Association of preoperative asymptomatic chronic pulmonary inflammation with subsequent periprosthetic joint infection following total joint arthroplasty

Association of preoperative asymptomatic chronic pulmonary inflammation with subsequent periprosthetic joint infection following total joint arthroplasty | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Association of preoperative asymptomatic chronic pulmonary inflammation with subsequent periprosthetic joint infection following total joint arthroplasty Haoliang Zhang, Si-Jia Xia, An-Dong Wang, He-Ping Wang, Zhi-Jun Shen, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6195490/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Purpose .Periprosthetic joint infection(PJI) is a catastrophic complication after total joint arthroplasty (TJA). Previous studies have shown that there are some factors such as urinary tract infection and dental infection before operation, which can lead to PJI. However, it is not clear whether preoperative asymptomatic chronic pulmonary inflammation will increase the risk of PJI. Methods The data of 1610 patients who underwent TJA in the affiliated Hospital of Xuzhou Medical University from December 2019 to July 2021 were analyzed retrospectively. According to the chest CT report, the patients were divided into pneumonia group and normal group. The patients were followed up for at least one year to compare the incidence of PJI between the pneumonia group and the normal group, and to determine the risk factors of PJI in patients with asymptomatic chronic pulmonary inflammation. Results 1610 patients were followed up, including pneumonia group in 573 cases (35.59%) and normal group in 1037 cases (64.41%). The postoperative PJI rate in the pneumonia group was 2.61%, which was significantly higher than that in the normal group (0.96%). Univariate analysis showed that there were significant differences in chronic pulmonary inflammation (P < 0.010), diabetes (P < 0.015), ESR (P < 0.01), albumin (P < 0.001), C-reactive protein (P < 0.001), hemoglobin (P < 0.001) and lymphocyte percentage (P < 0.023). Multivariate analysis showed that chronic pulmonary inflammation (OR 2.693, P = 0.021) and diabetes mellitus (OR 3.469, P = 0.005) were risk factors of PJI after TJA. Conclusion Patients undergoing elective TJA have a high prevalence of preoperative asymptomatic chronic pulmonary inflammation, and preoperative asymptomatic chronic pulmonary inflammation is a risk factor for PJI after prosthetic arthroplasty. It is recommended that prior to elective TJA surgery, a complete chest CT examination be performed to assess and control chronic inflammation in the lungs, thus effectively reducing the risk of PJI. asymptomatic pulmonary inflammation periprosthetic joint infection total joint arthroplasty chest CT bacteremia Introduction Total joint arthroplasty (TJA) is an effective treatment for end-stage joint disease, replacing the function of the diseased joint and providing pain relief. Periprosthetic joint infection (PJI) is a catastrophic complication after TJA, with an incidence of 1–3% [ 1 – 3 ]. Epidemiological investigation shows that PJI is the leading cause of revision after total knee arthroplasty(TKA), and it is also the third or fourth cause of revision after total hip arthroplasty(THA)[ 4 , 5 ], and the 5-year overall survival rate after PJI (THA is 67% TKA is 72%) is lower than that of breast cancer, melanoma and other malignant tumors[ 6 , 7 ]. The pathogens that cause PJI can come from local contamination (such as intraoperative contamination, local skin bacteria, etc.) and blood-derived migration (such as skin and soft tissue, urethra, oral tissue, intestinal and lung bacteremia)[ 8 – 11 ]. The occurrence of asymptomatic chronic pulmonary inflammation is associated with bacteremia, which may be an important risk factor for PJI[ 12 , 13 ]. Chronic pulmonary inflammation is one of the most common infectious diseases, which refers to the inflammation of the terminal airways, alveoli and pulmonary interstitium, and can be caused by pathogenic microorganisms, physicochemical factors, immune injury, allergies, and medications, especially pathogenic microbial infections. [ 14 ]. Along with the onset and progression of chronic pulmonary inflammation, there has been a gradual change in the view of the aseptic nature of the lungs, where many pathogens live with humans but do not cause disease or subacute or asymptomatic infections, which in turn has led to the neglect of the chronic pulmonary inflammation [ 15 ]. In China, preoperative assessment of pulmonary status usually requires only chest radiography. However, since the outbreak of the coronavirus in December 2019, doctors have started asking patients for chest CT scans instead of X-rays. This more precise assessment may help identify chronic pulmonary inflammation. Although previous studies have shown that hematogenous infection is an important cause of PJI[ 16 , 17 ], it is still unclear whether preoperative chronic pulmonary inflammation increases the risk of PJI after TJA. In view of this, the objectives of this study are: (1) to investigate the prevalence of asymptomatic chronic pulmonary inflammation before elective TJA; (2) to determine the PJI rate after TJA; and (3) to determine whether preoperative asymptomatic chronic pulmonary inflammation is a risk factor for PJI after TJA. Materials and Methods Patients The protocol was developed in accordance with the Code of Ethics of the Declaration of Helsinki and approved by the Ethics Committee of the Affiliated Hospital of Xuzhou Medical University .All data were obtained from the medical record system of the Affiliated Hospital of Xuzhou Medical University, and the data of 1,737 patients who underwent total hip arthroplasty and total knee arthroplasty in the Affiliated Hospital of Xuzhou Medical University were retrospectively analyzed from December 2019 to July 2021, of which 137 cases (including 49 cases who did not undergo preoperative chest CT, 33 cases who had infections caused by other reasons, 25 cases who had simultaneous bilateral total knee or hip arthroplasty, 11 cases of revision after arthroplasty, 2 cases of mental, consciousness and other disabling diseases, 17 patients with less than 1 year of follow-up, etc.) were excluded from the study, leaving 1,610 patients for inclusion in the final analysis, and chest CT reports were obtained preoperatively in all study patients. According to the chest CT imaging report, the patients were divided into two groups: pneumonia group (CT report showed chronic pulmonary inflammation) and normal group (CT report showed no chronic pulmonary inflammation).All diagnostic chest CT imaging findings were defined by two or more senior physicians. PJI diagnosis adopts the standard of 2018 Philadelphia PJI International consensus Conference[ 18 ]. Basic Characteristics and Laboratory Indicators For 1610 patients who met the criteria, patient demographics including age, gender, BMI, and co-morbidities were collected. Preoperative white blood cell (WBC), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), lymphocyte count, albumin (Alb), prealbumin (Pa), and percentage of lymphocytes levels were recorded from the patients. The general conditions of the patients in both groups are shown in Table 1 . Table 1 Laboratory indicators of pneumonia group versus normal group Lab metrics Pneumonia Group (n = 573) Normal Group (n = 1037) WBC(10 9 /L) 470(≤10×10 9 /L)82.02% 103(>10×10 9 /L)17.98% 838(≤10×10 9 /L)80.81% 199(>10×10 9 /L)19.19% ESR(mm/h) 413(≤20mm/h)72.08% 160(>20mm/h)27.92% 817(≤20mm/h)78.78% 220(>20mm/h)21.22% CRP(mg/L) 383(≤5mg/L)66.84% 190(>5mg/L)33.16% 763(≤5mg/L)73.58% 274(>5mg/L)26.42% Alb(g/L) 376(≥40g/L)65.62% 197(<40g/L)34.38% 756(≥40g/L)72.90% 281(<40g/L)27.10% Prealbumin(g/L) 471(≥0.2g/L)82.20% 102(<0.2g/L)17.80% 843(≥0.2g/L)81.29% 194(<0.2g/L)18.71% Hb(g/L) 277(≥120g/L)48.34% 296(<120g/L)51.66% 621(≥120g/L)59.88% 416(<120g/L)40.12% Lymphocyte count(10 9 /L) 441(≥1.1×10 9 /L)76.96% 132(<1.1×10 9 /L)23.04% 815(≥1.1×10 9 /L)78.59% 222(<1.1×10 9 /L)21.41% Lymphocyte percentage(%) 473(≥20%)82.55% 100(<20%)17.45% 894(≥20%)86.21% 143( 6.1mmol /L)85.34% 84(≤ 6.1mmol /L)14.66% 847(> 6.1mmol /L)81.68% 190(≤ 6.1mmol /L)18.32% Table 2. Univariate analysis results of the pneumonia group versus the normal group Variable Pneumonia Group (n = 573) Normal Group (n = 1037) Statistics P Value Female 373(65.10%) 664(64.03%) χ 2 = 0.407 0.523 Age, mean (SD), y 65.62(9.79) 65.31(10.18) t = 0.599 0.549 BMI, mean (SD), kg/m² 24.60(3.19) 24.74(9.14) t=-0.344 0.731 Hypertension 79(13.79%) 154(14.85%) χ 2 = 0.337 0.561 Diabetes 62(10.82%) 157(15.14%) χ 2 = 5.860 0.015 WBC, mean (SD),10 9 /L 7.43(2.66) 7.18(2.51) t = 1.857 0.064 ESR, mean (SD), mm/h 15.52(9.86) 13.80(10.36) t = 3.240 0.001 Alb, mean (SD), g/L 40.99(4.24) 41.90(4.21) t=-4.125 < 0.001 Prealbumin, mean (SD), g/L 0.24(0.06) 0.24(0.05) t = 1.235 0.217 CRP, mean (SD), mg/L 6.14(5.49) 4.84(6.62) t = 4.240 < 0.001 Hb, mean (SD), g/L 118.12(17.73) 123.73(17.14) t=-6.206 < 0.001 Lymphocyte count, mean (SD), 10 9 /L 1.45(0.55) 1.47(0.53) t=-0.907 0.364 Lymphocyte percentage, mean (SD), % 28.58(8.96) 29.63(8.82) t=-2.269 0.023 Glucose, mean (SD), mmol/L 4.98(1.32) 5.03(1.36) t=-0.771 0.441 Table 3. Multivariate analysis of periprosthetic joint infection Variable β SE Waldχ² Exp(B) 95%CI P Value ESR 0.016 0.016 0.948 1.016 (0.984, 1.048) 0.330 CRP 0.026 0.024 1.247 1.027 (0.980, 1.075) 0.264 Hb 0.002 0.012 0.039 1.002 (0.979, 1.026) 0.843 Alb -0.069 0.046 2.239 0.934 (0.853, 1.022) 0.135 Lymphocyte percentage -0.004 0.023 0.025 0.996 (0.953, 1.042) 0.875 Pulmonary inflammation 0.991 0.429 5.331 2.693 (1.162, 6.243) 0.021 Glucose 1.244 0.443 7.886 3.469 (1.456, 8.264) 0.005 Chest CT scan The preoperative chest CT scans were performed on all patients using the 64-slice spiral CT machine at the Department of Imaging, Affiliated Hospital of Xuzhou Medical University. The diagnosis of chronic pulmonary inflammation was made by two or more experienced physicians. If the imaging findings showed scattered patchy, flocculent, and cord-like increased density shadows, a diagnosis of chronic pulmonary inflammation could be established. Follow-up survey One month, three months, six months and one year after operation, the outpatient clinic was reexamined once a year. The patient recovery was recorded and observed through the outpatient electronic medical record system, and the patients who could not be followed up in the outpatient clinic were followed up by telephone or Wechat. Data Analyses SPSS version 25.0 software (IBM, Armonk, NY) was used for data processing. Measurement information was expressed as mean and standard deviation, independent samples t-test was performed between groups, and chi-square test was used for count data. The infection rate of PJI between the two groups was analyzed univariately, and independent risk factors for PJI were assessed using multivariate logistic regression modeling, and the ratio ratio (OR), 95% confidence interval (CI), and p-value were determined by comparing the patients' laboratory indices. Results Patients were followed up for 13–18 months. Among the 1610 patients, there were 573 (35.59%) patients with chronic pulmonary inflammation (pneumonia group), 196 males and 377 females, and 1037 patients with normal lungs (normal group), including 372 males and 665 females. Postoperative PJI occurred in 25 patients (25/1610, 1.55%), including 15 cases in the pneumonia group (15/573, 2.62%) and 10 cases in the normal group (10/1037, 0.96%). The difference was statistically significant ( P = 0.010). Univariate analysis showed that there were significant differences in ESR, Alb, CRP, hemoglobin, lymphocyte percentage and diabetes between the two groups (P < 0.05, Table 2 ). Multivariate logistic regression analysis showed that chronic pulmonary inflammation ( OR 2.693, 95% CI 1.162–6.243, P = 0.021) and diabetes ( OR 3.469, 95% CI 1.456–8.264, P = 0.005) were risk factors for PJI after TJA ( Table 3 ). Discussion PJI is a catastrophic complication after TJA, often leading to poor clinical outcomes, even amputation and endangering patients' lives. Understanding the influencing factors of PJI can be targeted prevention, which is helpful to reduce the incidence of PJI[ 19 , 20 ]. (1) The prevalence rate of preoperative asymptomatic chronic pulmonary inflammation in patients with elective TJA was 35.59%; (2) The postoperative PJI rate was 1.55%, among which the incidence rate of PJI in patients with preoperative asymptomatic chronic pulmonary inflammation was 2.62%, while the incidence rate of PJI in patients with normal lungs was 0.96% (P = 0.010) (3) Preoperative asymptomatic chronic pulmonary inflammation of the lungs (P = 0.021) and diabetes mellitus (P = 0.005) were independent risk factors for PJI after TJA. This study showed that the incidence of preoperative asymptomatic chronic pulmonary inflammation in patients with elective joint replacement was 35.59%. According to a 2014 report by the United States Center for Health Statistics, the eighth leading cause of death included pneumonia. In Europe, the annual incidence of pulmonary inflammation is 1.07–1.70, 1000 people a year, and about 10,000 people are hospitalized with pulmonary inflammation each year[ 21 – 23 ]. Enrico found that patients with preoperative pulmonary inflammation had an increased risk of periprosthetic infection after total knee arthroplasty and total hip arthroplasty [ 24 ]. Unlike chest X-ray, chest CT provides cross-sectional images, the difference between tissue attenuation and inflammatory process can be easily seen, and the diagnosis of pulmonary inflammation is more accurate. When Majzoub studied the detection rate of preoperative pulmonary inflammation by X-ray and chest CT, it was found that the detection rate of pulmonary inflammation by X-ray was 17.1%, while that by CT was 41.7%. 30% of the patients showed no abnormality by X-ray, but CT showed pulmonary inflammation [ 25 ]. The correlation between preoperative asymptomatic chronic pulmonary inflammation and postoperative PJI has not been reported in the literature. In this study, we showed that PJI after elective TJA was 1.55%, of which the incidence of PJI was 2.62% in patients with preoperative asymptomatic chronic pulmonary inflammation, compared with 0.96% in patients with normal lungs (P = 0.010), and asymptomatic chronic pulmonary inflammation was an independent risk factor for PJI after TJA (P = 0.021). PJI is a catastrophic postoperative complication of TJA, and despite the increasing level of prevention of PJI, the incidence of PJI has not seen a significant decrease[ 26 ]. Hematogenous infection accounts for 20–35% of PJI, mainly because bacteremia circulates to the prosthetic joint[ 27 ], which leads to a variety of pathways of hematogenous PJI, such as skin and soft tissue, intestinal tract, urinary tract and oral cavity[ 10 , 28 – 30 ]. Studies have shown that the imbalance of pulmonary microorganisms can induce pulmonary homeostasis disorder, and then induce pulmonary inflammation and other related lung diseases, and long-term pulmonary inflammation will also lead to an increase in the incidence of bacteremia[ 31 , 32 ], which may cause bacteria to spread to prosthetic joints with blood circulation. When Cook et al studied the hematogenous infection of total knee arthroplasty, they found that 14 patients had 15 knee infections (including 1 patient with bilateral infection) and 3 patients were infected with Streptococcus pulmonary inflammatione, which was thought to originate from the lungs. [ 33 ]. When studying the impact of coronavirus disease after total hip arthroplasty, Sandeep found that patients who tested positive within the first 19 weeks had a two-fold increased risk of developing prosthetic joint infection. These results further confirm that there is a correlation between the lung and the joint prosthesis [ 34 ]. This study showed that diabetes mellitus was an independent risk factor for PJI after TJA (P = 0.005). It may be due to the long-term instability of blood glucose in patients with diabetes, which is prone to secondary vascular lesions, which affects the circulatory function, especially the peripheral circulatory function, affects the blood supply around the incision, and then hinders wound healing, resulting in an increased risk of infection at the surgical site. Xiu et al. found that the increased risk of PJI after TJA in patients with hyperglycemic states was due to elevated serum glucose levels creating an optimal culture medium for bacterial growth, as well as compromising the patient's immune function[ 35 ]. In addition, previous studies have found that diabetes is also a risk factor for the occurrence of PJI after TJA. Patients with diabetes will increase the risk of PJI after TJA by about 2.8 times[ 36 , 37 ], which is also consistent with the results of this study, so it is necessary to optimize blood glucose and test regularly before TJA to reduce the risk of PJI. This study also has limitations. First, there are inherent drawbacks to its retrospective study design; although the study data belonged to a large-scale cohort, which reduces confounding effects and provides reliable results, it is not possible to completely exclude the influence of unknown factors because of limitations inherent in the database. In addition, the pathophysiologic mechanisms of preoperative asymptomatic chronic pulmonary inflammation and PJI have not been elucidated, including the bacteriologic pathogens involved in PJI, and patients with pulmonary inflammation have not been screened for pathogens. In this study, whether patients use antibiotics or not and the types of antibiotics are unknown, so it is impossible to investigate the preventive effect of antibiotic prevention. It is not clear whether the purpose of antibiotic prescription is prevention or other use, and it may be a confounding factor. Conclusion In conclusion, patients undergoing elective TJA have a high prevalence of preoperative asymptomatic chronic pulmonary inflammation, which may become a potential infection focus of patients, and this study found that asymptomatic chronic pulmonary inflammation is a risk factor for PJI after elective TJA. In addition, when considering elective TJA surgery, we should pay attention to the screening of patients with asymptomatic chronic pulmonary inflammation. Declarations Acknowledgements ：We would like to thank all participants for their contributions to the study. We would like to express our heartfelt gratitude to the faculty and staff of the Department of Orthopedics of the Affiliated Hospital of Xuzhou Medical University for their support of this research project Authors' contributions ： Zhang Haoliang was responsible for the implementation of the experiment and the writing of the paper, Xia Sijia and Wang Heping were responsible for data collection and processing, Wang Andong and Shen Zhijun were responsible for follow-up, and Zha Guochun was responsible for the review and revision of the article. Availability of data and materials ：The datasets used this study are available from the corresponding author on reasonable request. Funding :This research received no external funding. Ethics approval and consent to participate ：The protocol was developed in accordance with the Code of Ethics of the Declaration of Helsinki and approved by the Institutional Ethics Committee of the Affiliated Hospital of Xuzhou Medical University. All the participants were provided oral and written informed consent. Consent for publication ： Not applicable. Competing interests ：we have no potential conflict of interest. References Padegimas EM, et al. Periprosthetic shoulder infection in the United States: incidence and economic burden. J Shoulder Elbow Surg. 2015;24(5):741–6. http.//doi.org/10.1016/j.jse.2014.11.044 . Gonzalez AI, et al. Is There an Association Between Smoking Status and Prosthetic Joint Infection After Primary Total Joint Arthroplasty? J Arthroplasty. 2018;33(7):2218–24. http.//doi.org/doi.org/10.1016/j.arth.2018.02.069 . Tarazi JM, et al. The Epidemiology of Revision Total Knee Arthroplasty. J Knee Surg. 2021;34(13):1396–401. http.//doi.org/10.1055/s-0041-1735282 . 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Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 19 May, 2025 Reviews received at journal 18 May, 2025 Reviewers agreed at journal 05 May, 2025 Reviews received at journal 25 Apr, 2025 Reviewers agreed at journal 16 Apr, 2025 Reviewers invited by journal 30 Mar, 2025 Editor assigned by journal 30 Mar, 2025 Editor invited by journal 25 Mar, 2025 Submission checks completed at journal 23 Mar, 2025 First submitted to journal 23 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6195490","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":443857472,"identity":"6bd8554b-c8fb-4c5e-8964-c0e30e175a70","order_by":0,"name":"Haoliang Zhang","email":"","orcid":"","institution":"Affiliated Hospital of Xuzhou Medical College","correspondingAuthor":false,"prefix":"","firstName":"Haoliang","middleName":"","lastName":"Zhang","suffix":""},{"id":443857473,"identity":"38aa0685-c027-420b-a037-339f25f22420","order_by":1,"name":"Si-Jia Xia","email":"","orcid":"","institution":"Affiliated Hospital of Xuzhou Medical College","correspondingAuthor":false,"prefix":"","firstName":"Si-Jia","middleName":"","lastName":"Xia","suffix":""},{"id":443857474,"identity":"d17b5700-820b-41c8-80b0-a72c89d20d24","order_by":2,"name":"An-Dong Wang","email":"","orcid":"","institution":"Affiliated Hospital of Xuzhou Medical College","correspondingAuthor":false,"prefix":"","firstName":"An-Dong","middleName":"","lastName":"Wang","suffix":""},{"id":443857475,"identity":"12a5774c-2b7f-47b9-b8b2-7579877c6657","order_by":3,"name":"He-Ping Wang","email":"","orcid":"","institution":"Affiliated Hospital of Xuzhou Medical College","correspondingAuthor":false,"prefix":"","firstName":"He-Ping","middleName":"","lastName":"Wang","suffix":""},{"id":443857476,"identity":"a44daf59-9dee-4e42-988d-139dce1d6283","order_by":4,"name":"Zhi-Jun Shen","email":"","orcid":"","institution":"Affiliated Hospital of Xuzhou Medical College","correspondingAuthor":false,"prefix":"","firstName":"Zhi-Jun","middleName":"","lastName":"Shen","suffix":""},{"id":443857477,"identity":"81657216-8471-4a89-8788-75b7b9565ef7","order_by":5,"name":"guochun Zha","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+ElEQVRIie3PMWrDMBSAYQkFezF1R4mAz/CCIGnAuFepEHgKtEeQEaSLyexj+AhqTZIlB3ChQ6DQrh5F8dC4UybZY6H6hze9j8dDyOf7k+HzMJN7jYtzB2k2gRAYJodQ60X1lMvJRNTRcTuPulesxgC0MmD2O+MrKtQ8BUNQ2OxrF2GVDCjbyWRdCcU38H6DojxvXSSmjwe6KA1HrVByA58E0WjpJAG9XBGlEepCmjtosBoj8UCMNaI+vRQaTSGs/CDrQknOnguNS8hlMPYLHCV+s32WxCT8srZPszhsDk6Cbh9mFG+vv3Ou/z5jSIf60TWfz+f7z/0AMN9OztnhRz0AAAAASUVORK5CYII=","orcid":"","institution":"Affiliated Hospital of Xuzhou Medical College","correspondingAuthor":true,"prefix":"","firstName":"guochun","middleName":"","lastName":"Zha","suffix":""}],"badges":[],"createdAt":"2025-03-10 12:23:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6195490/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6195490/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":80921802,"identity":"e5b16f1e-eb4d-4bf8-bc84-80ad44942dca","added_by":"auto","created_at":"2025-04-18 20:59:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":724256,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6195490/v1/f08d39a4-f58a-4612-8146-58bcfec0acef.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Association of preoperative asymptomatic chronic pulmonary inflammation with subsequent periprosthetic joint infection following total joint arthroplasty","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTotal joint arthroplasty (TJA) is an effective treatment for end-stage joint disease, replacing the function of the diseased joint and providing pain relief. Periprosthetic joint infection (PJI) is a catastrophic complication after TJA, with an incidence of 1\u0026ndash;3% [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Epidemiological investigation shows that PJI is the leading cause of revision after total knee arthroplasty(TKA), and it is also the third or fourth cause of revision after total hip arthroplasty(THA)[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], and the 5-year overall survival rate after PJI (THA is 67% TKA is 72%) is lower than that of breast cancer, melanoma and other malignant tumors[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe pathogens that cause PJI can come from local contamination (such as intraoperative contamination, local skin bacteria, etc.) and blood-derived migration (such as skin and soft tissue, urethra, oral tissue, intestinal and lung bacteremia)[\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The occurrence of asymptomatic chronic pulmonary inflammation is associated with bacteremia, which may be an important risk factor for PJI[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Chronic pulmonary inflammation is one of the most common infectious diseases, which refers to the inflammation of the terminal airways, alveoli and pulmonary interstitium, and can be caused by pathogenic microorganisms, physicochemical factors, immune injury, allergies, and medications, especially pathogenic microbial infections. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Along with the onset and progression of chronic pulmonary inflammation, there has been a gradual change in the view of the aseptic nature of the lungs, where many pathogens live with humans but do not cause disease or subacute or asymptomatic infections, which in turn has led to the neglect of the chronic pulmonary inflammation [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In China, preoperative assessment of pulmonary status usually requires only chest radiography. However, since the outbreak of the coronavirus in December 2019, doctors have started asking patients for chest CT scans instead of X-rays. This more precise assessment may help identify chronic pulmonary inflammation. Although previous studies have shown that hematogenous infection is an important cause of PJI[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], it is still unclear whether preoperative chronic pulmonary inflammation increases the risk of PJI after TJA.\u003c/p\u003e \u003cp\u003eIn view of this, the objectives of this study are: (1) to investigate the prevalence of asymptomatic chronic pulmonary inflammation before elective TJA; (2) to determine the PJI rate after TJA; and (3) to determine whether preoperative asymptomatic chronic pulmonary inflammation is a risk factor for PJI after TJA.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003e The protocol was developed in accordance with the Code of Ethics of the Declaration of Helsinki and approved by the Ethics Committee of the Affiliated Hospital of Xuzhou Medical University .All data were obtained from the medical record system of the Affiliated Hospital of Xuzhou Medical University, and the data of 1,737 patients who underwent total hip arthroplasty and total knee arthroplasty in the Affiliated Hospital of Xuzhou Medical University were retrospectively analyzed from December 2019 to July 2021, of which 137 cases (including 49 cases who did not undergo preoperative chest CT, 33 cases who had infections caused by other reasons, 25 cases who had simultaneous bilateral total knee or hip arthroplasty, 11 cases of revision after arthroplasty, 2 cases of mental, consciousness and other disabling diseases, 17 patients with less than 1 year of follow-up, etc.) were excluded from the study, leaving 1,610 patients for inclusion in the final analysis, and chest CT reports were obtained preoperatively in all study patients. According to the chest CT imaging report, the patients were divided into two groups: pneumonia group (CT report showed chronic pulmonary inflammation) and normal group (CT report showed no chronic pulmonary inflammation).All diagnostic chest CT imaging findings were defined by two or more senior physicians. PJI diagnosis adopts the standard of 2018 Philadelphia PJI International consensus Conference[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eBasic Characteristics and Laboratory Indicators\u003c/h3\u003e\n\u003cp\u003eFor 1610 patients who met the criteria, patient demographics including age, gender, BMI, and co-morbidities were collected. Preoperative white blood cell (WBC), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), lymphocyte count, albumin (Alb), prealbumin (Pa), and percentage of lymphocytes levels were recorded from the patients. The general conditions of the patients in both groups are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLaboratory indicators of pneumonia group versus normal group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"17\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c16\" colnum=\"16\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c17\" colnum=\"17\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLab metrics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"8\" nameend=\"c9\" namest=\"c2\"\u003e \u003cp\u003ePneumonia Group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;573)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"8\" nameend=\"c17\" namest=\"c10\"\u003e \u003cp\u003eNormal Group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;1037)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBC(10\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e470(\u0026le;10\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L)82.02%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e \u003cp\u003e103(\u0026gt;10\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L)17.98%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e \u003cp\u003e838(\u0026le;10\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L)80.81%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c17\" namest=\"c13\"\u003e \u003cp\u003e199(\u0026gt;10\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L)19.19%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eESR(mm/h)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e413(\u0026le;20mm/h)72.08%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e \u003cp\u003e160(\u0026gt;20mm/h)27.92%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e \u003cp\u003e817(\u0026le;20mm/h)78.78%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c17\" namest=\"c13\"\u003e \u003cp\u003e220(\u0026gt;20mm/h)21.22%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCRP(mg/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e383(\u0026le;5mg/L)66.84%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e \u003cp\u003e190(\u0026gt;5mg/L)33.16%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e \u003cp\u003e763(\u0026le;5mg/L)73.58%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c17\" namest=\"c13\"\u003e \u003cp\u003e274(\u0026gt;5mg/L)26.42%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlb(g/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e376(\u0026ge;40g/L)65.62%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e \u003cp\u003e197(\u0026lt;40g/L)34.38%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e \u003cp\u003e756(\u0026ge;40g/L)72.90%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c17\" namest=\"c13\"\u003e \u003cp\u003e281(\u0026lt;40g/L)27.10%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrealbumin(g/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e471(\u0026ge;0.2g/L)82.20%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e \u003cp\u003e102(\u0026lt;0.2g/L)17.80%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e \u003cp\u003e843(\u0026ge;0.2g/L)81.29%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c17\" namest=\"c13\"\u003e \u003cp\u003e194(\u0026lt;0.2g/L)18.71%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHb(g/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e277(\u0026ge;120g/L)48.34%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e \u003cp\u003e296(\u0026lt;120g/L)51.66%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e \u003cp\u003e621(\u0026ge;120g/L)59.88%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c17\" namest=\"c13\"\u003e \u003cp\u003e416(\u0026lt;120g/L)40.12%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLymphocyte count(10\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e441(\u0026ge;1.1\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L)76.96%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e \u003cp\u003e132(\u0026lt;1.1\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L)23.04%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e \u003cp\u003e815(\u0026ge;1.1\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L)78.59%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c17\" namest=\"c13\"\u003e \u003cp\u003e222(\u0026lt;1.1\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L)21.41%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLymphocyte percentage(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e473(\u0026ge;20%)82.55%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e \u003cp\u003e100(\u0026lt;20%)17.45%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e \u003cp\u003e894(\u0026ge;20%)86.21%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c17\" namest=\"c13\"\u003e \u003cp\u003e143(\u0026lt;20%)13.79%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlucose(mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e489(\u0026gt;\u0026thinsp;6.1mmol\u003c/p\u003e \u003cp\u003e/L)85.34%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e \u003cp\u003e84(\u0026le;\u0026thinsp;6.1mmol\u003c/p\u003e \u003cp\u003e/L)14.66%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e \u003cp\u003e847(\u0026gt;\u0026thinsp;6.1mmol\u003c/p\u003e \u003cp\u003e/L)81.68%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c17\" namest=\"c13\"\u003e \u003cp\u003e190(\u0026le;\u0026thinsp;6.1mmol\u003c/p\u003e \u003cp\u003e/L)18.32%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"16\" nameend=\"c16\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTable\u0026nbsp;2. Univariate analysis results of the pneumonia group versus the normal group\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c17\" namest=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e \u003cp\u003ePneumonia Group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;573)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003eNormal Group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;1037)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c14\" namest=\"c12\"\u003e \u003cp\u003eStatistics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c16\" namest=\"c15\"\u003e \u003cp\u003eP Value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c17\" namest=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e \u003cp\u003e373(65.10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003e664(64.03%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c14\" namest=\"c12\"\u003e \u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.407\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c16\" namest=\"c15\"\u003e \u003cp\u003e0.523\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c17\" namest=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eAge, mean (SD), y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e \u003cp\u003e65.62(9.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003e65.31(10.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c14\" namest=\"c12\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;0.599\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c16\" namest=\"c15\"\u003e \u003cp\u003e0.549\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c17\" namest=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eBMI, mean (SD), kg/m\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e \u003cp\u003e24.60(3.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003e24.74(9.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c14\" namest=\"c12\"\u003e \u003cp\u003et=-0.344\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c16\" namest=\"c15\"\u003e \u003cp\u003e0.731\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c17\" namest=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e \u003cp\u003e79(13.79%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003e154(14.85%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c14\" namest=\"c12\"\u003e \u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.337\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c16\" namest=\"c15\"\u003e \u003cp\u003e0.561\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c17\" namest=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e \u003cp\u003e62(10.82%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003e157(15.14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c14\" namest=\"c12\"\u003e \u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;5.860\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c16\" namest=\"c15\"\u003e \u003cp\u003e\u003cb\u003e0.015\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c17\" namest=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eWBC, mean (SD),10\u003csup\u003e9\u003c/sup\u003e/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e \u003cp\u003e7.43(2.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003e7.18(2.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c14\" namest=\"c12\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;1.857\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c16\" namest=\"c15\"\u003e \u003cp\u003e0.064\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c17\" namest=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eESR, mean (SD), mm/h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e \u003cp\u003e15.52(9.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003e13.80(10.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c14\" namest=\"c12\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;3.240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c16\" namest=\"c15\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c17\" namest=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eAlb, mean (SD), g/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e \u003cp\u003e40.99(4.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003e41.90(4.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c14\" namest=\"c12\"\u003e \u003cp\u003et=-4.125\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c16\" namest=\"c15\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c17\" namest=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003ePrealbumin, mean (SD), g/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e \u003cp\u003e0.24(0.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003e0.24(0.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c14\" namest=\"c12\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;1.235\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c16\" namest=\"c15\"\u003e \u003cp\u003e0.217\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c17\" namest=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eCRP, mean (SD), mg/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e \u003cp\u003e6.14(5.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003e4.84(6.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c14\" namest=\"c12\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;4.240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c16\" namest=\"c15\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c17\" namest=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eHb, mean (SD), g/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e \u003cp\u003e118.12(17.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003e123.73(17.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c14\" namest=\"c12\"\u003e \u003cp\u003et=-6.206\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c16\" namest=\"c15\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c17\" namest=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eLymphocyte count, mean (SD), 10\u003csup\u003e9\u003c/sup\u003e/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e \u003cp\u003e1.45(0.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003e1.47(0.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c14\" namest=\"c12\"\u003e \u003cp\u003et=-0.907\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c16\" namest=\"c15\"\u003e \u003cp\u003e0.364\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c17\" namest=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eLymphocyte percentage, mean (SD), %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e \u003cp\u003e28.58(8.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003e29.63(8.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c14\" namest=\"c12\"\u003e \u003cp\u003et=-2.269\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c16\" namest=\"c15\"\u003e \u003cp\u003e\u003cb\u003e0.023\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c17\" namest=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eGlucose, mean (SD), mmol/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e \u003cp\u003e4.98(1.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003e5.03(1.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c14\" namest=\"c12\"\u003e \u003cp\u003et=-0.771\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c16\" namest=\"c15\"\u003e \u003cp\u003e0.441\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c17\" namest=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"15\" nameend=\"c15\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTable\u0026nbsp;3. Multivariate analysis of periprosthetic joint infection\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eWaldχ\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003eExp(B)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c15\" namest=\"c14\"\u003e \u003cp\u003eP Value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eESR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.948\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003e1.016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003e(0.984, 1.048)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c15\" namest=\"c14\"\u003e \u003cp\u003e0.330\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCRP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e0.024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.247\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003e1.027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003e(0.980, 1.075)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c15\" namest=\"c14\"\u003e \u003cp\u003e0.264\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eHb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.039\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003e1.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003e(0.979, 1.026)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c15\" namest=\"c14\"\u003e \u003cp\u003e0.843\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAlb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.069\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e0.046\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.239\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003e0.934\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003e(0.853, 1.022)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c15\" namest=\"c14\"\u003e \u003cp\u003e0.135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eLymphocyte percentage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e0.023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003e0.996\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003e(0.953, 1.042)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c15\" namest=\"c14\"\u003e \u003cp\u003e0.875\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePulmonary inflammation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.991\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e0.429\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5.331\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003e2.693\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003e(1.162, 6.243)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c15\" namest=\"c14\"\u003e \u003cp\u003e\u003cb\u003e0.021\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGlucose\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.244\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e0.443\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.886\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003e3.469\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003e(1.456, 8.264)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c15\" namest=\"c14\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c17\" namest=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eChest CT scan\u003c/h3\u003e\n\u003cp\u003eThe preoperative chest CT scans were performed on all patients using the 64-slice spiral CT machine at the Department of Imaging, Affiliated Hospital of Xuzhou Medical University. The diagnosis of chronic pulmonary inflammation was made by two or more experienced physicians. If the imaging findings showed scattered patchy, flocculent, and cord-like increased density shadows, a diagnosis of chronic pulmonary inflammation could be established.\u003c/p\u003e\n\u003ch3\u003eFollow-up survey\u003c/h3\u003e\n\u003cp\u003eOne month, three months, six months and one year after operation, the outpatient clinic was reexamined once a year. The patient recovery was recorded and observed through the outpatient electronic medical record system, and the patients who could not be followed up in the outpatient clinic were followed up by telephone or Wechat.\u003c/p\u003e\n\u003ch3\u003eData Analyses\u003c/h3\u003e\n\u003cp\u003eSPSS version 25.0 software (IBM, Armonk, NY) was used for data processing. Measurement information was expressed as mean and standard deviation, independent samples t-test was performed between groups, and chi-square test was used for count data. The infection rate of PJI between the two groups was analyzed univariately, and independent risk factors for PJI were assessed using multivariate logistic regression modeling, and the ratio ratio (OR), 95% confidence interval (CI), and p-value were determined by comparing the patients' laboratory indices.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003ePatients were followed up for 13\u0026ndash;18 months. Among the 1610 patients, there were 573 (35.59%) patients with chronic pulmonary inflammation (pneumonia group), 196 males and 377 females, and 1037 patients with normal lungs (normal group), including 372 males and 665 females. Postoperative PJI occurred in 25 patients (25/1610, 1.55%), including 15 cases in the pneumonia group (15/573, 2.62%) and 10 cases in the normal group (10/1037, 0.96%). The difference was statistically significant (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.010).\u003c/p\u003e \u003cp\u003eUnivariate analysis showed that there were significant differences in ESR, Alb, CRP, hemoglobin, lymphocyte percentage and diabetes between the two groups (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05, \u003cb\u003eTable\u0026nbsp;2\u003c/b\u003e).\u003c/p\u003e \u003cp\u003eMultivariate logistic regression analysis showed that chronic pulmonary inflammation (\u003cem\u003eOR\u003c/em\u003e 2.693, 95% \u003cem\u003eCI\u003c/em\u003e 1.162\u0026ndash;6.243, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.021) and diabetes (\u003cem\u003eOR\u003c/em\u003e 3.469, 95% \u003cem\u003eCI\u003c/em\u003e 1.456\u0026ndash;8.264, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.005) were risk factors for PJI after TJA (\u003cb\u003eTable\u0026nbsp;3\u003c/b\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePJI is a catastrophic complication after TJA, often leading to poor clinical outcomes, even amputation and endangering patients' lives. Understanding the influencing factors of PJI can be targeted prevention, which is helpful to reduce the incidence of PJI[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. (1) The prevalence rate of preoperative asymptomatic chronic pulmonary inflammation in patients with elective TJA was 35.59%; (2) The postoperative PJI rate was 1.55%, among which the incidence rate of PJI in patients with preoperative asymptomatic chronic pulmonary inflammation was 2.62%, while the incidence rate of PJI in patients with normal lungs was 0.96% (P\u0026thinsp;=\u0026thinsp;0.010) (3) Preoperative asymptomatic chronic pulmonary inflammation of the lungs (P\u0026thinsp;=\u0026thinsp;0.021) and diabetes mellitus (P\u0026thinsp;=\u0026thinsp;0.005) were independent risk factors for PJI after TJA.\u003c/p\u003e \u003cp\u003eThis study showed that the incidence of preoperative asymptomatic chronic pulmonary inflammation in patients with elective joint replacement was 35.59%. According to a 2014 report by the United States Center for Health Statistics, the eighth leading cause of death included pneumonia. In Europe, the annual incidence of pulmonary inflammation is 1.07\u0026ndash;1.70, 1000 people a year, and about 10,000 people are hospitalized with pulmonary inflammation each year[\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Enrico found that patients with preoperative pulmonary inflammation had an increased risk of periprosthetic infection after total knee arthroplasty and total hip arthroplasty [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Unlike chest X-ray, chest CT provides cross-sectional images, the difference between tissue attenuation and inflammatory process can be easily seen, and the diagnosis of pulmonary inflammation is more accurate. When Majzoub studied the detection rate of preoperative pulmonary inflammation by X-ray and chest CT, it was found that the detection rate of pulmonary inflammation by X-ray was 17.1%, while that by CT was 41.7%. 30% of the patients showed no abnormality by X-ray, but CT showed pulmonary inflammation [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe correlation between preoperative asymptomatic chronic pulmonary inflammation and postoperative PJI has not been reported in the literature. In this study, we showed that PJI after elective TJA was 1.55%, of which the incidence of PJI was 2.62% in patients with preoperative asymptomatic chronic pulmonary inflammation, compared with 0.96% in patients with normal lungs (P\u0026thinsp;=\u0026thinsp;0.010), and asymptomatic chronic pulmonary inflammation was an independent risk factor for PJI after TJA (P\u0026thinsp;=\u0026thinsp;0.021). PJI is a catastrophic postoperative complication of TJA, and despite the increasing level of prevention of PJI, the incidence of PJI has not seen a significant decrease[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Hematogenous infection accounts for 20\u0026ndash;35% of PJI, mainly because bacteremia circulates to the prosthetic joint[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], which leads to a variety of pathways of hematogenous PJI, such as skin and soft tissue, intestinal tract, urinary tract and oral cavity[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Studies have shown that the imbalance of pulmonary microorganisms can induce pulmonary homeostasis disorder, and then induce pulmonary inflammation and other related lung diseases, and long-term pulmonary inflammation will also lead to an increase in the incidence of bacteremia[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], which may cause bacteria to spread to prosthetic joints with blood circulation. When Cook et al studied the hematogenous infection of total knee arthroplasty, they found that 14 patients had 15 knee infections (including 1 patient with bilateral infection) and 3 patients were infected with Streptococcus pulmonary inflammatione, which was thought to originate from the lungs. [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. When studying the impact of coronavirus disease after total hip arthroplasty, Sandeep found that patients who tested positive within the first 19 weeks had a two-fold increased risk of developing prosthetic joint infection. These results further confirm that there is a correlation between the lung and the joint prosthesis [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study showed that diabetes mellitus was an independent risk factor for PJI after TJA (P\u0026thinsp;=\u0026thinsp;0.005). It may be due to the long-term instability of blood glucose in patients with diabetes, which is prone to secondary vascular lesions, which affects the circulatory function, especially the peripheral circulatory function, affects the blood supply around the incision, and then hinders wound healing, resulting in an increased risk of infection at the surgical site. Xiu et al. found that the increased risk of PJI after TJA in patients with hyperglycemic states was due to elevated serum glucose levels creating an optimal culture medium for bacterial growth, as well as compromising the patient's immune function[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. In addition, previous studies have found that diabetes is also a risk factor for the occurrence of PJI after TJA. Patients with diabetes will increase the risk of PJI after TJA by about 2.8 times[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], which is also consistent with the results of this study, so it is necessary to optimize blood glucose and test regularly before TJA to reduce the risk of PJI.\u003c/p\u003e \u003cp\u003eThis study also has limitations. First, there are inherent drawbacks to its retrospective study design; although the study data belonged to a large-scale cohort, which reduces confounding effects and provides reliable results, it is not possible to completely exclude the influence of unknown factors because of limitations inherent in the database. In addition, the pathophysiologic mechanisms of preoperative asymptomatic chronic pulmonary inflammation and PJI have not been elucidated, including the bacteriologic pathogens involved in PJI, and patients with pulmonary inflammation have not been screened for pathogens. In this study, whether patients use antibiotics or not and the types of antibiotics are unknown, so it is impossible to investigate the preventive effect of antibiotic prevention. It is not clear whether the purpose of antibiotic prescription is prevention or other use, and it may be a confounding factor.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, patients undergoing elective TJA have a high prevalence of preoperative asymptomatic chronic pulmonary inflammation, which may become a potential infection focus of patients, and this study found that asymptomatic chronic pulmonary inflammation is a risk factor for PJI after elective TJA. In addition, when considering elective TJA surgery, we should pay attention to the screening of patients with asymptomatic chronic pulmonary inflammation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e：We would like to thank all participants for their contributions to the study. We would like to express our heartfelt gratitude to the faculty and staff of the Department of Orthopedics of the Affiliated Hospital of Xuzhou Medical University for their support of this research project\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eZhang Haoliang was responsible for the implementation of the experiment and the writing of the paper, Xia Sijia and Wang Heping were responsible for data collection and processing, Wang Andong and Shen Zhijun were responsible for follow-up, and Zha Guochun was responsible for the review and revision of the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e：The datasets used this study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e:This research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e：The protocol was developed in accordance with the Code of Ethics of the Declaration of Helsinki and approved by the Institutional Ethics Committee of the Affiliated Hospital of Xuzhou Medical University.\u0026nbsp;All the participants were provided oral and written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e：we have no potential conflict of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePadegimas EM, et al. 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Does Intermittent Catheterization Compared to Indwelling Catheterization Decrease the Risk of Periprosthetic Joint Infection Following Total Knee Arthroplasty? J Arthroplast. 2020;35(6):S308. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003eS312.http.//doi.org/10.1016/j.arth.2020.02.055\u003c/span\u003e\u003cspan address=\"S312.http.//10.1016/j.arth.2020.02.055\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"asymptomatic pulmonary inflammation, periprosthetic joint infection, total joint arthroplasty, chest CT, bacteremia","lastPublishedDoi":"10.21203/rs.3.rs-6195490/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6195490/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003e.Periprosthetic joint infection(PJI) is a catastrophic complication after total joint arthroplasty (TJA). Previous studies have shown that there are some factors such as urinary tract infection and dental infection before operation, which can lead to PJI. However, it is not clear whether preoperative asymptomatic chronic pulmonary inflammation will increase the risk of PJI.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe data of 1610 patients who underwent TJA in the affiliated Hospital of Xuzhou Medical University from December 2019 to July 2021 were analyzed retrospectively. According to the chest CT report, the patients were divided into pneumonia group and normal group. The patients were followed up for at least one year to compare the incidence of PJI between the pneumonia group and the normal group, and to determine the risk factors of PJI in patients with asymptomatic chronic pulmonary inflammation.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e1610 patients were followed up, including pneumonia group in 573 cases (35.59%) and normal group in 1037 cases (64.41%). The postoperative PJI rate in the pneumonia group was 2.61%, which was significantly higher than that in the normal group (0.96%). Univariate analysis showed that there were significant differences in chronic pulmonary inflammation (P\u0026thinsp;\u0026lt;\u0026thinsp;0.010), diabetes (P\u0026thinsp;\u0026lt;\u0026thinsp;0.015), ESR (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), albumin (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), C-reactive protein (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), hemoglobin (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and lymphocyte percentage (P\u0026thinsp;\u0026lt;\u0026thinsp;0.023). Multivariate analysis showed that chronic pulmonary inflammation (OR 2.693, P\u0026thinsp;=\u0026thinsp;0.021) and diabetes mellitus (OR 3.469, P\u0026thinsp;=\u0026thinsp;0.005) were risk factors of PJI after TJA.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePatients undergoing elective TJA have a high prevalence of preoperative asymptomatic chronic pulmonary inflammation, and preoperative asymptomatic chronic pulmonary inflammation is a risk factor for PJI after prosthetic arthroplasty. It is recommended that prior to elective TJA surgery, a complete chest CT examination be performed to assess and control chronic inflammation in the lungs, thus effectively reducing the risk of PJI.\u003c/p\u003e","manuscriptTitle":"Association of preoperative asymptomatic chronic pulmonary inflammation with subsequent periprosthetic joint infection following total joint arthroplasty","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-18 20:51:02","doi":"10.21203/rs.3.rs-6195490/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-19T08:37:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-18T09:31:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"235051260699864465556499420100125039546","date":"2025-05-06T01:12:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-25T11:58:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"230960801220409801134881986951664708164","date":"2025-04-16T13:05:30+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-30T18:20:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-30T18:17:18+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-03-25T19:49:05+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-23T15:46:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2025-03-23T15:45:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a06b2186-645e-46b5-8ae1-a9c4d1b417e8","owner":[],"postedDate":"April 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-06-09T22:08:22+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-18 20:51:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6195490","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6195490","identity":"rs-6195490","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}