient baseline characteristics including age, sex, race, body
mass index (BMI), American Society of Anesthesiology score,
Charlson comorbidity index [13], smoking status, laboratory data
and latest follow-up time were collected from our institution’s
electronic medical record database (Epic Caboodle. Version 15,
Verona, Wisconsin). Follow-up duration was defined as the time
from surgery to either the last office visit at our institution or the
date of death.
We compared perioperative data including surgical time,
lengths of stay (LOS), discharge dispositions, 30-day and 90-day
readmissions, and complication rates between groups. The 30-
day and 90-day complication rates were categorized as major (PJI,
sepsis, mortality, all-cause revision) and minor (SSI and wound
dehiscence). The PJIs within the follow-up period were identified
and were diagnosed if patients met PJI criteria as defined by the
Musculoskeletal Infection Society [14,15].
All-cause, septic, and aseptic revisions were compared between
groups. The incidence of septic and aseptic revisions was evaluated
until the latest follow-up for all patients.
Data Analyses
Due to significant differences in demographic parameters be-
tween groups as shown in Table 1, we performed a 1:1:1 propensity
match by age, BMI, American Society of Anesthesiology score,
Charlson comorbidity index, sex, smoking status, race, and follow-
up duration to account for any potential confounding variables. The
propensity score was defined as the conditional probability for any
of the outcome variables given a patient’s baseline demographic
variables. The 1:1:1 match was performed using a balanced,
nearest-neighbor propensity score. Propensity score matching has
been described in the literature as an optimal modality of esti-
mating differences between groups [16,17]. For subanalyses by type
of surgery, MRSAþ patients who underwent THA (n ¼ 102, 43%),
and TKA (n ¼ 135, 57%) were separately propensity matched using
the same variables to MSSAþ and MRSA/MSSA- patients who un-
derwent THA and TKA, respectively.
Demographic and clinical baseline characteristics were
described as means with ranges for continuous variables and fre-
quencies with percentages for categorical variables. Differences in
continuous variables were statistically analyzed using 1-way
analysis of variance and categorical variables were analyzed using
chi-squared analyses (c2). P values less than .05 were considered
statistically significant. Survivorships were analyzed and presented
graphically using the KaplaneMeier methods and log-rank tests.
Outcomes and survivorship data were calculated by using time of
latest follow-up. Patients who died with the implant in situ and
patients lost to follow-up were considered censored at the date of
death and last follow-up, respectively. All data analyses were per-
formed using statistical package for the social sciences v25 (IBM
Corporation, Armonk, New York).
Comparison Groups
Overall, a total of 33,854 primary TJA procedures were per-
formed during the study period. There were 1,670 patients (4.9%)
who did not have available preoperative nasal swab test for MRSA
colonization and were excluded from the study. This resulted in
32,184 patients (95.1%) meeting inclusion criteria. The majority of
patients had a MRSA/MSSA negative preoperative colonization
status (n ¼ 29,670, 92.2%), followed by MSSAþ patients (n ¼ 2,197,
6.8%) and MRSAþ patients (n ¼ 317, 1%). Demographic data of the
matched groups is presented in Table 2. After propensity matching,
no differences in demographic variables were observed between
groups. Mean follow-up duration was also comparable between
groups.
 I. Ashkenazi et al. / The Journal of Arthroplasty xxx (2023) 1e8 3

Table 1
Demographic and Surgery Data for Unmatched Group.

Variable MRSA/MSSA-(n ¼ 29,670) MSSAþ (n ¼ 2,197) MRSAþ (n ¼ 317) P Value

Sex (women) no. (%) 18,777 (63.3) 1,153 (52.5) 175 (55.2) <.001
Age (y), mean [range] 65 [18-99] 62 [21-94] 64 [31-90] <.001
Race, no. (%) <.001
White 18,882 (63.6) 1,562 (71.1) 223 (70.3)
African-American 4,898 (16.5) 236 (10.7) 46 (14.5)
Asian 1,049 (3.5) 67 (3.0) 8 (2.5)
Other race 4,841 (16.3) 332 (15.1) 40 (12.6)
Smoking, no. (%) .179
Never smoker 16,051 (54.9) 1,144 (54.1) 172 (57.0)
Former smoker 10,778 (36.9) 763 (36.1) 109 (36.1)
Current smoker 2,161 (7.4) 179 (8.5) 19 (6.3)
Not assessed 246 (0.8) 27 (1.3) 2 (0.7)
ASA, no. (%) <.001
1 1,207 (4.1) 101 (4.6) 10 (3.2)
2 17,464 (58.9) 1,406 (64.5) 168 (53.0)
3 10,490 (35.4) 643 (29.5) 128 (40.4)
4 464 (1.6) 30 (1.4) 11 (3.5)
5 1 (0.0) 0 (0.0) 0 (0.0)
Missing 44 (0.2) 17 (0.8) 0 (0.0)
CCI, mean (SD) 1.31 (2.03) 1.01 (1.68) 1.46 (2.19) <.001
BMI (kg/m2), mean [range] 30.9 [13.9-6.9] 31.1 [17.0-62.1] 31.5 [17.8-55.5] .237
Anesthesia, no. (%) <.001
General 3,788 (12.8) 389 (17.7) 54 (17.0)
Regional 25,882 (87.2) 1,808 (82.3) 263 (83.0)
Follow-up duration (y), mean [range] 3.83 [0.00-11.34] 5.81 [0.46-11.35] 5.25 [0.10-11.33] <.001

MSSA, methicillin sensitive staphylococcus aureus; MRSA, methicillin resistant staphylococcus aureus; ASA, American society of anesthesiologists; CCI, Charlson comorbidity
index; SD, standard deviation; BMI, body mass index.

Results Rates of 90-day major and minor complications including

The MRSAþ patient group had significantly longer LOS (P ¼
.008) and were less likely to be discharged home (P ¼ .003)
compared to MSSAþ and MSSA/MRSA- patients. The 30-day read-
mission rates (P ¼ .033) and 90-day readmission rates (P ¼ .030)
were higher for MRSAþ patients compared to MSSAþ and MRSA/
MSSA- patients. Indications for 90-day readmission were compa-
rable between groups (Table 3).
mortality (P ¼ .367), sepsis (P ¼ .606), SSI (P ¼ .778) and wound
dehiscence (P ¼ .172) were similar between groups. There was a
trend towards higher 90-day PJI rates (P ¼ .094) and higher 90-day
all-cause revision rates (P ¼ .108) in the MRSAþ group compared to
the MSSAþ and MRSA/MSSA- groups (Table 3).
During the follow-up period, the MRSAþ group had significantly
higher rates of all-cause (P ¼ .002), aseptic (P ¼ .025) and septic (P ¼
.049) revisions (see Table 4). Indications for aseptic revisions were

Table 2
Demographic and Surgery Data for Matched Group.

Variable MRSA/MSSA-(n ¼ 237) MSSAþ (n ¼ 237) MRSAþ (n ¼ 237) P Value

Sex (women), no. (%) 155 (65.4) 135 (57.0) 135 (57.0) .096
Age (y), mean [range] 65 [19-90] 64 [29-94] 65 [31-90] .848
Race, no. (%) .353
White 177 (74.7) 167 (70.5) 170 (71.7)
African-American 34 (14.3) 40 (16.9) 31 (13.1)
Asian 8 (3.4) 9 (3.8) 5 (2.1)
Other race 18 (7.6) 21 (8.9) 31 (13.1)
Smoking, no. (%) .941
Never smoker 128 (54.0) 134 (56.5) 136 (57.4)
Former smoker 89 (37.6) 83 (35.0) 82 (34.6)
Current smoker 19 (8.0) 17 (7.2) 17 (7.2)
Not assessed 1 (0.4) 3 (1.3) 2 (0.8)
ASA, no. (%) .276
1 6 (2.5) 8 (3.4) 8 (3.4)
2 117 (49.4) 132 (55.7) 125 (52.7)
3 112 (47.3) 90 (38.0) 96 (40.5)
4 2 (0.8) 7 (3.0) 8 (3.4)
5
Missing 0 (0.0) 1 (0.4) 0 (0.0)
CCI, mean (SD) 1.25 (1.73) 1.53 (2.01) 1.36 (1.66) .240
BMI (kg/m2), mean [range] 31.8 [16.8-57.0] 31.7 [18.3-62.1] 31.6 [17.8-55.5] .906
Anesthesia, no. (%) .245
General 27 (11.4) 39 (16.5) 37 (15.6)
Regional 210 (88.6) 198 (83.5) 200 (84.4)
Follow-up duration (y), mean [range] 4.51 [0.03-10.24] 4.32 [0.01-9.76] 4.53 [0.00-9.63] .647

MSSA, methicillin sensitive staphylococcus aureus; MRSA, ethicillin resistant staphylococcus aureus; ASA, American society of anesthesiologists; CCI, Charlson comorbidity
index; SD, standard deviation; BMI, body mass index.
4 I. Ashkenazi et al. / The Journal of Arthroplasty xxx (2023) 1e8

Table 3
Clinical Outcomes for Matched Groups.

Variable MRSA/MSSA-(n ¼ 237) MSSAþ (n ¼ 237) MRSAþ (n ¼ 237) P Value

Length of stay (d), mean [range] 2.58 [0.33-14.38] 2.85 [0.33-19.46] 3.07 [0.33-10.00] .008
Discharge deposition, no. (%) .003
Home 195 (82.3) 203 (85.7) 170 (71.7)
SNF 33 (13.9) 25 (10.5) 49 (20.7)
ARC 9 (3.8) 9 (3.8) 18 (7.6)
30-day readmission (all-cause), no. (%) 5 (2.1) 4 (1.7) 13 (5.5) .033
90-day readmission (all-cause), no. (%) 9 (3.8) 14 (5.9) 23 (9.7) .030
Nonorthopedic related 3 (33.3) 5 (35.7) 6 (26.1) .808
Periprosthetic fracture 1 (11.1) 3 (21.4) 0 (0.0) .077
PJI 1 (11.1) 2 (14.3) 6 (26.1) .528
Surgical site noninfectious complicationa 3 (33.3) 1 (7.1) 5 (21.7) .283
Nonsurgical site infectious complication 0 (0.0) 2 (14.3) 2 (8.7) .495
SSI 1 (11.1) 1 (7.1) 2 (8.7) .947
Mechanical implant complication 0 (0.0) 0 (0.0) 2 (8.7) .352
Major complications at 90-d, no. (%)
Mortality 0 (0.0) 0 (0.0) 1 (0.4) .367
Sepsis 0 (0.0) 1 (0.4) 1 (0.4) .606
PJI 1 (0.4) 2 (0.8) 6 (2.5) .094
All-Cause Revision 2 (0.8) 6 (2.5) 9 (3.8) .108
Minor complications at 90-d, no. (%)
SSI 1 (0.4) 1 (0.4) 2 (0.8) .778
Dehiscence 1 (0.4) 0 (0.0) 3 (1.3) .172

MSSA, methicillin sensitive staphylococcus aureus; MRSA, methicillin resistant staphylococcus aureus; SNF, skilled nurse facility; ARC, acute rehabilitation center; PJI,
prosthetic joint infection; SSI, surgical site infection.
a
Surgical site noninfectious complications included dehiscence, hematoma and seroma.

comparable between groups. Intraoperative culture results were
positive for MRSA for the majority of the septic revisions in the
MRSAþ colonization group (n ¼ 8, 61.5%). Proportions of MRSA
related PJI in the MSSAþ patient group (n ¼ 2, 33.3%) and the
MRSA/MSSA- patient group (n ¼ 1, 25%) were lower, although not
statistically significant (P ¼ .314).
These findings held true for both TKA and THA patients when
analyzed separately; subanalyses of patients who received TKA (n ¼
135, 57%) or THA (n ¼ 102, 43%) are presented in Table 5. The LOS
was significantly longer in the MRSAþ group for both TKA (P < .001)
and THA (P < .001) compared to the other groups. Rates of 30-day
readmission for MRSAþ patients who underwent THA were
significantly higher than in for the MSSAþ and MRSA/MSSA-
groups (P ¼ .041). This trend was also seen for 30-day read-
mission of MRSAþ patients who underwent TKA, although not to a
level of statistical significance (P ¼ .199). Rates of 90-day read-
missions in the MRSAþ group were higher in TKA (P ¼ .013) and
THA (P ¼ .038) compared to both MSSAþ and MSSA/MRSA-
patients. For TKA no significant differences were found for major
(P ¼ .600) or minor (P ¼ .070) complications. No cases of PJI at
90-days were identified in the TKA group. Rates of all-cause revi-
sion TKA during the follow-up period were higher for the MRSAþ
patients (P ¼ .036), with a trend towards increased septic revisions
(P ¼ .072) compared to the other groups. MRSAþ patients who
underwent THA had significantly more major complications (P ¼
.021) and 90-days PJIs (0.040) compared to MSSAþ patients and
MRSA/MSSA- patients, though no differences in minor complica-
tions rates were observed (P ¼ .613). Similarly, MRSAþ patients
who underwent THA had significantly higher rates of revisions (P ¼
.001), higher rates of aseptic revisions (P ¼ .026) and trended to-
wards a higher septic revision rate (P ¼ .065).
KaplaneMeyer survivorship analysis describing freedom from
all-cause revision during the study period is presented in Figure 1,
and shows significantly decreased survivorship for the MRSAþ
group (P ¼ .002) when compared to MSSAþ and MSSA/MRSA-
patients. At 2 years, freedom from all-cause revision was 92.9,
93.7, and 98.7% for MRSAþ, MSSAþ, and MRSA/MSSA- groups,
respectively. At latest follow-up freedom from all-cause revision
was 82.9, 90.1, and 95.7% for MRSAþ, MSSAþ, and MRSA/MSSA-
groups, respectively.

Table 4
Revision Data for Matched Groups.

Variable MRSA/MSSA-(n ¼ 237) MSSAþ (n ¼ 237) MRSAþ (n ¼ 237) P Value

All-cause revision during follow-up period, no. (%) 7 (3.0) 18 (7.6) 27 (11.4) .002
Aseptic revision, no. (%) 3 (1.3) 12 (5.1) 14 (5.9) .025
Aseptic loosening 2 (66.7) 3 (25.0) 6 (42.9) .359
Instability 0 (0.0) 2 (16.7) 4 (28.6) .489
Periprosthetic fracture 0 (0.0) 5 (41.7) 1 (7.1) .062
Dehiscence 1 (33.3) 0 (0.0) 1 (7.1) .125
Arthrofibrosis 0 (0.0) 0 (0.0) 1 (7.1) .574
Other 0 (0.0) 2 (16.7) 1 (7.1) .601
Septic Revision, no. (%) 4 (1.7) 6 (2.5) 13 (5.5) .049
MRSA 1 (25.0) 2 (33.3) 8 (61.5) .314
MSSA 0 (0.0) 2 (33.3) 3 (23.1) .450
Other gram-positive 1 (25.0) 0 (0.0) 0 (0.0) .083
Other gram-negative 1 (25.0) 1 (16.7) 0 (0.0) .217
Polybacterial 1 (25.0) 0 (0.0) 1 (7.7) .382
Fungal 0 (0.0) 1 (16.7) 0 (0.0) .227
Culture-negative 0 (0.0) 0 (0.0) 1 (7.7) .669

MSSA, methicillin sensitive staphylococcus aureus; MRSA, methicillin resistant staphylococcus aureus.
 I. Ashkenazi et al. / The Journal of Arthroplasty xxx (2023) 1e8 5

Table 5
Clinical Outcomes for Matched Groups Stratified by Type of Surgery.

Variable MRSA/MSSA- MSSAþ MRSAþ P Value

TKA
Number of patients n ¼ 135 n ¼ 135 n ¼ 135
Length of stay (d), mean [range] 2.33 [0.42-8.25] 2.99 [0.33-13.38] 3.07 [0.42-14.38] <.001
30-day readmission (all-cause), no. (%) 2 (1.5) 2 (1.5) 6 (4.4) .199
90-day readmission (all-cause), no. (%) 4 (3.0) 5 (3.8) 10 (7.4) .013
Major complicationsa at 90-day, no. (%) 2 (1.5) 1 (0.7) 3 (2.2) .600
PJI at 90-day, no (%) 0 (0.0) 0 (0.0) 0 (0) -
Minor complicationsb at 90-day, no. (%) 0 (0) 1 (0.7) 4 (3.0) .070
All-cause revision during follow-up period, no. (%) 1 (0.7) 5 (3.7) 9 (6.7) .036
Aseptic revision 1 (0.7) 4 (3.0) 5 (3.7) .264
Septic revision 0 (0.0) 1 (0.7) 4 (3.0) .072
THA
Number of patients n ¼ 102 n ¼ 102 n ¼ 102
Length of stay (d), mean [range] 2.42 [0.42-7.21] 2.25 [0.38-7.29] 3.06 [0.33-12.96] .003
30-Day readmission (all-cause), no. (%) 2 (2.0) 1 (1.0) 7 (6.9) .041
90-Day readmission (all-cause), no. (%) 3 (2.9) 9 (8.8) 13 (12.7) .038
Major complicationsa at 90-day, no. (%) 1 (1.0) 3 (2.9) 9 (8.8) .021
PJI at 90-day, no (%) 1 (1.0) 1 (1.0) 6 (5.9) .040
Minor complicationsb at 90-day, no. (%) 1 (1.0) 0 (0) 1 (1.0) .613
All-cause revision during follow-up period, no. (%) 3 (2.9) 8 (7.8) 18 (17.6) .001
Aseptic revision 1 (1.0) 4 (3.9) 9 (8.8) .026
Septic revision 2 (2.0) 4 (3.9) 9 (8.8) .065

MSSA, methicillin sensitive staphylococcus aureus; MRSA, methicillin resistant staphylococcus aureus; TKA, total knee arthroplasty; PJI, prosthetic joint infection; THA, total
hip arthroplasty.
a
Major complications included sepsis, mortality and revision of any cause.
b
Minor complications included surgical site infection and wound dehiscence.

Similarly, freedom from septic revision during the study period
was decreased for the MRSAþ group (P ¼ .045) compared to the
other groups, as shown in Figure 2. At 2 years, freedom from septic
revision was 95.6, 97.3, and 99.6% for MRSAþ, MSSAþ, and MRSA/
MSSA- groups, respectively. For total follow-up duration, freedom
from septic revision was 93.4, 97.3, and 97.6% for MRSAþ, MSSAþ,
and MRSA/MSSA- groups, respectively.
Discussion
To our knowledge, this is the largest propensity-matched study
analyzing perioperative characteristics and clinical outcomes of TJA
patients based on MRSA colonization status, and the first study
reporting on revision rates after TJA based on MRSA colonization
status. The principal findings of our study are as follows: (1) MRSAþ
patients had longer LOS and were less likely to be discharged home
after surgery; (2) MRSAþ patients had higher 30-day and 90-day
readmission rates than MRSA/MSSA- patients; (3) Ninety-day ma-
jor and minor complications were comparable regardless of colo-
nization status; (4) MRSAþ patients had higher rates of all-cause,
septic, and aseptic revisions than noncolonized patients; and (5)
proportions of MRSA related PJIs were higher in the MRSAþ patient
group compared to both other groups, although not statistically
significant.

Fig. 1. KaplaneMeier survivorship curve for the matched total groups for freedom from all-cause revision.
6 I. Ashkenazi et al. / The Journal of Arthroplasty xxx (2023) 1e8
Fig. 2. KaplaneMeier survivorship curve for the matched total groups for freedom from septic revision.
Prior analyses have demonstrated associations between preop-
erative MRSA colonization, the development of postoperative in-
fections, and extended LOS [3,18,19]. After matching for baseline
demographics and comorbidities, we found that patients who were
MRSAþ had the longest LOS, while those who were MRSA/MSSA-
had the shortest LOS. Furthermore, patients in the MRSAþ group
were more likely to be discharged to acute rehab or a skilled
nursing facility, whereas MSSAþ and MRSA/MSSA-patients were
more frequently discharged home. Though extended LOS for
MRSAþ has been attributed to early postoperative complications,
our matched analysis demonstrated longer LOS in the MRSAþ
group, despite comparable early complication rates. It is possible
that patients requiring discharge to such facilities due to lower
baseline functional status and independence may be more likely to
be colonized with resistant bacteria due to prior medical history or
exposure to MRSA during a previous hospital or rehabilitation
center admission. Additionally, placement at such facilities may
extend LOS for these patients as they await bed availability.
With regards to 90-day postoperative major and minor com-
plications (ie, sepsis, PJI, and SSI), we found no differences between
our matched groups. Rates of major and minor complications were
notably low in all groups. Prior analyses of TJA patients found to be
MRSAþ have demonstrated higher rates of SSI than those found in
noncolonized patients [7,10]. However, innate differences in base-
line patient characteristicsdnamely age, BMI, and smoking sta-
tusdmay also play a role in the development of SSI, and lack of
adequate control for these confounders has limited prior studies.
Furthermore, though prior literature on the efficacy of decoloni-
zation for MRSA in TJA patients has been conflicting and is
commonly limited by small sample sizes [7], recent systematic
reviews and meta-analyses have shown trends towards minimized
SSI with decolonization [20,21]. At our institution, patients found to
be MRSAþ received intravenous vancomycin in addition to the
standard nasal iodine, chlorhexidine wash, and perioperative
antibiotic protocol administered to all patients. These findings
suggest that when adjusting for baseline characteristics, TJA pa-
tients who are MRSAþ and receive prophylactic vancomycin peri-
operatively have comparable risk of SSI to MRSA/MSSA- patients
who receive standard antibiotic protocol.
When looking at readmissions within 90-days for any reason,
we found that rates were higher in the MRSAþ group, and this
trend held true in subanalyses for both THA and TKA. Importantly,
the finding that 90-day infectious complications such as SSI and
sepsis did not show a similar, correlative difference between groups
does not support a causative role of MRSA in the higher read-
mission rates. Rather, it is possible that the patients found to be
colonized with MRSA have other comorbid diagnoses necessitating
additional hospital visits, thus predisposing them to colonization
with resistant bacteria.
We found no differences in revision rates between groups
within 90 days of surgery. This trend held true for both THA and
TKA and when considering both aseptic and septic revisions. In
contrast, KaplaneMeier survival analysis for freedom from re-
visions at latest follow-up demonstrated poorer survival for MSSAþ
and MRSAþ patients, with the worst survival seen in MRSAþ pa-
tients. Though prior analyses have demonstrated an association
between MRSA colonization and SSI, the association between MRSA
colonization and revision has not yet been investigated [22e25].
While all-cause and aseptic revisions were higher in the MSSAþ
group than the MRSA/MSSA- group, the incidence of septic re-
visions within the follow-up period was comparable between
MSSAþ and MRSA/MSSA- patients. These findings suggest that
while MSSAþ status may be associated with other patient factors
that predispose to aseptic revision, MSSAþ status alone does not
appear to increase the risk of septic revision. When comparing
MRSAþ patients to MRSA/MSSA- patients, we observed a trend
towards higher rates of septic revisions within 90-days of surgery,
and significantly higher rates of both septic and aseptic revisions in
the MRSAþ group at latest follow-up. Our findings suggest that
despite undergoing a validated decolonization process as previ-
ously described, MRSAþ patients still experience higher septic
revision rates than noncolonized patients. Higher rates of post-
operative infection in MRSAþ patients even after confirmed nasal
decolonization have already been observed [7]. Tandon et al.
retrospectively studied 83 MRSA carriers undergoing TJAeof which
79 had confirmed decolonization by preoperative nasal swabeand
found that rates of superficial and deep infection were higher than
the noncolonized control group, even after confirmed decoloniza-
tion [7]. Furthermore, Baratz et al., reporting on 121 TJA patients
who had a positive MRSA colonization, found that even after a 5-
day decolonization regimen of nasal mupirocin and chlorhexidine
washes, 22% of patients remained colonized with MRSA when
 I. Ashkenazi et al. / The Journal of Arthroplasty xxx (2023) 1e8
rescreened at the time of surgery [6]. Thus, limited efficacy of
decolonization efforts may further explain the differences in pa-
tient outcomes based on colonization status. Importantly however,
there are multiple methodologies for MRSA decolonization
described within the literature [3,26,27]. However, none has
demonstrated superiority of any particular decolonization meth-
odology, thus limiting conclusions. Therefore, future work
including randomized controlled trials and larger meta-analyses
will be required to understand the relationship between staphy-
lococcal colonization and postoperative outcomes, and the role for
decolonization, in patients undergoing TJA. In addition, the
observed higher healthcare resource utilization by MRSAþ patients
may warrant future risk adjustment models for MRSAþ status, as
previously suggested for other high-risk patients in the bundle
payment setting [28,29].
MRSA was the most common organism causing PJI among the
MRSAþ patient group, substantially more than in the MSSAþ and
MRSA/MSSA- groups. However, there was a lack of statistical sig-
nificance, most likely due to the low incidence of septic revisions.
Prior studies have shown that among patients treated for PJI, MRSA
is the suspected causal pathogen in 13% to 22% of cases [30,31]. In
our subgroup of MRSAþ patients, the incidence of MRSA related
PJIs was markedly higher. These findings suggest that MRSAþ pa-
tients are at increased risk for MRSA related PJIs, which is associ-
ated with inferior outcomes [32], and highlights the importance of
proper infection prevention and decolonization.
This study is not without limitations. Due to its retrospective
design, an inherit selection bias and bias due to loss to follow-up
may have occurred. Also, though we were able to control for
baseline patient characteristics, we were unable to control for the
presence of other potential community or healthcare-related
staphylococcal exposures in the preoperative or postoperative
period. Additionally, though MRSAþ patients underwent a decol-
onization protocol prior to surgery, we were unable to assess
whether decolonization was achieved. This is due to the retro-
spective nature of the study and the fact that this is not the stan-
dard protocol in our institution. In addition, patients in our study
underwent a specific decolonization protocol, limiting the gener-
alizability of our findings to other decolonization methodologies
[3,26,27]. However, as there are no data suggesting superiority of 1
decolonization methodology over another [3,26,27], this study’s
findings may still be generalizable to other methodologies.
Furthermore, though we analyzed a robust sample size compared
to prior research on the topic, our study was still limited in power
after propensity matching due to the nature of the patients
investigated.
Conclusions
After controlling for other baseline factors, MRSAþ patients
undergoing TJA experience longer LOS and are less likely to
discharge home after surgery. While MRSAþ patients had more
readmissions for any reason within 30 and 90 days of surgery, rates
of SSI and sepsis were comparably low. Septic and aseptic revision
rates at latest follow-up were higher in the MRSAþ group, despite
receiving decolonization treatment and additional antibiotic pro-
phylaxis. These findings held true for both TKA and THA patient
cohorts when analyzed separately, as well as when combined to a
single TJA cohort. Therefore, despite decolonization protocols,
MRSAþ patients still carry an increased risk of complications
following TJA. There may be a role for evaluating rescreening and
confirmation of decolonization preoperatively to address this risk;
however, larger prospective trials are needed prior to imple-
mentation of such protocols in clinical practice.
7
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