Perioperative Proton Pump Inhibitor Use Linked to Lower Revision Surgery Risk in Joint Arthroplasty: Study

The widespread use of PPIs aims at preventing GI complications, such as ulcers and bleeding, when there is a concomitant use of NSAIDs, especially for patients who have undergone joint replacement surgery. However, animal studies have raised concerns that PPIs may hinder bone healing and promote immunosuppression. This study examines whether these possible drug actions are translated into unfavorable outcomes for patients undergoing THA and TKA, with a concentration on all-cause revision rates, periprosthetic joint infections, and other complications.

An administrative claims database was used to identify patients who underwent elective THA or TKA from 2010 through 2019. Patients were excluded if they had any prior diagnosis of gastrointestinal bleeding or GERD. The experimental group contained those with a PPI prescription in the perioperative period and controls were defined as those without a PPI prescription in the database. The analysis consisted of a 1:1 propensity score match in order to create comparable groups, matching patients according to age, sex, and Charlson comorbidity index. Of these, 11,450 patients were available for this study, including 3,103 TKA+PPI, 2,622 THA+PPI, 3,103 TKA controls, and 2,622 THA controls. The average age of the patients was 64 years of age, ranging from 38 to 94, with a total of 57% of the cohort consisting of females. For the purposes of statistical analyses, the level of significance was set at P < 0.05.

Results

The analysis yielded a number of significant associations between the use of PPI in the perioperative period and the surgical outcomes of interest in the following fashions:

Total Knee Arthroplasty (TKA):

• In patients where PPIs were dispensed, the rate of all-cause revision surgery was much lower compared to others, 3.0% versus 4.1%, P < 0.01.

• PPI use was associated with a lower rate of periprosthetic joint infection, 1.0% versus 1.8%, P < 0.01.

Total Hip Arthroplasty (THA):

• PPI use was associated with lower rates of all-cause revision surgery (2.8% vs 4.0%, P = 0.02).

Despite this, no significant differences between the PPI and non-PPI group in either cohort were recorded with regards to:

• Aseptic loosening

• Periprosthetic fractures

• GI bleed

• Surgical site infection

The final results showed that the perioperative administration of PPIs in patients with TKA and THA was associated with a lower risk of all-cause revision surgery. Moreover, for TKA patients, this corresponded to a reduced risk of periprosthetic joint infections. That would mean that PPIs, while being highly used for their gastroprotective effects, could bring additional benefits when performing joint replacement surgeries. Yet, confirmation by further studies will be needed, as well as detailed explanation of mechanisms that occurred.

Reference:

Harris, A. B., Agarwal, A. R., Hegde, V., Oni, J. K., & Khanuja, H. S. (2024). Routine prescription of proton pump inhibitors in the perioperative period is associated with decreased rates of 2-year revision surgery after total hip and knee arthroplasty. The Journal of Arthroplasty. https://doi.org/10.1016/j.arth.2024.08.042