Skip to main content Accessibility help

The cost of managing complex surgical site infections following primary hip and knee arthroplasty: A population-based cohort study in Alberta, Canada

  • Elissa D. Rennert-May (a1) (a2), John Conly (a1) (a3) (a4) (a5) (a6), Stephanie Smith (a7), Shannon Puloski (a8), Elizabeth Henderson (a2), Flora Au (a1) and Braden Manns (a1) (a2) (a5) (a9)...



Nearly 800,000 primary hip and knee arthroplasty procedures are performed annually in North America. Approximately 1% of these are complicated by a complex surgical site infection (SSI), leading to very high healthcare costs. However, population-based studies to properly estimate the economic burden are lacking. We aimed to address this knowledge gap.


Economic burden study.


Using administrative health and clinical databases, we created a cohort of all patients in Alberta, Canada, who received a primary hip or knee arthroplasty between April 1, 2012, and March 31, 2015. All patients who developed a complex SSI postoperatively were identified through a provincial infection prevention and control database. A combination of corporate microcosting data and gross costing methods were used to determine total mean 12- and 24-month costs, enabling comparison of costs between the infected and noninfected patients.


Mean 12-month total costs were significantly greater in patients who developed a complex SSI compared to those who did not (CAD$95,321 [US$68,150] vs CAD$19,893 [US$14,223]; P < .001). The magnitude of the cost difference persisted even after controlling for underlying patient factors. The most commonly identified causative pathogen (38%) was Staphylococcus aureus (95% MSSA).


Complex SSIs following hip and knee arthroplasty lead to high healthcare costs, which are expected to rise as the yearly number of surgeries increases. Using our costing estimates, the cost-effectiveness of different strategies to prevent SSIs should be investigated.


Corresponding author

Author for correspondence: Braden Manns; HRIC Building, 2500 University Drive NW, Calgary, AB T2N1N4. E-mail:


Hide All
1. Hip and knee replacements in Canada: Canadian joint replacement registry 2014 annual report. Canadian Institute for Health Information website. Published 2014. Accessed March 15, 2018.
2. Rennert-May, E, Bush, K, Vickers, D, Smith, S. Use of a provincial surveillance system to characterize postoperative surgical site infections after primary hip and knee arthroplasty in Alberta, Canada. Am J Infect Control 2016;44:13101314.
3. Total hip and total knee replacement. The Joint Commission website. Published 2017 Accessed April 2, 2018.
4. Hospitalizations, early revisions and infections following joint replacement surgery. Canadian Institute for Health Information website. Published 2008. Accessed March 15, 2018.
5. Miletic, KG, Taylor, TN, Martin, ET, Vaidya, R, Kaye, KS. Readmissions after diagnosis of surgical site infection following knee and hip arthroplasty. Infect Control Hosp Epidemiol 2014; 35:152157.
6. Horan, TC, Andrus, M, Dudeck, MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2018; 36:309332.
7. Osmon, DR, Berbari, EF, Berendt, AR, et al. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2013; 56:e1e25.
8. Zimlichman, E, Henderson, D, Tamir, O, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med 2013; 173:20392046.
9. Tansey, R, Mirza, Y, Sukeik, M, Shaath, M, Haddad, FS. Definition of periprosthetic hip and knee joint infections and the economic burden. Open Orthop J 2016;10:662668.
10. 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.
11. Kuiper, JW, Willink, RT, Moojen, DJF, van den Bekerom, MP, Colen, S. Treatment of acute periprosthetic infections with prosthesis retention: review of current concepts. World J Orthop 2014,5:667676.
12. Marculescu, CE, Berbari, EF, Hanssen, AD, et al. Outcome of prosthetic joint infections treated with debridement and retention of components. Clin Infect Dis 2006;42:471478.
13. Fehring, TK, Odum, SM, Berend, KR, et al. Failure of irrigation and debridement for early postoperative periprosthetic infection. Clin Orthop Relat Res 2013;471:250257.
14. Gehrke, T, Alijanipour, P, Parvizi, J. The management of an infected total knee arthroplasty. Bone Joint J 2015; 97B:2029.
15. Lauderdale, KJ, Malone, CL, Boles, BR, Morcuende, J, Horswill, AR. Biofilm dispersal of community-associated methicillin-resistant Staphylococcus aureus on orthopedic implant material. J Orthop Res 2010; 28:5561.
16. Hutzler, L, Williams, J. Decreasing the incidence of surgical site infections following joint replacement surgery. Bull Hosp Jt Dis 2013;75:268273.
17. Fabbian, F, De Giorgi, A, Maietti, E, et al. A modified Elixhauser score for predicting in-hospital mortality in internal medicine admissions. Eur J Intern Med 2017;40:3742.
18. Shrive, FMC, Ghali, WA, Donaldson, C, Manns, BJ. The impact of using different costing methods on the results of an economic evaluation of cardiac care: microcosting vs gross-costing approaches. Health Econ 2009; 18:377388.
19. Hutcheson G. GLM models and OLS regression. website. Published 2011. Accessed March 15, 2018.
20. Kapadia, BH, McElroy, MJ, Issa, K, Johnson, AJ, Bozic, KJ, Mont, MA. The economic impact of periprosthetic infections following total knee arthroplasty at a specialized tertiary-care center. J Arthroplasty 2014; 29:929932.
21. Kapadia, BH, Banerjee, S, Cherian, JJ, Bozic, KJ, Mont, MA. The eonomic impact of periprosthetic infections after total hip arthroplasty at a specialized tertiary-care center. J Arthroplasty 2016; 31:14221426.
22. Ramos, N, Stachel, A, Phillips, M, Vigdorchik, J, Slover, J, Bosco, JA. Prior Staphylococcus aureus nasal colonization: a risk factor for surgical site infections following decolonization. J Am Acad Orthop Surg 2016;24:880885.
23. Chen, AF, Heyl, AE, Xu, PZ, Rao, N, Klatt, BA. Preoperative decolonization effective at reducing staphylococcal colonization in total joint arthroplasty patients. J Arthroplasty 2013;28:1820.


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed