Periprosthetic Joint Infection: Practical Management Guide Javad Parvizi, Glenn J Kerr, Aaron Glynn, Carlos A Higuera
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Obstetric Vasculopathies
First Edition: 2013
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Section 1
1Basics of Infection
Glenn J Kerr2

Defining Periprosthetic Joint Infectionschapter 1

Benjamin Zmistowski
 
Current Evidence
A uniform definition specific to periprosthetic joint infection (PJI) did not exist until recently. The new definition provided by the Musculoskeletal Infection Society (MSIS),1 for adoption in clinical and research use, is presented in Table 1.1. PJI is present if one of two major criteria or four of six minor criteria are met.

Rothman Institute Current Practices

  1. MSIS definition is used for identifying and reporting cases of PJI.
  2. Frozen section is not currently performed. Therefore, only 3 of 5 MSIS minor criteria are required.
It is important to recognize that PJI may be present with fewer than four of the minor criteria, and a surgeon's judgment remains critical in identifying patients with PJI. Infections with low-virulence organisms such as Propionibacterium acnes may be particularly difficult to diagnose and may not meet all of the above criteria.

Pitfalls

  1. Dry aspirate limits definition.
  2. Frozen-section analysis is highly operator dependent.
  3. Aspiration of the hip requires radiological guidance and is also operator dependent.
  4. Gram stain has poor sensitivity and limited use.
  5. Serum white blood cell count and differential does not improve definition.
4
Table 1.1   MSIS definition for PJI
Major Criteria
Phenotypically identical organisms from two separate periprosthetic tissue cultures
Draining sinus tract
Minor Criteria
Elevated erythrocyte sedimentation rate and serum C-reactive protein
Elevated joint synovial white blood cell count
Elevated joint neutrophil percentage
Intra-articular purulence
Elevated neutrophil count on periprosthetic tissue histologic analysis
A single positive culture of periprosthetic tissue
A more cumbersome definition of joint and bursa infection has also been provided by the Centers for Disease Control (CDC).2 An infection is considered present if the patient has (1) positive cultures from joint fluid or synovial biopsy; (2) evidence of joint infection seen during surgery or on histological analysis; or (3) at least two of the following without other causes: joint pain, swelling, tenderness, heat, evidence of effusion, or limitation of motion. One of these criteria must be present in conjunction with one of the following: (1) positive Gram stain; (2) synovial fluid cell type analysis and chemistry studies consistent with infection and not explained by other diseases; (3) positive antigen test on blood, urine, or joint fluid; or (4) radiographic evidence of infection. This definition is notably broad and leaves significant interpretation to the physician. It also incorporates Gram stain results, the use of which has been discouraged in diagnosing PJI.3–65
Other authors have used various definitions of PJI for classifying cohorts of PJI patients. These definitions have consisted of various combinations of tissue culture, erythrocyte sedimentation rate, C-reactive protein, joint fluid analysis (leukocyte count and neutrophil percentage), intraoperative purulence, draining sinus tract, and histological analysis.7–12 Significant variance exists between these definitions and diagnosis of PJI cases.13
 
Controversies
  • The published thresholds for joint fluid leukocyte count and neutrophil percentage vary between the hip and knee joints.10, 14, 15 Future research is necessary to verify these thresholds.
  • It may be possible to have an “occult” infection that does not meet four of six criteria specified by the MSIS definition.
  • The utility of histological analysis remains debatable, as the thresholds for inflammatory signs characteristic of PJI on frozen section are unproven.16 Histological analysis in diagnosing PJI is highly operator dependent and requires an experienced pathologist collaborating with the surgical team.
  • Appropriate duration of tissue culture continues to be debated. Evidence exists that longer culture duration improves sensitivity without increasing contaminant growth.17
 
References
  1. Parvizi J, Zmistowski B, Berbari EF, et al. New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res. 2011;469(11):2992–4.6
  1. CDC/NHSN Surveillance definition of healthcare-associated infection and criteria for specific types of infections in the acute care setting. 2012. Available at: www.cdc.gov/nhsn/PDFs/pscManual/17pscNosInfDef_current.pdf.
  1. Della Valle CJ, Scher DM, Kim YH, et al. The role of intraoperative Gram stain in revision total joint arthroplasty. J Arthroplasty. 1999;14(4):500-4. Available at: Accessed July 23, 2011.
  1. Ghanem E, Ketonis C, Restrepo C, Joshi A, Barrack R, Parvizi J. Periprosthetic infection: where do we stand with regard to Gram stain? Acta Orthop. 2009;80(1):37-40. Available at: Accessed July 23, 2011.
  1. Johnson AJ, Zywiel MG, Stroh DA, Marker DR, Mont MA. Should gram stains have a role in diagnosing hip arthroplasty infections? Clin Orthop Relat Res. 2010;468(9):2387-91. Available at: Accessed December 28, 2011.
  1. Morgan PM, Sharkey P, Ghanem E, et al. The value of intraoperative Gram stain in revision total knee arthroplasty. J Bone Joint Surg Am. 2009;91(9):2124-9. Available at: Accessed April 11, 2010.
  1. Berbari EF, Hanssen AD, Duffy MC, et al. Risk factors for prosthetic joint infection: case-control study. Clin Infect Dis. 1998;27(5):1247-54. Available at: Accessed August 30, 2010.
  1. Parvizi J, Ghanem E, Menashe S, Barrack RL, Bauer TW. Periprosthetic infection: what are the diagnostic challenges? J Bone Joint Surg Am. 2006;88 Suppl 4:138-47. Available at: Accessed December 21, 2009.
  1. Parvizi J, Ghanem E, Sharkey P, Aggarwal A, Burnett RSJ, Barrack RL. Diagnosis of infected total knee: findings of a multicenter database. Clin Orthop Relat Res. 2008;466(11):2628-33. Available at: Accessed August 30, 2010.
  1. Schinsky MF, Della Valle CJ, Sporer SM, Paprosky WG. Perioperative testing for joint infection in patients undergoing revision total hip arthroplasty. J Bone Joint Surg Am. 2008;90(9):1869-75. Available at: Accessed August 30, 2010.7
  1. Spangehl MJ, Masri BA, O'Connell JX, Duncan CP. Prospective analysis of preoperative and intraoperative investigations for the diagnosis of infection at the sites of two hundred and two revision total hip arthroplasties. J Bone Joint Surg Am. 1999;81(5):672-83. Available at: Accessed April 11, 2010.
  1. Trampuz A, Piper KE, Jacobson MJ, et al. Sonication of removed hip and knee prostheses for diagnosis of infection. N Engl J Med. 2007;357(7):654-63. Available at: Accessed April 11, 2010.
  1. Parvizi J, Jacovides C, Zmistowski B, Jung KA. Definition of periprosthetic joint infection: is there a consensus? Clin Orthop Relat Res. 2011;469(11):3022–30.
  1. Bedair H, Ting N, Jacovides C, et al. The Mark Coventry Award: diagnosis of early postoperative TKA infection using synovial fluid analysis. Clin Orthop Related Res. 2010. Available at: http://www.ncbi.nlm.nih.gov.proxy1.lib.tju.edu:2048/pubmed/20585914. Accessed August 30, 2010.
  1. Ghanem E, Parvizi J, Burnett RSJ, et al. Cell count and differential of aspirated fluid in the diagnosis of infection at the site of total knee arthroplasty. J Bone Joint Surg Am. 2008;90(8):1637-43. Available at: Accessed August 30, 2010.
  1. Della Valle C, Parvizi J, Bauer TW, et al. American Academy of Orthopedic Surgeons clinical practice guideline on: the diagnosis of periprosthetic joint infections of the hip and knee. J Bone Joint Surg Am. 2011;93(14):1355-7. Available at: Accessed February 10, 2012.
  1. Neut D, van Horn JR, van Kooten TG, van der Mei HC, Busscher HJ. Detection of biomaterial-associated infections in orthopaedic joint implants. Clin Orthop Relat Res. 2003;(413):261-8. Available at: Accessed April 11, 2010.8

Incidence and Burden of Periprosthetic Joint Infectionschapter 2

Ibrahim J Raphael,
Hooman Bakhshi
Periprosthetic joint infection (PJI) is now the most common indication for revision total knee arthroplasty (TKA) and an increasing reason for hip revision in Europe.1,2 The incidence and burden of PJI can vary markedly by both region and population. The PJI rates in the United States differ from those reported in Europe and Australia and also vary between TKA and total hip arthroplasty (THA). Regional variations in the types of responsible infectious organisms also have been reported, even within the United States. The fiscal and treatment burden varies by infecting organism and may be quantified by measures such as length of stay (LOS) in the hospital. As the numbers of primary operations performed each year increase, the total number of PJI cases is expected to rise, and the inpatient cost may double by 2020.
 
Incidence and Burden: United States
Evaluation of data from Medicare has revealed troubling statistics regarding PJI. Medicare patients aged 65 and over, who underwent elective joint arthroplasty between 1997 and 2006 demonstrated a PJI rate of 1.55% for TKA and 1.11% for THA. Over time, this incidence decreased to a steady state of 0.46% and 0.33% for PJI following 10elective TKA and THA, respectively. Significant risk factors for infection included a Charlson Comorbidity Index (CCI) score of 1 or greater, an operative duration exceeding 120 minutes, male gender, and being the recipient of public assistance from Medicare premiums.3,4 Data from the National Inpatient Sample (NIS) demonstrated a twofold increase in the overall rate of PJI after THA and TKA from 1990 and 2004 (Table 2.1). The cumulative number of infections increased annually by a rate of approximately 5%. PJI was more common in large hospitals, and rates there also were influenced by the geographic location and type of hospital. Urban non-teaching institutions had higher PJI rates compared with urban teaching and more rural hospitals. Other risk factors included male gender, black race, and operating in a large hospital.5 Regionally, infection rates were higher in the Northeast, followed by the South, the West, and the Midwest.
The LOS for infected TKA and THA was 1.87 and 2.21 times longer than reported for uninfected TKA and THA. Hospital charges were 1.52 and 1.76 times higher for infected TKA and THA, respectively, when compared with hospital charges for uninfected cases.5 Parvizi et al evaluated the difference in LOS between patients infected with methicillin-resistant Staphylococcus aureus (MRSA) and those infected with methicillin-sensitive Staphylococcus aureus (MSSA).
Table 2.1   National inpatient sample rates of PJI: temporal trend
Primary 1990/2004
Revision 1990/2004
Overall 1990/2004
Total knee PJI
0.18%/0.05%
5.98%/15.16%
0.63%/1.21%
Total hip PJI
0.16%/0.09%
3.31%/8.01%
0.66%/1.23%
Patients with a MRSA infection of their THA had an LOS twice as long as that for patients with 11MSSA infection, and the LOS for MRSA-infected TKAs was 1.5 times as long.6 The total cost of treatment for PJI due to MRSA ($107,264) was significantly higher than that for MSSA infection ($68,053).6 In another, more recent study by Kurtz et al, which reviewed NIS records from 2001 to 2009, the incidence of PJI following total joint arthroplasty ranged from 2.0% to 2.4% and increased annually for both THA and TKA (Table 2.2). Even though the mean costs per case will stay relatively stable, the total annual inpatient cost for infected total joint arthroplasty is projected to increase from $608 million in 2009 to more than $1.6 billion in 2020 (SM Kurtz, unpublished data, 2012).
 
Incidence and Burden: Europe and Australia
From 2005 to 2009, the Norwegian Health Registry reported an incidence of surgical site infection (SSI) of 3.0% after primary THA and a 1-year incidence of PJI of 0.7% following THA.
Table 2.2   Projection of inpatient costs for PJI treatment
2001
2009
2020 (projected)
Number of infected THAs
4,545
7,162
16,584
Mean cost per case (2011 US $)
$ 31,300
$ 30,300
$ 29,750
Mean LOS per case (days)
11.5
9.5
–
Number of infected TKAs
7,113
14,802
48,971
Mean cost per case (2011 US $)
$ 25,300
$ 24,200
$ 24,659
Mean LOS per case (days)
9.3
7.2
–
12
The median time for revision due to infection was 29 days after index THA.7 PJI rates were also found to increase with time. Risk factors associated with an increased PJI rate were male gender, operative duration over 99 minutes, and uncemented fixation.8
The 2011 Australian National Joint Replacement Registry reports that the rates of revision due to PJI were 0.52% and 0.64% for primary THA and TKA, respectively. Infection was the third most common reason for all hip revisions and the second most common indication for all knee revision operations.2 In contrast, the American data suggest that infection was the most common reason for revision knee arthroplasty, followed by mechanical loosening and implant failure/breakage.1 For hip revisions, infection was also the third most common cause after instability/dislocation and mechanical loosening.9
 
Organism Profile
A number of organisms have been implicated in SSI. The infecting bacterium is a strong predictor of treatment success in the eradication of a PJI.10 The distribution of infecting organisms differs by region. S. aureus is the most common microorganism in the United States and Australia.11,12 European data, mainly from the United Kingdom, report coagulase-negative staphylococcal species as the most common organisms implicated in PJI.13 Data from our institution show an overwhelming predominance of S. aureus in PJI (Table 2.3). Approximately 10% of PJI cases are culture-negative.14 This finding may result from prior antibiotic administration, presence of fastidious pathogens, inadequate handling of specimens, or even pathogen sequestration or embedding in biofilms.15
Staphylococcal species account for 50% to 65% of all PJI cases throughout the world and are the most common 13causative agents.16
Table 2.3   Organism profile in different parts of the world (%)
Organism
United States11
United Kingdom13
Australia12
Rothman Institute 2011
Staphylococcus aureus
35
29
40
46
CoNS
31
36
13
19
Streptococcus spp.
11
7
3
6
Enterococcus spp.
7
9
1.5
2.5
Gram-negative bacilli
5
12
5
2.5
Other bacterial spp.
11
7
37
24
Abbreviations: CoNS, coagulase-negative Staphylococcus; spp., species.
The most challenging organisms in this group are MRSA and methicillin-resistant coagulase-negative staphylococcal species. Unfortunately, the incidence of MRSA has dramatically increased in the past years,17 and rates continue to climb. In some institutions, MRSA is the causative pathogen in more than half of PJI cases.6
MRSA infections can be divided into two distinct groups: community-acquired and hospital-acquired. The community-acquired form is more susceptible to β-lactam antibiotics, erythromycin, and quinolones.18 MRSA infections have a high rate of failure with isolated debridement and polyethylene exchange. One study reports failure rates of up to 63%.19 Even with 2-stage exchange protocols, failure rates of up to 25% have been reported.19
A minority of PJI cases are secondary to Gram-negative organisms (5 – 23%). Because a considerable number of 14these organisms are resistant, broad-spectrum antibiotics should be used when these organisms are identified or suspected.10 Polymicrobial (two or more organisms) infections represent 4% to 27% of all PJI.20 These infections commonly involve MRSA and anaerobes.14,20 Atypical infections, including fungal and mycobacterial organisms, represent approximately 1% of all PJI infections.14 The emerging use of tumor necrosis factor α (TNF-α) in inflammatory joint disease may increase the incidence of these unusual organisms, especially Mycobacterium tuberculosis.14
 
References
  1. Bozic KJ, Kurtz SM, Lau E, et al. The epidemiology of revision total knee arthroplasty in the United States. Clin Orthop Relat Res. 2010;468(1):45–51.
  1. The 2011 Australian National Joint Replacement Annual Report. Available at: http://www.dmac.adelaide.edu.au/aoanjrr/publications.jsp?section=reports2011.
  1. Kurtz SM, Ong KL, Lau E, et al. Prosthetic joint infection risk after TKA in the medicare population. Clin Orthop Relat Res. 2010;468(1):52–6.
  1. Ong KL, Kurtz SM, Lau E, et al. Prosthetic joint infection risk after total hip arthroplasty in the medicare population. J Arthroplasty. 2009;24(6)(suppl):105-9.
  1. Kurtz SM, Lau E, Schmier J, et al. Infection burden for hip and knee arthroplasty in the United States. J Arthroplasty. 2008;23(7):984–91.
  1. Parvizi J, Pawasarat IM, Azzam KA, et al. Periprosthetic joint infection: the economic impact of methicillin-resistant infections. J Arthroplasty. 2010;25(6)(suppl):103-7.
  1. Dale H, Skråmm I, Løwer HL, et al. Infection after primary hip arthroplasty: a comparison of 3 Norwegian health registers. Acta Orthop. 2011;82(6):646–54.
  1. Dale H, Hallan G, Hallan G, et al. Increasing risk of revision due to deep infection after hip arthroplasty. Acta Orthop. 2009;80(6):639–45.15
  1. Bozic KJ, Kurtz SM, Lau E, et al. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am. 2009;91(1):128–33.
  1. Zmistowski B, Fedorka CJ, Sheehan E, Deirmengian G, Austin MS, Parvizi J. Prosthetic joint infection caused by gram-negative organisms. J Arthroplasty. 2011;26(6)(suppl):104-8.
  1. Fulkerson E, Valle CJ, Wise B, et al. Antibiotic susceptibility of bacteria infecting total joint arthroplasty sites. J Bone Joint Surg Am. 2006;88(6):1231–7.
  1. Peel TN, Dowsey MM, Daffy JR, et al. Risk factors for prosthetic hip and knee infections according to arthroplasty site. J Hosp Infect. 2011;79(2):129–33.
  1. Phillips JE, Crane TP, Noy M, Elliott TS, Grimer RJ. The incidence of deep prosthetic infections in a specialist orthopaedic hospital: a 15-year prospective survey. J Bone Joint Surg Br. 2006;88(7):943–8.
  1. Shuman EK, Urquhart A, Malani PN. Management and prevention of prosthetic joint infection. Infect Dis Clin North Am. 2012;26(1):29–39.
  1. Berbari EF, Marculescu C, Sia I, et al. Culture-negative prosthetic joint infection. Clin Infect Dis. 2007;45(9):1113–9.
  1. Del Pozo JL, Patel R. Clinical practice. Infection associated with prosthetic joints. N Engl J Med. 2009;361(8):787–94.
  1. Wisplinghoff H, Bischoff T, Tallent SM, Seifert H, Wenzel RP, Edmond MB. Nosocomial bloodstream infections in US hospitals: analysis of 24,179 cases from a prospective nationwide surveillance study. Clin Infect Dis. 2004;39(3):309–17.
  1. Patel A, Calfee RP, Plante M, Fischer SA, Arcand N, Born C. Methicillin-resistant Staphylococcus aureus in orthopaedic surgery. J Bone Joint Surg Br. 2008;90(11):1401–6.
  1. Parvizi J, Azzam K, Ghanem E, Austin MS, Rothman RH. Periprosthetic infection due to resistant staphylococci: Serious problems on the horizon. Clin Orthop Relat Res. 2009;467(7):1732–9.
  1. Marculescu CE, Cantey JR. Polymicrobial prosthetic joint infections: risk factors and outcome. Clin Orthop Relat Res. 2008;466(6):1397–4.16

Economics of Periprosthetic Joint Infectionchapter 3

Christina Gutowski
 
Current Evidence
Both domestically and internationally, orthopedic revision surgeries performed for infections have been associated with much higher costs than procedures performed for aseptic loosening or mechanical failure.1,4 In addition, the cost burden associated with periprosthetic joint infection (PJI) surgery has been rising at an impressive rate.5 European data show that although the length of hospital stay for uninfected revisions has been decreasing significantly in recent years, length of stay for infected revisions has unfortunately not followed this trend.4 Currently, the direct medical cost of treating a case of infected total hip arthroplasty is 2.8 times greater than the direct cost of treating a case of aseptic loosening and is 4.8 times greater than the cost of primary total hip arthroplasty.1
As listed in Table 3.1, several differences between revisions for PJI and those for nonseptic reasons drive this cost disparity. The cost of long-term intravenous antibiotics administered between resection arthroplasty and reimplantation (one of the most common methods of treating PJI) is rarely mentioned in the literature and is an additional contributor to the cost discrepancy.
Within the setting of increasing background incidence of postarthroplasty deep joint infection, the proportion 18of methicillin-resistant infection is also climbing.5,6
Table 3.1   Characteristics of revision procedures for infection, compared with revision for aseptic loosening
Longer operative times
More blood loss during surgery
Higher complication rate
More total hospitalizations
More total days in hospital
More total surgical procedures
More outpatient visits
More outpatient charges
Higher total inpatient hospital charges
This escalation is extremely expensive, as the in-hospital cost of treating a deep postoperative infection caused by a methicillin-resistant organism was found by one study to be $107,264, compared with $68,053 for a sensitive strain.6 A recent query of our institution's joint infection database suggests that the charges associated with treating one case of PJI tops, on average, $100,000. A separate examination of each of three common treatment methods (irrigation and debridement, one-stage implant exchange, and two-stage implant exchange) revealed that each procedure was more expensive for a methicillin-resistant organism than for a sensitive one.6 Patients with resistant infection experienced a more complex and protracted hospital course, as well as more hospital admissions. They also had increased rates of treatment failure and poorer overall clinical outcomes.3 These findings cannot be attributed to a higher amount of comorbidity because no significant differences have been found in the Charlson indices of patients with resistant versus sensitive strains.5 Associated with these unfortunate findings are the financial costs linked to decreased quality of life, lost productivity and functionality at work, and long-term 19postoperative morbidity that is difficult to quantify and often not accounted for in the health economics literature.
Another interesting trend in recent years is seen in the demand for revision surgery among various institutions. A growing proportion of patients with PJI are being referred to high-volume tertiary care centers, despite many of these patients having undergone primary arthroplasty by an outside surgeon.1 Many studies have shown that the rate of PJI is inversely proportional to hospital and surgeon volume.7–9 Revision arthroplasty for infection is a complex and technically demanding procedure; this concept may explain why patients in need of revision are being referred to high-volume centers in increasing numbers. Unfortunately, though, for the hospital, these procedures result in a financial loss of approximately $15,000 for treating a single case of PJI and of up to $30,000 for a Medicare patient.2 As a result of the time- and resource-intensive nature of treating deep infection after joint arthroplasty, a considerable disincentive to accept these patients exists. If institutions respond to this disincentive by limiting the availability of PJI treatment, in the future, access to necessary care may be severely restricted for patients with infected arthroplasty.10

The Future: By the Numbers

  • An increasing proportion of primary joint arthroplasties are predicted to succumb to infection postoperatively.11
  • Hospital charges for all (septic or aseptic) revision procedures are projected to rise 450%, to $4.1 billion by 2015.12
  • The economic burden of infected total knee arthroplasty is projected to exceed 50% of inpatient resources available for all knee revisions by 2016.13
 
Looking Ahead
The future holds many important economic policy decisions and clinical goals concerning PJI.20
  • Cheaper, more reliable diagnostic tests for PJI must be developed; these would prevent unnecessary expenditures of time and cost-associated with investigating potential cases.
    Fair ways to incentivize more rapid and cost-conscious care without sacrificing patient safety will be the goal. Algorithms for effectively diagnosing suspected PJI are currently being developed.
  • Attempts at shortening the length of hospitalization will produce cost reduction, as length of stay and number of admissions are two major drivers of the overall cost of PJI.
    As providers strive to minimize inpatient days, safety must remain a key priority, and policy regarding readmission will need to be considered.
  • Which surgeons and institutions will bear the costly burden of treating infected arthroplasties?
    Currently, the cost is disproportionately shouldered by urban, high-volume hospitals, where cases are referred after the more lucrative primary arthroplasty was performed at a smaller, low-volume institution.1 Is this a financially fair paradigm? Reimbursement reform must occur so that those hospitals bearing a greater proportion of this burden are able to stay afloat.
 
References
  1. Bozic KJ, Ries MD. The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization. J Bone Joint Surg Am. 2005;87-A(8):1746-51.
  1. Hebert CK, Williams RE, Levy RS, Barrack RL. Cost of treating an infected total knee replacement. Clin Orthop Relat Res. 1996;331:140–5.
  1. Walls RJ, Roche SJ, O'Rourke A, McCabe JP. Surgical site infections with methicillin-resistant Staphylococcus aureus after primary total hip arthroplasty. J Bone Joint Surg Br. 2008;90:292.21
  1. Oduwole KO, Molony D, Walls RJ, Bashir SP, Mulhall KJ. Increasing financial burden of revision total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2010;18:945–8.
  1. Parvizi J, Pawasarat IM, Azzam KA, Joshi A, Hansen EN, Bozic KJ. Periprosthetic joint infection. The economic impact of methicillin-resistant infection. J Arthroplasty. 2010;25(6-S1):103–7.
  1. Parvizi J, Ghanem E, Azzam K, Davis E, Jaberi F, Hozack W. Periprosthetic joint infection: are current treatment strategies adequate? Acta Orthop Belg. 2008;74(793).
  1. Katz JN, Phillips CB, Baron JA, et al. Association of hospital and surgeon volume of total hip replacment with function status and satisfaction three years following surgery. Arthritis Rheum. 2003;19:694–9.
  1. Sharkey PF, Shastri S, Teloken MA, Parvizi J, Hozack WJ, Rothman RH. Relationship between surgical volume and early outcomes of total hip arthroplasty: do results continue to get better? J Arthroplasty. 2004;19:694–9.
  1. Katz JN, Losina E, Barrett J, et al. Association between hospital and surgeon procedure volume and outcomes of total hip replacement in the United States Medicare population. J Bone Joint Surg Am. 2001;83:1622–9.
  1. Sculco TP. The economic impact of infected total joint arthroplasty. Instructional Course Lecture. 1993;42:349–51.
  1. Kurtz SM, Lau E, Schmier J, Ong KL, Zhao K, Parvizi J. Infection burden for hip and knee arthroplasty in the US. J Arthroplasty. 2008;23(7):984–91.
  1. Lavernia C, Lee DJ, Hernandez VH. The increasing burden of knee revision surgery in the US. Clin Orthop Relat Res. 2006;446:221–6.
  1. Kurtz SM, Ong KL, Schmier J, et al. Future clinical and economic impact of revision total hip and knee arthroplasty. J Bone Joint Surg Am. 2007;89(S-3):144–51.
 
Acknowledgment
The author would like to acknowledge Ben Zmistowski for assistance with statistical calculation of institutional data.22

Antibiotics and Periprosthetic Joint Infection: Basic Sciencechapter 4

Nader Toossi
Antibiotics are an essential tool in combating periprosthetic joint infection (PJI). An understanding of the major classes of antibiotics and their mechanism of action is fundamental to selecting the appropriate antibiotic coverage for a specific organism. The activity, side effects, and mechanism of action of the major classes of antibiotics used in the treatment of PJI are shown in the Table 4.1.1,2 Antibiotics are categorized according to their cellular activity against different aspects of individual bacterial cells. For example, some, such as penicillins, cephalosporins, monobactams, glycopeptides, and carbapenem, inhibit bacterial cell wall synthesis. Others act at the ribosomal subunit level to inhibit protein synthesis; these include aminoglycosides, macrolides, lincosamides, oxazolidinones, and streptogramins. Still others, such as the quinolones and rifampin, affect bacterial DNA and RNA, respectively, to inhibit protein synthesis. Lipopeptides inhibit protein, DNA, and RNA synthesis by disrupting plasma membranes.3
Owing to the rapid emergence of multidrug-resistant species of bacteria in hospitals and health care facilities, extreme caution should be exercised in selecting the appropriate antibiotic or combination of antibiotics.24
Table 4.1   Major classes of antibiotics used to treat PJI
Class (Typical example)
Activity Against
Potential Side effects
Mechanism of Action
Aminoglycosides
(gentamicin)
Gram-negative bacteria: Escherichia coli, Klebsiella, and particularly Pseudomonas aeruginosa; also aerobic bacteria (not obligate/facultative anaerobes)
Nephrotoxicity, neuromuscular blockade, vertigo, ototoxicity
Binds to the bacterial ribosomal subunit, inhibiting translocation of the peptidyl tRNA from the A-site to the P-site and also causing misreading of mRNA
Carbapenems
(imipenem/cilastatin)
Both Gram-positive and Gram-negative organisms (bactericidal), useful for empiric broad-spectrum antibacterial coverage (Note: MRSA resistant to this class)
Rash and allergy, gastrointestinal upset and diarrhea, nausea, seizures, and headache
Inhibition of cell wall synthesis25
Cephalosporins
First generation (cefazolin)
Gram-positive infections
Gastrointestinal upset and diarrhea,
nausea (if alcohol taken concurrently), allergic reactions including rash and pruritis
Disrupts the synthesis of the peptidoglycan layer of bacterial cell walls26
Second generation (cefuroxime)
Reduced Gram-positive coverage, improved Gram-negative coverage
Third generation (cefixime)
Improved coverage of Gram-negative organisms, except Pseudomonas ; reduced Gram-positive coverage
Fourth generation (cefepime)
Pseudomonas
Fifth generation (ceftaroline fosamil)
MRSA
Glycopeptides
(vancomycin)
Gram-positive bacteria, including methicillin-resistant organisms
Hypersensitivity, phlebitis, fever, chills, ototoxicity, nephrotoxicity, and red man syndrome for vancomycin
Inhibits later stages of bacterial cell wall peptidoglycan synthesis
Lincosamides
(clindamycin)
Gram-positive cocci, anaerobes
Hypersensitivity reactions, pseudomembranous enterocolitis, myopathy
Binds to 50S subunit of bacterial ribosomal RNA, thereby inhibiting protein synthesis
Lipopeptides
(daptomycin)
Gram-positive organisms, including MRSA and vancomycin-resistant enterococci3
Paresthesias or reversible paralysis (e.g., Bell's palsy)
Binds to the plasma membrane and causes rapid depolarization, leading to inhibition of DNA, RNA, and protein synthesis27
Macrolides
(erythromycin)
Aerobic Gram-positive cocci and bacilli
Hepatotoxicity, gastrointestinal toxicity, cardiac toxicity,
auditory impairment, visual disturbance
Binds reversibly to 50S ribosomal subunit and inhibits protein synthesis
Monobactams
(aztreonam)
Gram-negative pathogens, especially Pseudomonas
Nausea, vomiting, diarrhea
Disrupts cell wall synthesis
Oxazolidinones
(linezolid)
Multidrug-resistant Gram-positive cocci such as MRSA
Peripheral neuropathy, rash, nausea, vomiting, bone marrow suppression, tongue discoloration
Inhibits bacterial translation at the initiation phase of protein synthesis
Penicillins
(cloxacillin)
Wide range of infections; penicillin used for streptococcal infections;
carbenicillin, ticarcillin, mezlocillin, piperacillin are also active against Pseudomonas
Gastrointestinal upset, diarrhea, allergy with serious anaphylactic reactions, brain and kidney damage (rare),
Coombs-positive hemolytic anemia, seizure activity,
Disrupts the synthesis of the peptidoglycan layer of bacterial cell walls28
Quinolones
(ciprofloxacin)
Gram-negative organisms, including activity against Enterobacteriaciae, Staphylococcus aureus (variable), and S. epidermidis
Nausea (rare), anaphylaxis, vasculitis,
irreversible damage to central nervous system (uncommon), tendinopathies, hypo- or hyperglycemia, photosensitivity, serum sickness–like reactions, increased Q-T intervals
Inhibits the bacterial DNA gyrase or the topoisomerase IV enzyme, thereby inhibiting DNA replication and transcription
Rifamycin
(rifampin)
Bactericidal against many Gram-positive and Gram-negative bacteria
Orange-red discoloration of body fluid, hepatitis, mild immunosuppression
Inhibits protein synthesis by preventing transcription to RNA
Streptogramins
(quinupristin/dalfopristin)
Most Gram-positive organisms:
vancomycin-resistant Enterococcus (VRE) faecium, MRSA, MRSE
Itching, pain, burning, vomiting, diarrhea, phlebitis, myalgia8
Binds to 50S subunit of bacterial ribosomal RNA, thereby inhibiting protein synthesis9
Abbreviations: MRSA, methicillin-resistant Staphylcoccus aureus; MRSE, methicillin-sensitive Staphylococcus aureus.
29
Certain combinations may offer a synergistic effect and decrease the chance of drug resistance. An example is the combining of rifampin with a semisynthetic penicillin to treat osteomyelitis caused by methicillin-sensitive Staphylococcus species.2 Dosing and treatment guidelines are outlined in separate chapters, but it is also important to understand how different antibiotics may be affected by the formation of a biofilm around an implant. The glycocalyx is positively charged (because of carbohydrate residues on its exterior), and so it is relatively impenetrable to the positively charged hydrophilic antibiotics, such as aminoglycosides and polypeptides. Other classes of antibiotics, like the β-lactams, quinolones, and macrolides, are better suited to penetrate biofilm, once established.4 The bioavailability of different antibiotics within a joint varies as well. Schurman et al5 demonstrated that cefazolin levels in bone around the hip were 7% to 40% lower than serum concentrations but did reach minimum inhibitory concentrations and dropped dramatically after 1.8 hours. Bone and synovial samples reached therapeutic concentrations within minutes of administration and should be administered prior to tourniquet inflation for total knee arthroplasty.6 In contrast, cephalexin, a commonly used oral antibiotic, has a bioavailability of 90 ± 9% in serum, reducing its effective levels in bone and synovium.7
 
References
  1. Brunton L, Chabner B, Knollman B, eds. Goodman and Gilman's The Pharmacological Basis of Therapeutics. 12th ed. New York: McGraw-Hill;  2011.
  1. Mader JT, Wang J, Calhoun JH. Antibiotic therapy for musculoskeletal infections. Instructional Course Lecture 2002;51:539–51.
  1. Vilhena C, Bettencourt A. Daptomycin: a review of properties, clinical use, drug delivery and resistance. Mini Rev Med Chem. 2012;12(3):202–9.30
  1. Cloete TE. Resistance mechanisms of bacteria to antimicrobial compounds. International Biodeterioration and Biodegradation. 2003;51(4):277–82.
  1. Schurman DJ, Hirshman HP, Kajiyama G, Moser K, Burton DS. Cefazolin concentrations in bone and synovial fluid. J Bone Joint Surg Am. 1978;60(3):359–62.
  1. Meehan J, Jamali AA, Nguyen H. Prophylactic antibiotics in hip and knee arthroplasty. J Bone Joint Surg Am. 2009;91(10):2480–90.
  1. Spyker DA, Thomas BL, Sande MA, Bolton WK. Pharmacokinetics of cefaclor and cephalexin: dosage nomograms for impaired renal function. Antimicrob Agents Chemother. 1978;14(2):172–7.
  1. Culos KA, Cannon JP, Grim SA. Alternative agents to vancomycin for the treatment of methicillin-resistant Staphylococcus aureus infections. Am J Ther. 2011;Jun 3.
  1. Linden P. Quinupristin-dalfopristin. Curr Infect Dis Rep. 1999;1(5):480–7.

The Role of Biofilm in Periprosthetic Joint Infectionchapter 5

Aaron Glynn
 
Current Evidence
The most common bacteria responsible for orthopedic device-related infections are Staphylococcus aureus and Staphylococcus epidermidis, accounting for over 50% of chronic biomaterial-related infections. Their prevalence is related to the ubiquitous presence of these organisms in normal skin flora and their ability to form biofilm. A biofilm has been defined by Costerton1 as a “community of bacterial cells that is adherent to a surface interface or to each other and encased in a self-produced polymeric matrix.” Shirtliff2 noted that bacteria found in biofilm behave differently from unicellular or planktonic bacteria. Biofilm formation allows bacterial survival during suboptimal periods of growth or in the presence of an environmental stress, such as antimicrobial therapy.

Rothman Institute Current Practices

  1. A chronically infected prosthesis is removed when feasible.
  2. Thorough debridement of all foreign and necrotic material is performed in preparation for one- or two-stage revision arthroplasty.
  3. Antibiotic suppression of biofilm infection is recommended only with a sensitive organism, the availability of a well-tolerated antibiotic, and a medically unfit patient.
32
Many biofilms in nature can be visualized with the naked eye as a slimy layer adhering to a surface, such as dental plaque. Biofilm development follows several stages, which include an initial attachment, microcolony formation, maturation, and shedding.
 
Bacterial Attachment to Surfaces
Biofilm infection of medical devices occurs when bacteria win the “race for the surface” and attach to an implanted device, defeating host defenses or prior to host integration.3 Development of infection is facilitated by the presence of a biomaterial,4 and Southwood et al5 found that it was easier to induce infection in a rabbit hip model if a prosthesis was inserted. In vitro studies on biomaterials have shown that S. aureus preferentially attaches to metals over polymethylmethacrylate (PMMA) and bone.6 S. epidermidis has less ability to adhere to metals, especially titanium,7 and preferentially attaches to polymers.3 Biofilm-related infection can also occur in the absence of a foreign body; chronic S. aureus infection of native tissues (e.g. heart valves, bone, teeth) is also biofilm based (Figure 5.1).
 
Microcolony Formation
Microcolony formation is stimulated by bacterial adherence to a surface. “Quorum sensing” is the ability of bacteria to sense and to communicate with one another. It occurs in the presence of high microbial density, with increased cell-to-cell signaling leading to activation of genes responsible for biofilm production.8

Pitfalls

  1. Bacterial biofilm cannot be eradicated by antibiotic therapy alone.
  2. Failure to remove a chronically infected biomaterial is associated with a high chance for recurrence of infection.
33
Figure 5.1: An S. aureus biofilm of the surface of a catheter (Obtained from the CDC Public Health Image Library. Image credit: CDC/Rodney M. Donlan, PhD; Janice Carr (PHIL #7488), 2005.)
Biofilm formation occurs over a matter of a few hours. The microcolonies become surrounded by a slimy matrix of polysaccharide expressed by the bacteria. In S. epidermidis, this slime substance is known as polysaccharide intercellular adhesin (PIA).9 Not all isolates of S. epidermidis produce PIA, but studies have shown that bacteria producing it are more likely to form biofilm10 and cause chronic biomaterial-related infections in animal models.11
 
Biofilm Maturation
Following attachment, microorganisms develop into complex communities resembling multicellular organisms.15 Not all extracellular matrix of in vivo biofilms is produced by the bacteria; Buret16 found that a large proportion of the biofilm mass of Pseudomonas aeruginosa grown on Silastic implants inserted into rabbit peritoneal cavities was host generated and typically contained polymorphonuclear neutrophils trapped within a thick mesh of fibrin.34
 
Bacterial Shedding
The final phase in biofilm formation is shedding. Shedding of bacteria from the mature biofilm represents a dispersal of viable planktonic organisms, capable of causing metastatic infection. This may occur in response to nutrient limitation, whereby cells are released to colonize a new environment with less competition for nutrient availability. It is a survival and propagation strategy, and it may be actively controlled by changes in extracellular polymer production3 or by production of a substance capable of lysing the adhesive polysaccharide. This is particularly troubling in patients with an isolated periprosthetic joint infection with other aseptic and functional joint replacements.
 
Antimicrobial Resistance
Biofilm infection, once established, cannot be eradicated by the host's immune mechanisms. Even antimicrobial therapy is unlikely to be successful. Darouiche17 showed that vancomycin can penetrate the glycocalyx of a staphylococcal biofilm, to levels exceeding the minimal inhibitory concentration and minimum bactericidal concentration of the bacteria, but found that even extremely high drug concentrations did not eradicate bacteria embedded in biofilm. It has been suggested that bacteria living within biofilm exist as a distinct and protected biofilm phenotype.2,15 They exist in a stationary phase of growth and are not as active metabolically as their planktonic counterparts. This characteristic reduces their susceptibility to many antimicrobial agents; for example, antibiotics such as the β-lactam ring-based penicillins are effective only against rapidly dividing bacteria.19
Biofilm-mediated survival of bacteria thus causes chronic infection of implants. Owing to the slow rate of growth, it may not present clinically for months or 35years following prosthetic implantation. Subclinical infections may only become apparent years later because of loosening of the implant, and many of these cases of implant failure are incorrectly attributed to “aseptic loosening”.21 At this stage, the only therapeutic option available is to remove the implant, with or without reinsertion of a new prosthesis.
 
References
  1. Costerton JW, Lewandowski Z, Caldwell DE, Korber DR, Lappin-Scott HM. Microbial biofilms. Annu Rev Microbiol. 1995;49:711–45.
  1. Shirtliff ME, Mader JT, Camper AK. Molecular interactions in biofilms. Chem Biol. 2002;9(8):859–71.
  1. Gristina AG. Biomaterial-centered infection: microbial adhesion versus tissue integration. Science. 1987;237(4822):1588–95.
  1. Zimmerli W, Waldvogel FA, Vaudaux P, Nydegger UE. Pathogenesis of foreign body infection: description and characteristics of an animal model. J Infect Dis. 1982;146(4):487–97.
  1. Southwood RT, Rice JL, McDonald PJ, Hakendorf PH, Rozenbilds MA. Infection in experimental hip arthroplasties. J Bone Joint Surg Br. 1985;67(2):229–31.
  1. Gracia E, Fernandez A, Conchello P, et al. Adherence of Staphylococcus aureus slime-producing strain variants to biomaterials used in orthopaedic surgery. Int Orthop. 1997;21(1):46–51.
  1. Sheehan E, McKenna J, Mulhall KJ, Marks P, McCormack D. Adhesion of Staphylococcus to orthopedic metals, an in vivo study. J Orthop Res. 2004;22(1):39–43.
  1. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med. 2004;351(16):1645–54.
  1. Mack D, Fischer W, Krokotsch A, et al. The intercellular adhesin involved in biofilm accumulation of Staphylococcus epidermidis is a linear beta-1,6-linked glycosaminoglycan: purification and structural analysis. J Bacteriol. 1996;178(1):175–83.36
  1. Mack D, Haeder M, Siemssen N, Laufs R. Association of biofilm production of coagulase-negative staphylococci with expression of a specific polysaccharide intercellular adhesin. J Infect Dis. 1996;174(4):881–4.
  1. Rupp ME, Ulphani JS, Fey PD, Mack D. Characterization of Staphylococcus epidermidis polysaccharide intercellular adhesin/hemagglutinin in the pathogenesis of intravascular catheter-associated infection in a rat model. Infect Immun. 1999;67(5):2656–9.
  1. Heilmann C, Schweitzer O, Gerke C, Vanittanakom N, Mack D, Gotz F. Molecular basis of intercellular adhesion in the biofilm-forming Staphylococcus epidermidis. Mol Microbiol. 1996;20(5):1083–91.
  1. Ziebuhr W, Heilmann C, Gotz F, et al. Detection of the intercellular adhesion gene cluster (ica) and phase variation in Staphylococcus epidermidis blood culture strains and mucosal isolates. Infect Immun. 1997;65(3):890–6.
  1. Gotz F. Staphylococcus and biofilms. Mol Microbiol. 2002;43(6):1367–78.
  1. Costerton JW, Stewart PS, Greenberg EP. Bacterial biofilms: a common cause of persistent infections. Science. 1999;284(5418):1318–22.
  1. Buret A, Ward KH, Olson ME, Costerton JW. An in vivo model to study the pathobiology of infectious biofilms on biomaterial surfaces. J Biomed Mater Res. 1991;25(7):865–74.
  1. Darouiche RO, Dhir A, Miller AJ, Landon GC, Raad II, Musher DM. Vancomycin penetration into biofilm covering infected prostheses and effect on bacteria. J Infect Dis. 1994;170(3):720–3.
  1. Dunne WM Jr, Mason EO Jr, Kaplan SL. Diffusion of rifampin and vancomycin through a Staphylococcus epidermidis biofilm. Antimicrob Agents Chemother. 1993;37(12):2522–6.
  1. Widmer AF. New developments in diagnosis and treatment of infection in orthopedic implants. Clin Infect Dis. 2001;33 Suppl 2:S94–106.
  1. Garvin KL, Hanssen AD. Infection after total hip arthroplasty. Past, present, and future. J Bone Joint Surg Am. 1995;77(10):1576–88.37
  1. Nguyen LL, Nelson CL, Saccente M, Smeltzer MS, Wassell DL, McLaren SG. Detecting bacterial colonization of implanted orthopedic devices by ultrasonication. Clin Orthop Relat Res. 2002(403):29-37.38

Multidisciplinary Approach and Management of Patients with Periprosthetic Infectionschapter 6

Claudio Diaz-Ledezma
 
Current Evidence
A multidisciplinary approach is advocated for both prevention and treatment of periprosthetic joint infection (PJI). Involvement of a specialist in evaluation and care can affect the rate of PJI and improve the outcomes in patients with chronic infections.
The American Academy of Orthopaedic Surgeons (AAOS), the Infectious Diseases Society of America (IDSA), and the Musculoskeletal Infection Society (MSIS) have no established guidelines or criteria regarding a multidisciplinary approach to PJI. The present chapter includes our institutional recommendations.

Rothman Institute Current Practices

  1. Preoperative clearance by cardiologist.
  2. Preoperative dental clearance for all patients.
  3. Active participation of infectious disease specialist in PJI treatment.
40
 
PJI: Prevention
Modifiable risk factors associated with PJI can be divided into two broad categories: (1) those that impair the patient's immune system (e.g. diabetes mellitus, HIV, nutrition) and (2) those that increase the risk of bacteremia owing to local conditions (e.g. dialysis, dental abscess, and urinary incontinence).1,2 Some of these issues may be addressed by the orthopaedic surgeon but many will require the recruitment of additional subspecialists.
Independent risk factors for PJI include obesity, diabetes mellitus, malignancy, rheumatoid arthritis (and other rheumatologic diseases), myocardial infarction, congestive heart disease, pulmonary circulation disorders, urinary tract infections, preoperative anemia, depression, renal disease, psychoses, peripheral vascular disease, heart valvular disease,3–10 and hepatitis C.11 Two scores have been used to quantify risk factors: (1) an American Society of Anesthesiologists score > 2 (included in the National Nosocomial Infection Surveillance [NNIS] score)4 and (2) the Charlson Comorbidity Index;12 a preoperative Charlson Index > 3 has been linked to increased risk of PJI in revision TKA.8
Preoperative evaluation of comorbidities and modifiable risk factors is encouraged prior to total joint arthroplasty (TJA). To date, measurable objectives for optimization have not been clearly identified and may vary by hospital or regionally (e.g. the optimal hemoglobin A1c in diabetic patients prior to TJA). Other specific conditions that have an impact on PJI and that can be optimized are malnutrition, HIV (CD4 count), and anticoagulation.13,14
Barrington15 examined the prevalence of dental disease in preoperative TJA, finding a prevalence of 23% prior to surgery. However, no official recommendation for dental clearance before TJA has been made by the AAOS.16,17 Moreover, this kind of intervention is not supported 41by the indicators of quality of care in TJA.18 Dental care interventions after TJA are an important subject. The most recent AAOS statement regarding antibiotic prophylaxis for dental care intervention after TJA17 has been questioned by the American Academy of Oral Medicine (AAOM).19 Dental clearance prior to surgery is obtained on all patients scheduled for elective TJA at our institution, and prophylaxis is based on AAOS recommendations.17
Following surgery, continued involvement is crucial because many infections may occur more than two years following the index surgery.20 In patients with a well-functioning asymptomatic arthroplasty, routine follow-up has been questioned.21–23 Patient compliance may also be a confounding issue.24 Regardless, we recommend regular periodic follow-up, particularly in patients with multiple risk factors. Our most common practice for follow-up in well-functioning TJAs is postoperative visits at six weeks, six months, one year, two years, and then at three-year intervals.
 
PJI: Treatment
Once infection is diagnosed, a multidisciplinary approach is the most logical strategy. Selection of individuals for a multidisciplinary team is recommended particularly in academic or high-volume referral centers. In smaller community hospitals, this degree of support may not be readily available, and referral to a tertiary facility is advised. Table 6.1 presents recommendations for the inclusion and role of different health care professionals who may be needed on the multidisciplinary team. Other chapters within this book cover the treatment of specific infections.
 
Controversies
 
References
  1. Khayr WF, CarMichael MJ, Dubanowich CS, Latif RH, Waiters L. Bacteremia in veterans administration nursing home patients. Am J Ther. 2004;11(4):251–7.
  1. Richardson JP, Hricz L. Risk factors for the development of bacteremia in nursing home patients. Arch Fam Med. 1995;4(9):785–9.
  1. Bozic KJ, Lau E, Kurtz S, Ong K, Berry DJ. Patient-related risk factors for postoperative mortality and periprosthetic joint infection in Medicare patients undergoing TKA. Clin Orthop Relat Res. 2012;470(1):130–7.
  1. Berbari EF, Hanssen AD, Duffy MC, et al. Risk factors for prosthetic joint infection: case-control study. Clin Infect Dis. 1998;27(5):1247–54.
  1. Bongartz T, Halligan CS, Osmon DR, et al. Incidence and risk factors of prosthetic joint infection after total hip or knee replacement in patients with rheumatoid arthritis. Arthritis Rheum. 2008;59(12):1713–20.
  1. Dowsey MM, Choong PF. Obese diabetic patients are at substantial risk for deep infection after primary TKA. Clin Orthop Relat Res. 2009;467(6):1577–81.
  1. Jamsen E, Huhtala H, Puolakka T, Moilanen T. Risk factors for infection after knee arthroplasty. A register-based analysis of 43,149 cases. J Bone Joint Surg Am. 2009;91(1):38–47.
  1. Mortazavi SM, Schwartzenberger J, Austin MS, Purtill JJ, Parvizi J. Revision total knee arthroplasty infection: incidence and predictors. Clin Orthop Relat Res. 2010;468(8):2052–9.49
  1. Peersman G, Laskin R, Davis J, Peterson M. Infection in total knee replacement: a retrospective review of 6489 total knee replacements. Clin Orthop Relat Res. 2001(392):15-23.
  1. Pulido L, Ghanem E, Joshi A, Purtill JJ, Parvizi J. Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res. 2008;466(7):1710–5.
  1. Pour AE, Matar WY, Jafari SM, Purtill JJ, Austin MS, Parvizi J. Total joint arthroplasty in patients with hepatitis C. J Bone Joint Surg Am. 2011;93(15):1448–54.
  1. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83.
  1. Minnema B, Vearncombe M, Augustin A, Gollish J, Simor AE. Risk factors for surgical-site infection following primary total knee arthroplasty. Infect Control Hosp Epidemiol. 2004;25(6):477–80.
  1. Parvizi J, Ghanem E, Joshi A, Sharkey PF, Hozack WJ, Rothman RH. Does “excessive” anticoagulation predispose to periprosthetic infection? J Arthroplasty. 2007;22(6)(suppl 2):24-8.
  1. Barrington JW, Barrington TA. What is the true incidence of dental pathology in the total joint arthroplasty population? J Arthroplasty. 2011;26(6 Suppl):88–91.
  1. Parvizi J, Della Valle CJ. AAOS Clinical Practice Guideline: diagnosis and treatment of periprosthetic joint infections of the hip and knee. J Am Acad Orthop Surg. 2010;18(12):771–2.
  1. AAOS. Information statement: antibiotic prophylaxis for bacteremia in patients with joint replacements. February 2009. Revised June 2010.: http://www.aaos.org/about/papers/advistmt/1033.asp. Accessed March 31, 2012.
  1. SooHoo NF, Lieberman JR, Farng E, Park S, Jain S, Ko CY. Development of quality of care indicators for patients undergoing total hip or total knee replacement. BMJ Qual Saf. 2011;20(2):153–7.
  1. Little JW, Jacobson JJ, Lockhart PB. The dental treatment of patients with joint replacements: a position paper from the American Academy of Oral Medicine. J Am Dent Assoc. 2010;141(6):667–71.50
  1. Jamsen E, Furnes O, Engesaeter LB, et al. Prevention of deep infection in joint replacement surgery. Acta Orthop. 2010;81(6):660–6.
  1. Hacking C, Weinrauch P, Whitehouse SL, Crawford RW, Donnelly WJ. Is there a need for routine follow-up after primary total hip arthroplasty? ANZ J Surg. 2010;80(10):737–40.
  1. Bhatia M, Obadare Z. An audit of the out-patient follow-up of hip and knee replacements. Ann R Coll Surg Engl. 2003;85(1):32–5.
  1. Bolz KM, Crawford RW, Donnelly B, Whitehouse SL, Graves N. The cost-effectiveness of routine follow-up after primary total hip arthroplasty. J Arthroplasty. 2010;25(2):191–6.
  1. Sethuraman V, McGuigan J, Hozack WJ, Sharkey PF, Rothman RH. Routine follow-up office visits after total joint replacement: do asymptomatic patients wish to comply? J Arthroplasty. 2000;15(2):183–6.
  1. Vissers MM, Bussmann JB, Verhaar JA, Busschbach JJ, Bierma-Zeinstra SM, Reijman M. Psychological factors affecting the outcome of total hip and knee arthroplasty: a systematic review. Semin Arthritis Rheum. 2012;41(4):576–88.

Periprosthetic Joint Infection: Future Trends and Challengeschapter 7

Joseph A Karam,
Peter F Sharkey
 
Current Evidence
The expected incidence of periprosthetic joint infection (PJI) following primary joint replacement ranges from 1% to 2%.1–3 Kurtz et al4 have predicted that by 2030, the demand for total hip arthroplasty (THA) will increase by 175% and for total knee arthroplasty (TKA) by 600%. This prediction translates into 572,000 primary THA and 3.48 million primary TKA procedures to be performed annually in the United States by 2030. According to conservative estimates, the burden of new PJI cases could exceed 40,000 cases per year, resulting in a significant fiscal and clinical burden. Evidence indicates that infection rates may be on the rise, and incidence may be affected by patient factors (e.g. obesity, diabetes, poor nutrition) and microbial virulence.5 The cost of revision surgery for PJI is significantly higher than that for aseptic revision: 1.76 times for hips and 1.52 times for knees, according to Kurtz et al6 Bozic and Ries7 estimated the cost of septic revision THA to be $96,166—much greater than for nonseptic revision THA ($34,866).
Outcomes comparing septic with nonseptic revision surgery generally reveal inferior results when infection is present. Barrack et al8 reported that range of motion and functional scores are lower after 2-stage TKA revision than 52for aseptic cases. Romano et al9 observed comparable outcomes after septic and aseptic revision THA; however, they reported a 2-fold greater incidence of complications following septic revision. Others have noted that septic THA revision requires longer operative times and is associated with greater blood loss.7
In the future, surgeons may expect to see increasing numbers of PJI cases; this presents many challenges regarding utilization, patient selection, and distribution of cases among providers and hospitals. This chapter will discuss controversies stimulated by PJI trends and the challenges created by this significant complication.
 
Controversies
 
What Effect will PJI have on Future THA and TKA Utilization?
Clearly, arthroplasty demands will exponentially rise, assuming novel, effective nonarthroplasty alternative treatments are not developed. However, changes in which health care is provided will likely lead to significant lag time between demand and utilization, as in Canada and other countries with socialized medical systems. In the United States, this “rationing” of care will be driven by the formation of accountable care organizations (ACO) and bundled payments for episodes of care (EOC). This new paradigm will lead surgeons to enter into a risk-sharing model with all other entities and individuals who provide care during a THA or TKA EOC.
Reimbursement for all care (including the surgical fee) provided during a negotiated preoperative and postoperative period (EOC) will be paid to 1 entity, the ACO, and then distributed by the ACO on the basis of some prearranged formula. Because all providers and institutions are paid by the ACO, the reimbursement formula has been termed a “bundled payment methodology.”53
There are known risk factors for PJI, and the cost of treating PJI is enormous. These two issues will likely lead most ACOs to develop parameters requiring patients to correct modifiable risk factors for PJI prior to surgery. In the future, obese patients will be required to lose weight, preoperative nutritional laboratory studies will be routine, and diabetic patients will be mandated to achieve glucose control prior to elective surgical intervention. In addition, many other potentially modifiable risk factors for PJI exist, and this will likely lead to a much lower level of THA and TKA utilization than previously predicted because many patients will not be able to modify these risk factors.
 
What Effect will PJI have on the Patient's Selection of the Provider for Replacement Surgery?
The incidence of PJI varies considerably when comparing institutions and surgeons. Transparency, part of the new health care mantra, coupled with the ubiquitous Internet, will allow patients to access myriad data that detail complication rates, patient satisfaction scores, and clinical outcome data. The morbidity of PJI equals or surpasses the magnitude of any other complication associated with joint replacement. Likely, patients will carefully scrutinize PJI data to preferentially choose providers (both hospital and surgeon) with a low incidence of PJI.
The complexities of risk stratifying this information and statistical analyses could very well influence patients to make choices based on erroneous interpretation of PJI incidence data.
The ramification of the above scenario is that those institutions and surgeons with low infection rates likely will realize substantial increases in the number of patients seeking their services for joint replacement. Conversely, if the PJI rate is high, surgical volume will decrease. Of course, the positive outcome related to this change will be an enormous emphasis on PJI reduction strategies. 54However, the downside will be larger surgical backlogs at well-performing facilities and additional pressure on providers not to perform total joint arthroplasty on so-called high-risk patients.
 
What Effect will PJI have on Tertiary and Teaching Hospitals?
As previously stated, the cost and complexity of treating an infected arthroplasty are substantial. Studies have shown that referral of PJI cases to tertiary or teaching hospitals is already common and creates a great financial burden on the accepting facility.6 Bundled payments will worsen this paradigm because the hospital accepting the referral of a patient with PJI will not be able to acquire additional funds for providing services. Nonetheless, treating a PJI often requires the expertise of a fellowship-trained adult reconstructive surgeon, and the demanding postoperative care is greatly facilitated when a highly skilled, low-cost labor force (i.e. interns, residents, and fellows) assists with the care of the patient.
These competing issues predictably will lead to creation of highly specialized centers that receive additional compensation for treating patients with a PJI who have been referred for care. The source of this compensation will be a point of major controversy, but likely the ACO performing the original surgery will bear the brunt of this financial hardship.
As with almost any change, a positive side can be noted. Centers of excellence created to treat PJI will develop efficiencies, surgical expertise, and knowledge that ultimately will lead to lower costs and better outcomes. Furthermore, these centers will have the clinical volume necessary to study PJI and create new evidence-based practices of medicine related to PJI. Evidence-based medicine is another pillar of the new health care paradigm, and physicians will be expected to make decisions based 55on high-level clinical studies. Finally, the challenges of PJI will prompt clinicians, researchers, and industries to develop improved technologies for preventing and treating the dreaded complication of PJI.
 
References
  1. Kurtz SM, Ong KL, Lau E, Bozic KJ, Berry D, Parvizi J. Prosthetic joint infection risk after TKA in the Medicare population. Clin Orthop Relat Res. 2010;468(1):52–6.
  1. Ong KL, Kurtz SM, Lau E, Bozic KJ, Berry DJ, Parvizi J. Prosthetic joint infection risk after total hip arthroplasty in the Medicare population. J Arthroplasty. 2009;24(suppl 6):105–9.
  1. Schmalzried TP, Amstutz HC, Au MK, Dorey FJ. Incidence of deep sepsis in total hip arthroplasty. Survivorship analysis over 17 years from one hospital. J Arthroplasty. 1991;Suppl 6:S47-51.
  1. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780–5.
  1. Kurtz SM, Ong KL, Schmier J, Mowat F, Saleh K, Dybvik E, et al. Future clinical and economic impact of revision total hip and knee arthroplasty. J Bone Joint Surg Am. 2007;89(suppl 3):144–51.
  1. Kurtz SM, Lau E, Schmier J, Ong KL, Zhao K, Parvizi J. Infection burden for hip and knee arthroplasty in the United States. J Arthroplasty. 2008;23(7):984–91.
  1. Bozic, KJ, Ries MD. The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization. J Bone Joint Surg Am. 2005;87(8):1746–51.
  1. Barrack RL, Engh G, Rorabeck C, Sawhney J, Woolfrey M. Patient satisfaction and outcome after septic versus aseptic revision total knee arthroplasty. J Arthroplasty. 2000;15(8):990–3.
  1. Romanò CL, Romanò D, Logoluso N, Meani E. Septic versus aseptic hip revision: how different? J Orthop Traumatol. 2010;11(3):167–74.56
Section 2
57Prevention
Aaron Glynn

Predisposing Factors for Periprosthetic Joint Infectionchapter 8

David N Vegari
 
Current Evidence
The most important decision influencing periprosthetic joint infection (PJI) appears to be the most basic: patient selection. Too often surgeons gloss over host risk factors that are relevant to this devastating complication. In this chapter, we discuss those patient comorbidities identified by the literature as strongly correlating with PJI. Our hope is to serve the surgeon by enabling him or her to acknowledge the patient's risk and to subsequently develop the appropriate strategy for combating this growing problem.

Rothman Institute Current Practices

  1. All patients are seen preoperatively by a physician to ensure they are medically optimized for surgery.
  2. Weight loss to a BMI < 40 kg/m2 is encouraged if required.
  3. Patients have their thromboembolism risk stratified to avoid excessive anticoagulation.
A number of studies have shown that morbidly obese patients have an extremely high odds ratio of developing periprosthetic joint infection. Malinzak et al1 retrospectively reviewed 8,494 patients who had undergone a total joint 60arthroplasty (TJA) over a 13-year period and found that patients with a body mass index (BMI) greater than 50 kg/m2 had an odds ratio of 21.3 when compared with their respective cohorts. This information was also confirmed by Bozic et al2 when they evaluated the Medicare database. Clearly, obesity must be acknowledged as a predisposing risk factor for PJI.
A number of medical comorbidities contributing to PJI have recently been identified. These include, and most likely are not limited to, diabetes, rheumatoid arthritis, hypercholesterolemia, congestive heart failure, chronic pulmonary disease, alcohol abuse, preoperative anemia, depression, renal disease, metastatic tumor, peripheral vascular disease, psychoses, venous thromboembolism, and valvular disease.2–4 Parvizi et al found PJI to be highly correlated as well for both the American Society of Anesthesiologists (ASA) scoring and the Charlson Comorbidity Index. A link between patient comorbidities and infection.4
Marchant et al5 found that glycemic control weighs heavily in the PJI arena. Specifically, he discovered that patients with uncontrolled diabetes, as indicated by their hemoglobin A1c levels, had a significantly increased risk of developing PJI, at an odds ratio of 2.31. Of interest, preoperative blood glucose level also appears to play a major role in the development of PJI. Mraovic et al6 found that infected patients had a higher preoperative blood glucose: 112 versus 105. The study also found that a postoperative day one blood glucose level greater than 200 mg/dL increased the risk for infection by greater than two-fold. Thus, the literature for PJI is consistent with that of other surgical disciplines in showing that uncontrolled diabetes with subsequent hyperglycemia leaves the body predisposed to infection.
Preoperative nutritional status has been a subject of recent discussion as well. Purtill et al7 found that patients 61with a serum transferrin level less than 200 mg/dL, a serum albumin level less than 3.5 g/dL, or a total lymphocyte count less than 1500/mm3, preoperatively, were more likely to develop a deep infection after TJA. The correlation of poor dietary intake with wound healing potential has been well documented. We recommend that nutritional parameters be included in the preoperative risk assessment, as poor nutritional markers leave the patient susceptible to PJI.
As previously mentioned, preoperative anemia is associated with PJI. Specifically, it leaves patients at risk for requiring increased postoperative blood transfusions. This need for blood transfusion has been shown to adversely affect patients by decreasing their immunomodulation abilities secondary to the transfusion.8 Pulido et al3 confirmed that those patients with increased postoperative blood transfusions did, in fact, have increased risk for infection.
Finally, it should be mentioned that two factors under the surgeon's control must be discussed: excessive anticoagulation and operative time. First, a number of studies have shown that longer operative times clearly have increased the risk for PJI. One study found that when the operative time surpassed 2.5 hours the risk of infection increased exponentially.9 As surgeons, we need to be conscientious and expeditious in approaches to procedures. Second, excessive anticoagulation has been shown to raise the risk for PJI. Parvizi et al4,10 found that an increased international normalized ratio (INR) was more prevalent in a group with PJI than in a control group. The type of anticoagulation used by surgeons plays a pivotal role, as excessive use can result in postoperative wound problems, hematoma formation, and drainage, all harbingers of an infection.
When considering patients as candidates for TJA, their comorbidities need to be taken seriously. As we have 62shown in the literature, these comorbidities can result in an undesirable outcome: PJI. We need to be vigilant in managing these comorbidities as well as accounting for our own surgical and decision-making processes during the perioperative period. Without doing so, the economic burden and patient dissatisfaction will exact a high cost.
 
References
  1. Malinzak RA, Ritter MA, Berend ME, Meding JB, Olberding EM, Davis KE. Morbidly obese, diabetic younger, and unilateral joint arthroplasty patients have elevated total joint arthroplasty infection rates. J Arthroplasty. 2009;24(suppl 6):84–8.
  1. Bozic KJ, Lau E, Kurtz S, Ong K, Berry D. Patient-related risk factors for postoperative mortality and periprosthetic joint infection in Medicare patients undergoing TKA. Clin Orthop Relat Res. 2012;470:130–7.
  1. Pulido L, Ghanem E, Joshi A, Purtill J, Parvizi J. Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res. 2008;466:1710–5.
  1. Garvin KL, Konigsberg BS. Infection following total knee arthroplasty. J Bone Joint Surg Am. 2011;93:1167–75.
  1. Marchant MH, Viens NA, Cook C, Vail TP, Bolognesi MP. The impact of glycemic control and diabetes on perioperative outcome after total joint arthroplasty. J Bone Joint Surg Am. 2009;91:1621–9.
  1. Mraovic B, Donghun S, Jacovides C, Parvizi J. Perioperative hyperglycemia and postoperative infection after lower limb arthroplasty. J Diabetes Science and Technology. 2011;5(2):412–27.
  1. Jaberi FM, Parvizi J, Haytmanek CT, Joshi A, Purtill J. Procrastination of wound drainage and malnutritiona the outcome of joint arthroplasty. Clin Orthop Relat Res. 2008; 466:1368–71.
  1. Raghavan M, Marik PE. Anemia, allogenic blood transfusion, and immunomodulation in the critically ill. Chest. 2005;127:295–07.63
  1. Peersman G, Laskin R, Davis J, Peterson M. Infection in total knee replacement: a retrospective review of 6,489 total knee replacements. Clin Orthop Relat Res. 2001;392:15–23.
  1. Parvizi J, Ghanem E, Joshi A, Sharkey PF, Hozack WJ, Rothman RH. Does “excessive” anticoagulation predispose to periprosthetic infection? J Arthroplasty. 2007;22:24–8.64

Patient Medical Optimizationchapter 9

Eric H Tischler
 
Current Evidence
A thorough preoperative medical evaluation helps to limit complications in patients undergoing total joint arthroplasty (TJA). This evaluation entails a careful and unhurried assessment, with adequate time for investigations and specialist anesthetic and medical opinion, as required. Patients must have adequate cardiopulmonary function to withstand anesthesia and varying shifts in fluid balance. To ensure medical optimization prior to TJA, some conditions that have the potential for harmful effects, and can be screened for, include diabetes mellitus, malnutrition, coronary artery disease, obesity, and lymphedema.

Rothman Institute Current Practices

  1. All patients are seen preoperatively by a physician to ensure fitness for surgery.
  2. Glucose levels are tightly controlled in diabetic patients perioperatively.
  3. Patients with a BMI > 40 kg/m2 are encouraged to lose weight prior to surgery (some surgeons use a BMI of 35 kg/m2 as their cutoff).
The literature indicates that approximately eight percent of patients undergoing total knee or hip replacement surgery are considered diabetic.1 Bolognesi et al1 found that controlling glucose levels perioperatively has real benefit for the patient. They showed that patients with uncontrolled glucose levels were more than three 66times as likely to experience a stroke or death after joint replacement, and approximately twice as likely to experience postoperative bleeding and infection. The benefits of tight glycemic control in diabetic patients have been well documented in many other studies. Coursin et al2 demonstrated a significant reduction in mortality when using a continuous infusion of insulin to maintain glycemic control between 80 and 110 mg/dL. For general medical and surgical patient candidates, a fasting glucose of 90–126 mg/dl and a random glucose reading of less than 180 mg/dl are recommended by the American Diabetes Association.
Another major issue is malnutrition. Protein and calorie malnutrition adversely affects the following humoral and cell-mediated immune functions: neutrophil chemotaxis, bacterial phagocytosis, neutrophil function, and delivery of inflammatory cells to sites of infection. Nutrition can be assessed with highly sensitive indicators such as skin antigen testing, nitrogen balance, and prealbumin or transferrin levels.
Hypoalbuminemia (< 3.5 g/dl) and a lymphocyte count of less than 1500 cells/ml are accepted indicators of malnutrition. Decreased albumin levels and lymphocyte counts have been associated with increased hospital stay, wound infection, pneumonia, sepsis, delayed physical rehabilitation, and decreased likelihood of survival.2
As a group, end-stage renal disease patients on dialysis do not approach the life expectancy of age-matched peers. These patients suffer from multiorgan imbalances inherent in renal disease and hemodialysis treatments. An immunocompromised state predisposes dialysis-dependent patients to a greater risk of infection due to poor healing potential from general nutritional deficiency and long-term steroid use. Sakalkale et al3 confirms the high early complication rate associated with renal dialysis, 67with complications occurring in 58% of their patient cohort. Other studies confirm the high potential for early complications.
Poor maintenance of nutritional status and control of serum glucose levels can be evident in a patient's preoperative body mass index (BMI) evaluation. Recent prevalence data show that 30% of adults, or more than 60 million adults, aged 20 years and over are classified as obese.4 According to the Centers for Disease Control (CDC) guidelines for the prevention of surgical site infection (SSI), an operative time longer than two hours is viewed as a risk factor for SSI in hip arthroplasty. Myriad studies have reported that operative time takes considerably longer for the morbidly obese group than for all other weight groups, which inevitably creates a greater risk for SSI or periprosthetic joint infection (PJI). Namba et al5 reported a higher incidence of infection rate after hip arthroplasty in patients who were “highly obese” (BMI ≥ 35kg/m2) than in patients who were “non-highly obese” (BMI < 35kg/m2), with an odds ratio of 4.2. To properly evaluate the impact of obesity on TJA, the orthopedic community must agree on a standard definition of obesity. However, a preoperative discussion of the increased risks of obesity with surgery is advised, which, it is hoped, will encourage and motivate patients to consider weight loss prior to surgery.
Regardless of the type of patient awaiting TJA, assessing his or her preoperative medications is vital. Medications such as immunosuppressives, corticosteroids, insulin, or anticoagulants need to be managed closely before and after surgery.
 
Drugs with Antiplatelet Effects1
  • Administration of anticoagulation chemoprophylaxis places patients at risk of bleeding after TJA.68
  • Occurrence of major bleeding complications creates potential for serious complications, including: infection, wound healing, functional disability, and loosening, and has a high probability of compromising surgical outcome.6
MUST STOP 1 WK PRIOR TO SURGERY.
(except Ticlid; stop 2 wk prior)
Aspirin (Bayer, Ecotrin, others)
Ibuprofen (Motrin, Advil)
Naproxen (Naprosyn, Aleve)
Mobic (Meloxicam)
Cilostazol (Pletal)
Celecoxib (Celebrex) or valdecoxib (Bextra)
Clopidogrel (Plavix)
Ticlopidine (Ticlid): stop 2 wk prior
Nabumetone (Relafen)
Arthritis medications (Arthrotec, etc.)
Piroxicam (Feldene, Fexicam)
Sulindac (Clinoril)
Dipyridamole (Persantine)
Eptifibatide (Integrilin)
Tirofiban (Aggrastat)
 
Supplements7
  • Herbal medications, used frequently, may cause clotting abnormalities and interactions with anesthetics.
  • Clinicians should specifically inquire about herbal medications; patients do not often readily disclose this information.
THE FOLLOWING SHOULD BE STOPPED 1 WK PRIOR TO SURGERY.
Garlic
Gingo biloba
Kava
St. John's wort
Echinacea
69
 
Rheumatologic Agents7
  • The infection rate in TJA is approximately 2.6 times greater in patients with rheumatoid arthritis than in patients undergoing surgery for management of osteoarthritis.8
  • Nonsteroidal anti-inflammatory drugs (NSAIDs), Prednisone, methotrexate, and other biological agents all have the potential to adversely affect surgical outcome by increasing infection rate or compromising wound healing.8
HOLD FOR 1 WK PRIOR.
NSAIDs
DISCONTINUE THERAPY UP TO 1 WK BEFORE DAY OF SURGERY.
CONTINUE THERAPY 2 WK FOLL OWING SURGERY. (IN PATIENTS WITH RENAL INSUFFICIENCY, HOLD 2 WK PRIOR TO SURGERY.)
Methotrexate
HOLD FOR 1 WK PRIOR.
Sulfasalazine/Azathioprine
HOLD FOR 2 WK PRIOR.
Leflunomide
CONTINUE THERAPY UP TO AND INCLUDING DAY OF SURGERY.
Hydroxychloroqine
HOLD FOR 2 WK PRIOR. RESUME 1–2 WK AFTER SURGERY.
Biologic response modifiers (etanercept, infliximab, anakinra, rituximab, adalimumab)
CONTINUE THERAPY UP TO THE NIGHT OF SURGERY AND HOLD THE MORNING DOSE.
Gout agents (colchicine, allopurinol, probenecid)
70
 
Controversies
  • An optimal range of preoperative glucose level has yet to be established.
  • The literature falls prey to the problem of multiple definitions of obesity. To properly evaluate the impact of obesity on TJA, the orthopedic community must agree on a standard definition of obesity.

Pitfall

Cessation of rheumatoid disease–modifying drugs must be tailored to each patient; a “flare-up” of rheumatoid symptoms may require a course of oral steroid therapy, with potential for further complication.
 
References
  1. Bolognesi MP, Marchant M, Viens N, Cook C, Pietrobon, Vail TP. The impact of diabetes on perioperative patient outcomes after total hip and total knee arthroplasty in the United States. J Arthroplasty. 2008;23:6.
  1. Coursin DB, Connery L, Ketzler JT. Perioperative diabetic and hyperglycemic management issues. Crit Care Med. 2004;32:4.
  1. Sakalkale D, Hozack W, Rothman R. Total hip arthoplasty in patients with long-term renal dialysis. J Arthroplasty. 1999;14:5.
  1. Dowsey, M, Choong P. Obesity is a major risk factor for prosthetic infection after primary hip arthroplasty. Clin Orthop Relat Res. 2008;466:153–8.
  1. Namba RS, Paxton L, Fithian DC, Stone ML. Obesity and perioperative morbidity in total hip and total knee arthroplasty patients. J Arthroplasty. 2005;20:7.
  1. Parvizi J, Khalid A, Rothman R. Deep venous thrombosis prophylaxis for total joint arthroplasty: American Academy of Orthopedic Surgeons Guid elines. J Arthroplasty. 2008;23:7.71
  1. Muluk V, Macpherson DS, Arson M, Sokol N, Collins K. Perioperative medication management. Waltham, MA: UpToDate (Wolters Kluwer Health).  www.uptodate.com/index. Accessed 2012.
  1. Howe C, Gardner G, Kadel N. Perioperative medication management for the patient with rheumatoid arthritis. J Am Acad Orthop Surg. 2006;14:9.72

Preoperative Diabetic Maintenance and Controlchapter 10

Eric H Tischler
 
Current Evidence
After total hip arthroplasty, diabetic patients face poor wound healing, increased incidence of acute renal failure, and higher infection rates. To minimize these devastating and costly complications, preoperative analysis and diabetic control are imperative.

Rothman Institute Current Practices

  1. Patients with diabetes have their glucose levels closely controlled during the perioperative period.
  2. HbA1c levels are checked preoperatively to ensure compliance with therapy.
Tight glycemic control is increasingly recognized as an important perioperative goal for diabetic patients. Hyperglycemia may delay wound healing by hindering collagen production, resulting in decreased tensile strength of surgical wounds. Hyperglycemia is also thought to increase infection because glucose levels above 250 mg/dl are believed to impair leukocyte chemotaxis and phagocytosis.1 Marchant Jr et al reported that controlled glucose levels are beneficial for the patient. The study found that patients with uncontrolled glucose levels were 74three times more likely to experience stroke or death after joint replacement, and approximately twice as likely to experience postoperative bleeding and infection.
Although it has been determined that uncontrolled glucose can cause increased surgical complications, the exact role of how hyperglycemia, insulin resistance/insufficiency, or both, result in increased morbidity and mortality rates during acute stress or illness remains under intense investigation.2 A single glucose measurement taken 2 to 4 weeks preoperatively does not precisely reflect the state of the patient's glucose metabolism. Nevertheless, preoperative screening could identify patients with an underlying glucose metabolism disorder that could lead to perioperative hyperglycemia and compromise clinical outcomes.3
Major orthopedic operations, specifically in the lower extremities, are associated with a high incidence of thromboembolic events, particularly deep venous thrombosis (DVT) and pulmonary embolus (PE). Nearly 1 in 1,000 patients is expected to die of PE. Diabetes mellitus (DM) is a hypercoagulable state, and a longitudinal study of 19,293 men and women revealed that patients with DM have an increased risk for developing DVT and PE.4
To prevent such complications, physicians and staff can take several practical steps to help minimize problems during surgery and in the postoperative period. Both fructosamine and hemoglobin A1c (HbA1C) tests are used primarily as monitoring tools to help patients control their blood glucose levels. However, the HbA1c test is much more popular and widely accepted because firm data indicate that a chronically elevated HbA1c level predicts an increased risk for certain diabetic complications, such as retinopathy, nephropathy, and neuropathy. The American Diabetes Association (ADA) recognizes both tests and states that fructosamine assessment may be useful when HbA1c cannot be reliably measured, as with rapid changes 75in diabetic treatment, diabetic pregnancy, abnormal forms of hemoglobin (hemolytic anemia, iron deficiency anemia, or sickle cell anemia), and major blood loss.
Elevated HbA1c levels may possibly predict a higher rate of postoperative infections. A retrospective cohort study of 490 diabetic men who underwent noncardiac surgery found that a preoperative HbA1c higher than seven percent was associated with a small but significant increase in postoperative infections compared with those having an HbA1c lower than seven percent. Baseline glucose levels can also help stratify risk for postoperative wound infections.5
Some studies show that achieving normoglycemia (80–110 mg/dl [4.4 – 6.1 mmol/L]) may reduce postoperative mortality rates; however, the lack of clear evidence on how tightly to control preoperative glucose levels in patients with diabetes is reflected in the varying glucose targets recommended by different guidelines.6,7 The ADA recommends a fasting glucose level lower than 180 mg/dl (10 mmol/L).

Pitfalls

  1. Protocols for aggressive and widespread use of insulin infusions are often expensive, labor intensive, and even impossible at some hospitals.
  2. Even well-coordinated plans for diabetic management are dynamic, influenced by predictable and sometimes unpredictable events.
Several strategies aim to maintain target-range glucose levels preoperatively, but no true consensus on the optimal strategy has been reached. Ideally, all patients with DM should have their operation as early as possible in the morning to minimize disruption of their management routine while being nil per os.5 Generally, patients with type II diabetes managed by diet alone do not require therapy preoperatively. Patients with type II diabetes who take oral hypoglycemic drugs or noninsulin injectables are advised to continue their usual routine of antidiabetic medications until the morning 76of surgery.5 Patients with type I diabetes, or those being treated with insulin for type II diabetes, can continue with subcutaneous insulin perioperatively (rather than an insulin infusion) for procedures that are not long and complex.8
A special consideration should be made for patients who receive glucocorticoid treatment. Glucocorticoids can worsen pre-existing DM and may precipitate steroid-induced hyperglycemia in others.5
 
Controversies
  • Clear evidence on how tightly to control preoperative glucose levels in diabetic patients is lacking.
  • Although it has been determined that uncontrolled glucose can cause increased surgical complications, the exact role of how hyperglycemia, insulin resistance/insufficiency, or both, result in increased morbidity and mortality rates during acute stress or illness remains under intense investigation.
 
References
  1. Haag BL. Presurgical management of the patient with diabetes. Medical Management of Diabetes. 2000; 631-9.
  1. McCowan KC, Malhoota A, Bistrian BR: Endocrine and metabolic dysfunction syndromes in the critically ill. Crit Care Clin. 2001;17:107–24.
  1. Nygren J, Thorell A, Ljungqvist O. Are there benefits from minimizing fasting and optimization of nutrition and fluid management for patients undergoing day surgery? Curr Opin Anaesthesiol. 2007;20(6):540–4.
  1. Tsai AW. Cardiovascular risk factors and venous thromboembolism incidence: the longitudinal investigation of thromboembolism etiology. Arch Intern Med. 2002;162:10.
  1. Khan N, Ghali W, Cagliero E. Perioperative management of diabetes mellitus. Basow DS, ed. Waltham, MA: UpToDate (Wolters Kluwer Health).  www.uptodate.com/index. Accessed 2012.77
  1. Canadian Diabetes Association. 2008 Clinical Practice Guidelines for the prevention and management of diabetes in Canada. Can J Diabetes. 2008;32:S71.
  1. Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care. 2009;32:1119.
  1. Jacober SJ, Sowers JR. An update on perioperative management of diabetes. Arch Intern Med. 1999;159:2405.78

Preoperative Skin Preparation: Decolonization and Antisepsischapter 11

Vinay Aggarwal,
Anthony Tokarski
 
Introduction
A patient's skin represents a double-edged sword; on the one hand, it serves as a protective structural barrier to the harsh external environment, but on the other hand, it harbors several potentially dangerous pathogens. The risk of bacterial infection from skin flora is never more apparent than in surgical patients, specifically in those undergoing total joint arthroplasty (TJA). The goal of this chapter is to outline evidence regarding the effectiveness of skin decolonization as well as the methods for skin antisepsis prior to surgery.
 
Current Evidence
Historically, native skin microorganisms have always played a large role in health care-associated infections. Even recently, according to genotyping studies, it was estimated that more than 80% of hospital-acquired Staphylococcus aureus infections were caused by endogenous bacteria colonizing the patient's epidermis.1 Although advances in antimicrobial prophylaxis during surgery have significantly decreased the risk of surgical site infection (SSI) from 80skin pathogens, many hypothesize that efforts to improve preoperative skin decolonization and antisepsis may diminish this risk even further.2

Rothman Institute Current Practices

  1. Patients are required to undergo a 4% chlorhexidine gluconate with 4% isopropyl alcohol (Hibiclens) shower scrub once a day, starting two days prior to surgery.
  2. No routine decolonization for nasal MRSA with mupirocin ointment or other techniques.
  3. Varied protocol for skin antisepsis with either iodine povacrylex (0.7% iodine) in 74% isopropyl alcohol or 2% chlorhexidine gluconate in 70% isopropyl alcohol. In all skin preparation protocols, alcohol solvents are always used and allowed to dry.
  4. Hair removal using electric clippers on day of procedure.
  5. Surgeon preference regarding hand antisepsis with povidone-iodine scrub, chlorhexidine scrub, or alcohol-based rub.
The Centers for Disease Control (CDC) estimates that SSI is the second leading cause of nosocomial infections, accounting for more than 22% to 25% of the approximately two million health care-associated infections that occur per year in the United States.3,4 Many SSIs in orthopedic surgery are reportedly acquired at the time of surgery, with direct inoculation from skin flora a major cause of infection.5,6 This is particularly the case when “clean” elective procedures such as TJA result in periprosthetic joint infection (PJI).
The organism profile of PJI has been well studied in the United States and internationally. It is the consensus of several studies that Gram-positive staphylococcal species, specifically S. aureus and coagulase-negative staphylococci, account for more than 50% of all microorganisms responsible for PJI.7–10 Furthermore, research has shown the high prevalence of these bacteria as native colonizers at both nasal and extranasal skin sites of humans.11,12 Specifically, 81S. epidermidis is reported to make up almost 90% of the resident skin flora in some areas, and methicillin-sensitive S. aureus (MSSA) has been reported to inhabit 20% to 40% of even healthy asymptomatic community populations.13–15
Skin decolonization prior to surgery has long been the subject of much debate. Many methods have been proposed for the eradication process. Although mupirocin nasal ointment is widely accepted for reducing nasal carriage loads of methicillin-resistant S. aureus (MRSA), long-term use of the agent has led to the development of bacterial resistance.12 Newer methods of decolonization, such as nonantibiotic “photodisinfection” therapies, have no clinical evidence to date. Another new method to reduce bacteria in the nares is the use of a 5% iodine based prep applied one hour prior to surgery. At this time, no randomized controlled studies have been published.
In addition to reducing nasal bacterial load, disinfecting extranasal sites such as the axillae and perineum has been recognized as equally important in potentially reducing the burden of SSIs.16 The CDC recommends that to ensure proper preparation for surgery, patients must shower or bathe with an antiseptic agent of any kind on at least the night before the procedure.17 Of the preoperative shower soaps and cleansers available, chlorhexidine gluconate (CHG) products have been studied the most extensively. Although some studies have shown that CHG showers are the most effective at eliminating residual bacteria on the skin, a Cochrane review of several trials reported no evidence that this product enhanced the prevention of SSIs.18,19 Newer variations of cleansers, such as a 2% CHG wipe, which does not require patients to bathe, have started to gain prominence in the orthopedic literature.20–22
With regard to skin antisepsis in the operating room prior to incision, several compounds are available, 82including alcohol, chlorhexidine, iodophors, polychloro phenoxy phenol (Triclosan), and para chloro meta xylenol (PCMX).23 The mechanism of action, spectrum of activity, and rapidity of action of the most common agents are shown in Table 11.1 below.2 The CDC currently has no guidelines regarding the optimal agent for preparing skin prior to a surgical procedure.17 The controversies surrounding the superiority of antiseptic agents are discussed in the following section.
 
Controversies
Although skin decolonization has been proven to reduce bacterial carriage rates prior to surgery, significant controversy surrounds the clinical impact of this practice on reducing SSI rates. Two randomized control trials in general surgery and orthopedic patients acknowledged a reduction in bacterial load; however, both failed to demonstrate any significant difference in S. aureus endogenous SSIs when treatment and placebo regimens were compared.24,25 This result has led some reviewers to suggest that routine screening for MRSA pathogens and decolonization is unwarranted in surgical patients. On the contrary, the New England Journal of Medicine randomized control trial by Bode et al16 showed that total body disinfection with mupirocin and CHG soap shower did, in fact, significantly reduce S. aureus SSIs from 7.7% to 3.4% when compared with no treatment. Complicating matters further, Tschudin-Sutter et al26 recently observed that on the basis of genotype testing, residual bacteria after adequate skin disinfection may not play a role in ensuing SSIs at all.
The discussion of skin antisepsis often centers on selection of a single agent for preoperative disinfection. Evidence now points to the use of alcohol as an adjunctive solvent regardless of which additional agent 83is used.27
Table 11.1   Most common operating room skin antiseptics
Agent
Mechanism of Action
Spectrum of Activity
Rapidity of Action
Alcohol
Denatures proteins
Gram-positive and -negative bacteria, Mycobacterium tuberculosis, fungi, and viruses
Most rapid, must dry to work
Chlorhexidine
Disrupts cell membranes
Gram-positive bacteria > Gram-negative bacteria, viruses
Intermediate, strong residual and persistent effects
Iodophors
Oxidation, substitution by free iodine reaction
Gram-positive > Gram-negative bacteria, fungi, viruses
Intermediate, good persistence when remain on skin**
** Rational: Data on iodophors having poor persistent activity come from hand scrub studies where the iodophor is completely washed away. In fact in the CDC SSI guideline it states that iodophors exert a bacteriostatic effect as long as they are present on the skin. Studies also show that due to the polymer, the iodine povacrylex/alcohol skin preparation has 48 hours of persistent activity and maintains persistent activity even after blood and saline challenge. In a recently published prospective randomized trial, iodine povacrylex/alcohol and CHG/alcohol were found to be equally effective skin-preparation solutions in eradicating skin bacteria. (REF: Savage JW, et al. Efficacy of Surgical Preparation Solutions in Lumbar Spine Surgery. J Bone Joint Surg Am. 2012;94:490-4)
Darouiche et al3 published a study in 2010 that demonstrated the superior efficacy of CHG-alcohol over 84povidone-iodine alone. However, subsequent studies have pointed to the lack of alcohol in the povidone-iodine group as a critical shortcoming of the study.28 Although newer studies have shown that the addition of alcohol increases the efficacy of iodophors and CHG, there have been no randomized clinical trials comparing CHG-alcohol and iodine-alcohol antisepsis for SSIs or PJIs in TJA patients.26,28 To achieve maximum efficacy of a prep, it must be applied according to the manufacturer's directions for use. The main drawback of alcohol combinations is ensuring that the skin preparation dries sufficiently to prevent fire hazard risks with the use of electrocautery devices in proximity to flammable materials.2,3
Hand washing by the surgeon is especially complex, given the great variety of hand hygiene regimens used across the United States and the world. In general, the CDC recommends extensive use of either an antimicrobial soap scrub for several minutes or an alcohol-based hand rub with persistent activity prior to wearing sterile surgical gloves.2 A problem exists regarding compliance with abrasive hand-scrub protocols, which often cause skin dryness and irritation, leading to a paradoxical increase in theoretical infection risk. A large trial of 4,387 consecutive patients undergoing clean and clean-contaminated surgery showed no difference in SSI rates whether newer waterless, scrubless alcohol-based hand antiseptics or traditional hand-scrubbing techniques were used (2.44% vs. 2.48%).29
Hair removal prior to surgery also continues to be controversial, as the accepted guidelines have frequently changed and are often not routinely followed. The CDC recommends not removing hair preoperatively at all unless the hair will interfere with the procedure and incision site.17 In the event that hair removal is necessary, it is suggested that electric clippers, rather than razor blade, be used 85directly before the procedure. A meta-analysis by Tanner et al30 agreed that electric clippers were associated with fewer SSIs than was razor shaving.30 In spite of this, the report disagreed with previous literature regarding the timing of hair removal, stating the day of hair removal ultimately made no difference in infection rates.30
 
Conclusion
It should be noted that although skin is often overlooked as a harbor of potential disease in the medical community, this natural barrier is significantly disrupted during surgical procedures and plays a large role in postsurgical infections. In summary, the process of skin preparation prior to TJA and all surgery requires extensive communication and relies heavily on the cooperation of a large team of individuals, including surgeons, operating room personnel, and even patients themselves.
 
References
  1. von Eiff C, Becker K, Machka K, Stammer H, Peters G. Nasal carriage as a source of Staphylococcus aureus bacteremia. Study Group. N Engl J Med. 2001;344(1):11–6.
  1. Napolitano LM. Decolonization of the skin of the patient and surgeon. Surg Infect. 2006;7(suppl 3):3S–15S.
  1. Darouiche RO, Wall MJ Jr, Itani KMF, et al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med. 2010;362(1):18–26.
  1. Hidron AI, Edwards JR, Patel J, et al. NHSN annual update: antimicrobial-resistant pathogens associated with healthcare-associated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006-2007. Infect Control Hosp Epidemiol. 2008;29(11):996–11.
  1. Lee J, Singletary R, Schmader K, et al. Surgical site infection in the elderly following orthopedic surgery. Risk factors and outcomes. J Bone Joint Surg Am. 2006;88(8):1705–12.86
  1. Prokuski L. Prophylactic antibiotics in orthopedic surgery. J Am Acad Orthop Surg. 2008;16(5):283–93.
  1. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med. 2004;351(16):1645–54.
  1. Del Pozo JL, Patel R. Clinical practice. Infection associated with prosthetic joints. N Engl J Med. 2009;361(8):787–94.
  1. Fulkerson E, Valle CJD, Wise B, et al. Antibiotic susceptibility of bacteria infecting total joint arthroplasty sites. J Bone Joint Surg Am. 2006;88(6):1231–7.
  1. Shuman EK, Urquhart A, Malani PN. Management and prevention of prosthetic joint infection. Infect Dis Clin North Am 2012;26(1):29–39.
  1. Wertheim HFL, Vos MC, Ott A, et al. Risk and outcome of nosocomial Staphylococcus aureus bacteraemia in nasal carriers versus non-carriers. Lancet. 2004;364(9435):703–5.
  1. Perl TM, Golub JE. New approaches to reduce Staphylococcus aureus nosocomial infection rates: treating S. aureus nasal carriage. Ann Pharmacother. 1998;32(1): 7S-16S.
  1. Davis CP. Normal flora. Medical Microbiology. NCBI Bookshelf. Galveston, TX: The University of Texas Medical Branch at Galveston, 1996. Available at: http://www.ncbi.nlm.nih.gov/books/NBK7617/#A512. Accessed March 26, 2012.
  1. Kenner J, O'Connor T, Piantanida N, et al. Rates of carriage of methicillin-resistant and methicillin-susceptible Staphylococcus aureus in an outpatient population. Infect Control Hosp Epidemiol. 2003;24(6):439–44.
  1. Schwarzkopf R, Takemoto RC, Immerman I, Slover JD, Bosco JA. Prevalence of Staphylococcus aureus colonization in orthopedic surgeons and their patients: a prospective cohort controlled study. J Bone Joint Surg Am. 2010;92(9):1815–19.
  1. Bode LGM, Kluytmans JAJW, Wertheim HFL, et al. Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. N Engl J Med. 2010;362(1):9–17.
  1. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control. 1999;27(2):97-132; quiz 133-134; discussion 96.87
  1. Kaiser AB, Kernodle DS, Barg NL, Petracek MR. Influence of preoperative showers on staphylococcal skin colonization: a comparative trial of antiseptic skin cleansers. Ann Thorac Surg. 1988;45(1):35–8.
  1. Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database Syst Rev. 2007;(2):CD004985.
  1. Johnson AJ, Daley JA, Zywiel MG, Delanois RE, Mont MA. Preoperative chlorhexidine preparation and the incidence of surgical site infections after hip arthroplasty. J Arthroplasty. 2010;25(suppl 6):98–102.
  1. Zywiel MG, Daley JA, Delanois RE, et al. Advance preoperative chlorhexidine reduces the incidence of surgical site infections in knee arthroplasty. Int Orthop. 2011;35(7):1001–6.
  1. Eiselt D. Presurgical skin preparation with a novel 2% chlorhexidine gluconate cloth reduces rates of surgical site infection in orthopedic surgical patients. Orthop Nurs. 2009;28(3):141–5.
  1. O'Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections. Infect Control Hosp Epidemiol. 2002;23(12):759–69.
  1. Perl TM, Cullen JJ, Wenzel RP, et al. Intranasal mupirocin to prevent postoperative Staphylococcus aureus infections. N Engl J Med. 2002;346(24):1871–7.
  1. Kalmeijer MD, Coertjens H, van Nieuwland-Bollen PM, et al. Surgical site infections in orthopedic surgery: the effect of mupirocin nasal ointment in a double-blind, randomized, placebo-controlled study. Clin Infect Dis. 2002;35(4):353–8.
  1. Tschudin-Sutter S, Frei R, Egli-Gany D, et al. No risk of surgical site infections from residual bacteria after disinfection with povidone-iodine-alcohol in 1014 cases: a prospective observational study. Ann Surg. 2012;255(3):565–9.
  1. Art G. Combination povidone-iodine and alcohol formulations more effective, more convenient versus formulations containing either iodine or alcohol alone: a review of the literature. J Infus Nurs. 2005;28(5):314–20.
  1. Swenson BR, Hedrick TL, Metzger R, et al. Effects of preoperative skin preparation on postoperative wound infection rates: a prospective study of 3 skin preparation protocols. Infect Control Hosp Epidemiol. 2009;30(10):964–71.88
  1. Parienti JJ, Thibon P, Heller R, et al. Hand-rubbing with an aqueous alcoholic solution vs traditional surgical hand-scrubbing and 30-day surgical site infection rates: a randomized equivalence study. JAMA. 2002;288(6):722–7.
  1. Tanner J, Woodings D, Moncaster K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev. 2006;(2):CD004122.

Controversial Preventive Strategieschapter 12

Joseph A Karam
 
Current Evidence
 
Introduction
Periprosthetic joint infection (PJI) remains one of the most challenging complications to manage after total joint arthroplasty (TJA). Even though much effort has been spent in past years to decrease its occurrence, it is still observed in roughly 1% to 2% of cases.1–3 Most hospitals in the United States currently use laminar airflow-equipped operating rooms, body exhaust suits, and prophylactic systemic antibiotics in TJA to reduce infection rates.4,5

Rothman Institute Current Practices

  1. Knife blades are systematically changed after skin incision.
  2. Most surgeons opt for triple gloving at the start of the procedure with removal of the outer gloves after draping.
  3. Outer gloves are systematically changed before opening the final components.
  4. Most surgeons use antibiotic impregnated cement in almost all cemented arthroplasty cases to reduce the risk of PJI (off-label use).
  5. In recent years we have moved towards adding vancomycin to cement in the operating room for better organism coverage.
In addition to those measures, which are specifically addressed in other chapters, many 90preventive strategies are routinely implemented in the operating room, even though no clear proof of efficacy exists. This chapter will present some of those measures that still stir controversy, including knife blade change after incision, triple gloving, autologous blood derivative application to the wound, and local antibiotic prophylaxis.
 
Knife Blade Change
In the vast majority of institutions, separate blades are used for the skin and the deeper tissues to avoid contaminating the wound, especially in procedures requiring ultraclean conditions, such as TJA. However, this practice has been controversial for many years, and several studies in the literature have found it to be unnecessary.6–8 Ritter et al6 in 1975 showed that blade contamination was significantly increased in the absence of laminar airflow, but when comparing contamination of skin and deep knives no difference was observed. More importantly, organisms cultured from deep wound swabs did not correlate with those cultured from knife blades, thus refuting deep wound contamination by the blades. Later studies revealed similar findings.7,8 However, Davis et al9 identified a 9.4% contamination rate of superficial blades and supported the routine practice of changing blades after incision.
A more recent study by Schindler et al10 reported a 15.3% contamination rate for skin blades, 74% of which grew coagulase-negative Staphylococcus, one of the most frequent culprits in PJI. They also found a 10.8% contamination of deep blades (50% of which grew coagulase-negative Staphylococcus) and a 6.4% contamination of control blades that were left untouched during the procedure. The authors concluded that the practice of changing the skin blade after incision should be continued, especially because cost implications are minimal relative to the health and economic burden caused by a possible PJI.91
 
Triple Gloving
Most arthroplasty teams use double gloving to decrease the rate of intraoperative glove perforation and contamination.11 However, even with such a practice, a large number of inner gloves are found to be perforated or contaminated during surgery.12,13 Hence, triple-gloving techniques have been suggested to reduce the risk of contamination, especially in TJA, to prevent PJI, and in maxillofacial surgery, in which perforation rates are particularly high. In 1992, Hester et al14 compared the rate of inner glove perforation with three different gloving protocols in TJA cases: latex/cloth, latex/latex, and latex/cloth/latex. They found a reduced rate of perforation when the outer glove was a cloth glove instead of a latex glove, and interposing a cloth glove between two latex gloves yielded the lowest rate of perforation. Whereas double gloving with an outer cloth glove had a notable impact on tactile sensation and was troublesome when manipulating cement, triple gloving with a cloth glove between two latex gloves was not perceived as having such an important impact. Nonetheless, this study failed to achieve statistical significance in perforation rate differences. Though far more expensive than latex gloves, cloth gloves can be sterilized and reused a certain number of times, which reduces the expense per single case. In 1993, Sebold15 used cloth gloves between two latex gloves, which decreased the inner glove puncture rate to zero in their series. They stated that surgeons did not believe this gloving technique affected their dexterity. Moreover, this study showed a decreased inner glove perforation rate when using “orthopedic” outer gloves versus regular latex gloves. Later, Sutton et al16 introduced a triple-gloving protocol with a cut-resistant liner interposed between the two latex gloves. This led to a significant decrease in the rate of perforation, compared with double gloving 92with two latex gloves. Pieper et al17 evaluated different triple-gloving protocols in maxillofacial surgical cases and compared them with double gloving. These protocols included: triple latex gloving, triple gloving with a Kevlar liner, and triple gloving with a stainless steel liner. In their series, all triple-gloving techniques proved superior to double latex gloving in terms of inner glove perforation but were perceived as uncomfortable for the surgeon.
Overall, triple gloving seems to decrease inner glove perforation rates; however, this benefit is at the expense of decreased surgical dexterity and tactile sensation. Other gloving strategies have been also shown to decrease perforation rates: Al-Maiyah et al18 showed that frequent changing of gloves during TJA procedures significantly reduced the rate of perforation and contamination. Routine change of gloves is especially important after draping and before opening the final components. Indeed, Dawson-Bowling et al19 conducted a study to confirm this routine practice. They found that 12% and 24% of gloves collected after draping and before opening the final components, respectively, were contaminated.
 
Autologous Blood-Derived Product Application to the Wound
Autologous platelet-rich plasma (PRP; also called platelet gel) and platelet-poor plasma (PPP; also called fibrin gel) have been used successfully to promote wound healing after primary closure in various surgical procedures.20 Their benefit stems from the hemostatic properties of the platelets themselves, as well as from the released growth factors, such as platelet-derived growth factor (PDGF) and transforming growth factor β (TGF-β), which promote wound healing.21,22 PRP is usually sprayed deeply in the wound, whereas PPP is applied more superficially.22 Several studies have evaluated the role of these products in total 93knee arthroplasty (TKA) and found a significant decrease in blood loss, higher postoperative range of motion, better pain control, and a shortened length of stay.21–23 Because of lower rates of bleeding and wound drainage, a possible role for these products in preventing PJI has been suggested, especially after demonstration of a decrease in surgical site infection in cardiothoracic surgery.24,25 However, several studies failed to identify any significant benefit of PRP in TKA,26–28 and no evidence in the currently available literature supports its use in reducing PJI risk.
 
Local Antibiotic Prophylaxis: Antibiotic Cement, Vancomycin Powder, Implant and Bone Graft Coating
Even though the use of antibiotic-loaded cement in cemented TJA is Food and Drug Administration (FDA) approved in patients with a history of infection, this is not the case for patients with no such history.29 Indeed, the role of antibiotic-impregnated cement as a prophylactic measure in TJA has raised much controversy. However, a multitude of papers have demonstrated its benefit, and a meta-analysis conducted by Parvizi et al30 on 19 studies, including 36,033 total hip arthroplasties (THAs), demonstrated a 50% decrease in the rate of PJI after primary cases and a 40% decrease after revision cases. No adverse events or complications were found. Similar results were also observed in TKA, and a Finnish register-based study including 43,149 TKAs revealed a significantly decreased rate of PJI when antibiotic-loaded cement was used in addition to intravenous antibiotic prophylaxis.31
Local vancomycin powder application in the wound before closure has shown a beneficial effect in preventing infection after instrumented fusion in spine surgery, and is now being used in many spine surgery centers, including ours.32–34 Some arthroplasty specialists have mentioned its possible use in TJA; however, to the best of our knowledge, no evidence in the literature supports such a practice.94
An additional way to provide local antibiotic activity in TJA is the use of “smart” implants that are coated with antibiotics. Several studies from our institution reported the results of successfully designed smart titanium implants coated with vancomycin.35–37 Vancomycin was covalently linked to the implant, thus forming a stable biocompatible bactericidal surface that prevents bacterial colonization and biofilm formation. An in vivo study further showed decreased periprosthetic infection in a rat model.38 Bone grafts with covalently linked vancomycin have also been designed and shown to effectively inhibit bacterial colonization.39 These could be used whenever bone grafting is deemed necessary, such as for extensive bone loss in revision TJA, with a potentially decreased risk of subsequent infection.
 
Conclusion
In conclusion, even though multiple strategies are used to maintain an ultraclean operative environment and prevent contamination of the surgical field, some of them lack sufficient supporting evidence and still raise much controversy among specialists. Changing knife blades after incision, even though criticized by some, is still widely recommended. Triple gloving has proved efficacious in decreasing perforation rates but is perceived by most surgeons as adversely affecting tactile sensation and dexterity. Other gloving practices, such as frequent outer glove change, especially after draping and before opening final components, are more widely recommended. Some recent practices, such as PRP application during wound closure, may potentially reduce PJI risk, but no definite proof can be found in the literature to support their use. Local antibiotic prophylaxis seems to further decrease the incidence of PJI when combined with systemic prophylaxis; 95however, the optimal way to deliver local antibiotics is still unclear. Prophylactic antibiotic-loaded cement used in cemented arthroplasty, even though not approved by the FDA, has had highly effective results. Uncemented arthroplasties, on the other hand, might benefit from antibiotic-coated “smart” implants, which have yielded encouraging experimental results.
 
References
  1. Schmalzried TP, Amstutz HC, Au MK, Dorey FJ. Incidence of deep sepsis in total hip arthroplasty. Survivorship analysis over 17 years from one hospital. J Arthroplasty. 1991;(suppl 6):47S-51S.
  1. Kurtz SM, Ong KL, Lau E, et al. Prosthetic joint infection risk after TKA in the Medicare population. Clin Orthop Relat Res. 2010;468:52–6.
  1. Ong KL, Kurtz SM, Lau E, et al. Prosthetic joint infection risk after total hip arthroplasty in the Medicare population. J Arthroplasty. 2009;24:105–9.
  1. Garvin KL, Hanssen AD. Infection after total hip arthroplasty. Past, present, and future. J Bone Joint Surg Am. 1995;77:1576–88.
  1. Pulido L, Ghanem E, Joshi A, et al. Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res. 2008;466:1710–5.
  1. Ritter MA, French ML, Eitzen HE. Bacterial contamination of the surgical knife. Clin Orthop Relat Res. 1975;(108):158–60.
  1. Fairclough JA, Mackie IG, Mintowt-Czyz W, Phillips GE. The contaminated skin-knife. A surgical myth. J Bone Joint Surg Br. 1983;65:210.
  1. Grabe N, Falstie-Jensen S, Fredberg U, et al. The contaminated skin-knife—fact or fiction. J Hosp Infect. 1985;6:252–6.
  1. Davis N, Curry A, Gambhir AK, et al. Intraoperative bacterial contamination in operations for joint replacement. J Bone Joint Surg Br. 1999;81:886–9.
  1. Schindler OS, Spencer RF, Smith MD. Should we use a separate knife for the skin? J Bone Joint Surg Br. 2006;88:382–5.96
  1. McCue SF, Berg EW, Saunders EA. Efficacy of double-gloving as a barrier to microbial contamination during total joint arthroplasty. J Bone Joint Surg Am. 1981;63:811–3.
  1. Carter AH, Casper DS, Parvizi J, Austin MS. A prospective analysis of glove perforation in primary and revision total hip and total knee arthroplasty. J Arthroplasty. 2012;27:1271–5.
  1. Demircay E, Unay K, Bilgili MG, Alataca G. Glove perforation in hip and knee arthroplasty. J Orthop Sci. 2010;15:790–4.
  1. Hester RA, Nelson CL, Harrison S. Control of contamination of the operative team in total joint arthroplasty. J Arthroplasty. 1992;7:267–9.
  1. Sebold EJ, Jordan LR. Intraoperative glove perforation. A comparative analysis. Clin Orthop Relat Res. 1993;(297):242–4.
  1. Sutton PM, Greene T, Howell FR. The protective effect of a cut-resistant glove liner. A prospective, randomised trial. J Bone Joint Surg Br. 1998;80:411–3.
  1. Pieper SP, Schimmele SR, Johnson JA, Harper JL. A prospective study of the efficacy of various gloving techniques in the application of Erich arch bars. J Oral Maxillofac Surg. 1995531174–6. discussion 1177.
  1. Al-Maiyah M, Bajwa A, Mackenney P, et al. Glove perforation and contamination in primary total hip arthroplasty. J Bone Joint Surg Br. 2005;87:556–9.
  1. Dawson-Bowling S, Smith J, Butt D, et al. Should outer surgical gloves be changed intraoperatively before orthopedic prosthesis implantation? J Hosp Infect. 2011;78:156–7.
  1. Carter MJ, Fylling CP, Parnell LK. Use of platelet rich plasma gel on wound healing: a systematic review and meta-analysis. Eplasty. 2011;11:e38.
  1. Gardner MJ, Demetrakopoulos D, Klepchick PR, Mooar PA. The efficacy of autologous platelet gel in pain control and blood loss in total knee arthroplasty. An analysis of the hemoglobin, narcotic requirement and range of motion. Int Orthop. 2007;31:309–13.
  1. Berghoff WJ, Pietrzak WS, Rhodes RD. Platelet-rich plasma application during closure following total knee arthroplasty. Orthopedics. 2006;29:590–8.97
  1. Everts PA, Devilee RJ, Brown Mahoney C, et al. Platelet gel and fibrin sealant reduce allogeneic blood transfusions in total knee arthroplasty. Acta Anaesthesiol Scand. 2006;50:593–9.
  1. Trowbridge CC, Stammers AH, Woods E, et al. Use of platelet gel and its effects on infection in cardiac surgery. J Extra Corpor Technol. 2005;37:381–6.
  1. Khalafi RS, Bradford DW, Wilson MG. Topical application of autologous blood products during surgical closure following a coronary artery bypass graft. Eur J Cardiothorac Surg. 2008;34:360–4.
  1. Peerbooms JC, de Wolf GS, Colaris JW, et al. No positive effect of autologous platelet gel after total knee arthroplasty. Acta Orthop. 2009;80:557–62.
  1. Diiorio TM, Burkholder JD, Good RP, et al. Platelet-rich plasma does not reduce blood loss or pain or improve range of motion after TKA. Clin Orthop Relat Res. 2012;470:138–43.
  1. Horstmann WG, Slappendel R, van Hellemondt GG, et al. Autologous platelet gel in total knee arthroplasty: a prospective randomized study. Knee Surg Sports Traumatol Arthrosc. 2011;19:115–21.
  1. Meehan J, Jamali AA, Nguyen H. Prophylactic antibiotics in hip and knee arthroplasty. J Bone Joint Surg Am. 2009;91:2480–90.
  1. Parvizi J, Saleh KJ, Ragland PS, et al. Efficacy of antibiotic-impregnated cement in total hip replacement. Acta Orthop. 2008;79:335–41.
  1. Jamsen E, Huhtala H, Puolakka T, Moilanen T. Risk factors for infection after knee arthroplasty. A register-based analysis of 43,149 cases. J Bone Joint Surg Am. 2009;91:38–47.
  1. Molinari RW, Khera OA, Molinari Iii WJ. Prophylactic intraoperative powdered vancomycin and postoperative deep spinal wound infection: 1,512 consecutive surgical cases over a 6-year period. Eur Spine J. 2012;21(suppl 4): 476 S-82S.
  1. Sweet FA, Roh M, Sliva C. Intrawound application of vancomycin for prophylaxis in instrumented thoracolumbar fusions: efficacy, drug levels, and patient outcomes. Spine (Phila Pa 1976). 2011;36:2084–8.98
  1. O'Neill KR, Smith JG, Abtahi AM, et al. Reduced surgical site infections in patients undergoing posterior spinal stabilization of traumatic injuries using vancomycin powder. Spine J. 2011;11:641–6.
  1. Antoci V Jr, King SB, Jose B, et al. Vancomycin covalently bonded to titanium alloy prevents bacterial colonization. J Orthop Res. 2007;25:858–66.
  1. Antoci V Jr, Adams CS, Parvizi J, et al. Covalently attached vancomycin provides a nanoscale antibacterial surface. Clin Orthop Relat Res. 2007;461:81–7.
  1. Parvizi J, Wickstrom E, Zeiger AR, et al. Frank Stinchfield Award. Titanium surface with biologic activity against infection. Clin Orthop Relat Res. 2004;(429):33–8.
  1. Antoci V Jr, Adams CS, Hickok NJ, et al. Vancomycin bound to Ti rods reduces periprosthetic infection: preliminary study. Clin Orthop Relat Res. 2007;461:88–95.
  1. Ketonis C, Barr S, Adams CS, et al. Vancomycin bonded to bone grafts prevents bacterial colonization. Antimicrob Agents Chemother. 2011;55:487–94.

The Operating Room Environmentchapter 13

Ibrahim J Raphael,
Eric B Smith
 
Current Evidence
 
Laminar Airflow Systems
Laminar airflow (LAF) systems were first introduced to operating rooms (ORs) in the US in 1964.1 They were designed to decrease airborne microbial counts and move particles away from the surgical field by using positive-pressure, unidirectional airflow. Several types of LAF systems are on the market. The most commonly used have a full or partial ceiling supply with vertical, downward-directed airflow. This system directs ultraclean air from the ceiling supply to intake vents at floor level. The positive pressure creates an invisible curtain that protects the surgical site from floating particles. Horizontal LAF systems also exist, however, their effectiveness can be compromised by objects, including the surgical personnel, impeding the flow of air across the OR table.

Rothman Institute Current Practices

  1. The majority of the ORs at the Rothman Institute use partial vertical LAF.
  2. Surgeons use helmets, exhaust suits and double glove, with regular changes of outer gloves.
  3. Patient normothermia is maintained intraoperatively with forced air warming devices.
  4. OR traffic is limited to staff essential to the procedure only.
Airflow 100impedance also occurs with vertical LAF due to obstacles such as OR lights and the operating personnel's heads and limbs over the operative field. LAF systems include high-efficiency particulate air (HEPA) filters that block 99.97% of particles 0.3 μm or larger that pass through.2 These filters require regular maintenance for adequate functioning.
In 1982, Lidwell et al3 reported a direct association between deep postoperative infection rates and the number of airborne microorganisms. Many studies have proved the efficacy of LAF in decreasing the incidence of surgical site infection (SSI) as well as bacterial counts in the wound and on surgical instruments.4–11 A multicentric study showed a decrease in SSI incidence from 3.4% to 1.6% by using LAF only.3 However, the benefit of using LAF in the OR setting remains controversial. Other studies that attempt to control for confounding variables report no protective effect associated with LAF.12–15 Hooper et al16 studied the New Zealand Joint Registry to assess the efficacy of LAF and space suits in reducing periprosthetic joint infection (PJI) following total joint arthroplasty. He reports that LAF and space suits used together or separately were associated with a significant increase in early infection rates. Another large retrospective study from Germany showed that the use of LAF during hip arthroplasty was associated with an increased risk of SSI.17
Some argue that the cost of purchasing and installing these systems is not yet justified.16 However, over time, prices have dropped considerably. At present, LAF prices have dropped considerably compared to 10 or 20 years ago.6 This is approximately the same cost for treating a single PJI (see Chapter 2); therefore, the installation of LAF in every OR may be warranted.
According to the United Kingdom National Joint Registry, 98% of hip arthroplasties in the United Kingdom take place under LAF. In the United States, only 30% of hospitals reported using LAF in more than 75% of 101knee arthroplasty procedures.18 The Centers for Disease Control and Prevention (CDC) states that LAF may reduce the incidence of SSI. They do not give specific recommendations for performing joint arthroplasty procedures under LAF; however, they do distribute the following guidelines19:
 
CDC Guidelines20
  1. Maintain positive-pressure ventilation with respect to corridors and adjacent areas.
  2. Maintain ≥15 air changes per hour (ACH), of which ≥ 3 ACH should be fresh air.
  3. Filter all recirculated and fresh air through the appropriate filters, providing 90% efficiency (dust-spot testing) at a minimum.
  4. In rooms not engineered for horizontal LAF, introduce air at the ceiling and exhaust air near the floor.
 
Ultraviolet Light
Germicidal irradiation through ultraviolet (UV) light was first introduced in 1936. A mercury arc lamp emits short-wavelength (254 nm) UV light. UV light is reported to significantly decrease infection rates and bacterial counts when used with21–23 or without24–27 LAF. Ritter et al22 reported that in joint arthroplasty procedures, the infection rate with LAF and without UV light was 1.77%. When UV light was added with LAF, the infection rate dropped significantly to 0.57%.
Operating under UV light increases harmful exposure for OR personnel by 6 – 28 times the recommended limit.6 Prolonged exposure has been linked with corneal thermal injuries, skin lesions, and skin cancer.20 Even though this technology can be acquired for a small cost, the health hazards it poses do not warrant its everyday use in the OR.102
 
CDC Guideline20
  • Do not use UV lights to prevent surgical site infections.
 
OR Traffic
Operating room (OR) traffic flow has been linked to increased contamination rates.28 It has been hypothesized that OR personnel are the major contributors to OR contamination because of bacterial shedding, mainly from the skin.29,30 The bacterial load in the OR has been directly associated with the number of members present.31 In addition, increased traffic implies more door openings. Any obstacles (staff, lamp, operating table, and so on) in the path of the directional flow, as well as repeated door openings, create turbulence that allows mixing of filtered air with unclean air.5,32
A study at the Rothman Institute reported an average of 60 (0.65/min) door openings per primary arthroplasty case and 135 (0.84/min) per revision arthroplasty. Approximately 35% of total door openings occur in the preincision period. The people most commonly linked to door opening were the circulating nurses and surgical equipment representatives. Regarding the reason why people entered, 47% had no identifiable purpose.33 This study showed that the majority of OR traffic can easily be diminished. Other research has suggested that frequent traffic can also distract the surgeon, which can lead to contamination or error.32
 
CDC Guideline20
  • Keep OR doors closed except for the passage of equipment, personnel, and patients, and limit entry to essential personnel.
 
Surgical Attire
Bacterial shedding from OR personnel is an important cause of contamination.4,34 No studies have yet shown 103shedding to be directly related to SSI occurrence; however, precautions are still taken to minimize any potential risk of infection. Appropriate clothing is essential to protect the patient and OR staff alike.
In the late 1960s, Sir John Charnley first introduced OR helmets and body exhaust systems to decrease human contamination. He reported the infection rate dropped from 9% to 1% with the use of LAF and body exhaust suits.35 Currently, sterile body exhaust suits are worn during most joint arthroplasty operations across the United States. When used in combination with LAF, they provide further protection against bacterial shedding from the surgical team.3,35–41 A multicenter study by Lidwell et al3 showed a 2.6 times increase in infection rates with the use of conventional clothing when compared with body exhaust suits. Currently, no uniform guidelines exist with regard to washing scrub apparel. It is not clear whether wearing them only inside the OR or allowing them to be worn outside the OR leads to contamination or infection. Surgical masks, goggles, shields, hoods, and shoe covers may actually protect the surgeon more than the patient.42–47
Impermeable drapes and gowns provide an added barrier of protection. New, iodine-impregnated drapes have been shown to diminish patient bacterial flora, and in one study these drapes led to decreased wound contamination, from 15% to 1.6%.48–50 Blom et al51 examined the passage of bacteria through different types of drapes and showed that only nonwoven impermeable drapes provided adequate protection.
All scrubbed personnel conventionally wear sterile gloves. Gloves provide a barrier against the direct exchange of bacteria and body fluids. Swab samples of gloves taken immediately after skin preparation have shown a contamination rate of 28.7%.52 A multicentric study strongly suggested double gloving and routine changing 104of sterile gloves during surgery to decrease surgical team skin and mucous membrane contamination.53
 
Equipment and Surfaces
The Occupational Safety and Health Administration (OSHA)54 requires that all surfaces that have had contact with body fluids or other infectious materials be cleaned and decontaminated. According to the CDC guidelines, data are not sufficient to recommend the routine disinfection of equipment and surfaces without visible or obvious evidence of contamination.19
Dalstrom et al55 reported that the rate of contamination of open surgical trays correlated with the duration of exposure and recommended covering open trays with a sterile cloth, as this method has proved to be protective. Similarly, Brown et al56 advocates opening OR trays only after skin preparation and draping.
Splash basins used in surgery have repeatedly been shown to be contaminated and thus might be a potential cause of SSI.56–59 Implants and surgical tools placed inside or in proximity to the basin should not be used again in the surgical field.58
Suction tips are another source of contamination that may potentially increase infection rates.52,60–63 Contamination rates differ from one study to another, but up to 41% of suction tips may become contaminated.62 Many recommend routine changing of the suction tips, especially for longer procedures, or changing the suction tip before preparing the femora canal during total hip arthroplasty.61–63
 
Physical Properties
In a recent study by Teijwani et al,64 186 orthopedic surgeons reported that they believed longer operative times were associated with higher infection rates. In fact, 105many studies found no correlation between operative time and infection,65,66 whereas others found that they were correlated but that time was not a major risk factor.67–70 In contrast, Peersman et al70 retrospectively reviewed approximately 6,100 arthroplasty patients operated on under LAF, with the use of body exhaust suits, and found a significantly higher risk of infection in operations lasting 2.5 hours or longer.
Patient normothermia (36° – 38°C or 96.8° – 100.4°F) plays an important role in the development of SSI. Patient hypothermia (< 36°C or < 96.8°F) can lead to increased infection risks because of decreased oxygen partial pressure and impaired T cell and neutrophil function.71–73 A systematic review conducted by Scott et al74 showed the beneficial effect of patient normothermia with regard to infection risks. Several high-level studies have supported this finding.75–78 Patient temperature is maintained by forced air warming (FAW) systems or conductive warming blankets. McGovern et al79 reported an increased rate of PJI associated with FAW devices and advised against their use in orthopedic operations. In contrast, many studies show that convective air warming does not increase the risk of infection, even when used in LAF-equipped ORs.30,80–82 A recent paper by Parvizi et al83 reported that evidence was insufficient to state that FAW increases the risk of SSI.
The OR physical parameters found in the CDC guidelines are reported according to the American Institute of Architects and the United States Department of Health and Human Services. These recommend keeping the OR temperature between 68°F and 73°F (20°C and 22.8°C) and the relative humidity levels between 30% and 60%.19
 
References
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  1. Ritter MA. Operating room environment. Clin Orthop Rel Res. 1999;(369):103–9.
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  1. Evans RP. Current concepts for clean air and total joint arthroplasty: laminar airflow and ultraviolet radiation: a systematic review. Clin Orthop Relat Res. 2011;469(4):945–53.
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  1. Stocks GW, O'Connor DP, Self SD, Marcek GA, Thompson BL. Directed airflow to reduce airborne particulate and bacterial contamination in the surgical field during total hip arthroplasty. J Arthroplasty. 2011;26(5):771–6.
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  1. Breier AC, Brandt C, Sohr D, Geffers C, Gastmeier P. Laminar airflow ceiling size: no impact on infection rates following hip and knee prosthesis. Infect Control Hosp Epidemiol. 2011;32(11):1097–1102.
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  1. Brandt C, Hott U, Sohr D, et al. Operating room ventilation with laminar airflow shows no protective effect on the surgical site infection rate in orthopedic and abdominal surgery. Ann Surg. 2008;248(5):695–700.
  1. Miner AL, Losina E, Katz J, Fossel AH, Platt R. Infection control practices to reduce airborne bacteria during total knee replacement: a hospital survey in four states. Infect Control Hosp Epidemiol. 2005;26:910–5.
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  1. Ritter MA, Olberding EM, Malinzak RA. Ultraviolet lighting during orthopedic surgery and the rate of infection. J Bone Joint Surg Am. 2007;89:1935–40.
  1. Taylor GJ, Bannister GC, Leeming JP. Wound disinfection with ultraviolet radiation. J Hosp Infect. 1995;30:85–93.108
  1. Lowell JD, Kundsin RB, Schwartz CM, Pozin D. Ultraviolet radiation and reduction of deep wound infection following hip and knee arthroplasty. Ann N Y Acad Sci. 1980;353:285–93.
  1. Berg M, Bergman BR, Hoborn J. Shortwave ultraviolet radiation in operating rooms. J Bone Joint Surg Br. 1989;71(3):483–5.
  1. Hart D, Postlethwait RW, Brown IW Jr, Smith WW, Johnson PA. Postoperative wound infections: a further report on ultraviolet irradiation with comments on the recent (1964) national research council cooperative study report. Ann Surg. 1968;167(5):728–43.
  1. Moggio M, Goldner JL, McCollum DE, Beissinger SF. Wound infections in patients undergoing total hip arthroplasty. Ultraviolet light for the control of airborne bacteria. Arch Surg. 1979;114(7):815–23.
  1. Andersson AE, Bergh I, Karlsson J, Eriksson BI, Nilsson K. Traffic flow in the operating room: An explorative and descriptive study on air quality during orthopedic trauma implant surgery. AmJ Infect Control. 2012. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22285652. Accessed February 26, 2012.
  1. Ritter MA. Surgical wound environment. Clin Orthop Relat Res. 1984;(190):11–3.
  1. Tumia N, Ashcroft GP. Convection warmers—a possible source of contamination in laminar airflow operating theatres? J Hosp Infect. 2002;52(3):171–4.
  1. Ayliffe GA. Role of the environment of the operating suite in surgical wound infection. Rev Infect Dis. 1991;13(suppl 10): 800S-4S
  1. Young RS, O'Regan DJ. Cardiac surgical theatre traffic: time for traffic calming measures? Interact Cardiovasc Thorac Surg. 2010;10(4):526–9.
  1. Panahi P, Stroh M, Casper DS, Parvizi J, Austin MS. Operating room traffic is a major concern during total joint arthroplasty. Clin Orthop Relat Res. 2012. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22302655. Accessed March 26, 2012.
  1. Rao N, Cannella B, Crossett LS, Yates AJ Jr, McGough R III. A preoperative decolonization protocol for Staphylococcus aureus prevents orthopaedic infections. Clin Orthop Relat Res. 2008;466:1343–8.109
  1. Lidwell OM. Clean air at operation and subsequent sepsis in the joint. Clin Orthop Relat Res. 1986;211:91–102.
  1. Dharan S, Pittet D. Environmental controls in operating theaters. J Hosp Inf. 2002;51:79–84.
  1. Owers KL, James E, Bannister GC. Source of bacterial shedding in laminar flow theaters. J Hosp Inf. 2004;58;230-2
  1. Nelson JP. Five years experience with operating room clean rooms and personnel-isolator systems. Med Instrum. 1976; 10:277–81.
  1. Charnley J. Postoperative infection after total hip replacement with special reference to air contamination in the operating room. Clin Orthop Relat Res. 1972;87:167.
  1. Nelson JP, Glassburn AR, Talbott RD, McElhinney JP. The effect of previous surgery, operating room environment, and preventive antibiotics on post-operative infection following total hip arthroplasty. Clin Orthop Relat Res. 1980;147:167–9.
  1. Blomgren G, Hambraeus A, Malmborg AS. The influence of the total body exhaust suit on air and wound contamination in elective hip-operations. J Hosp Infect. 1983;4(3):257–68.
  1. Mitchell NJ, Hunt S. Surgical face masks in modern operating rooms—a costly and unnecessary ritual? J Hosp Infect. 1991;18(3):239–42.
  1. Tunevall TG, Jörbeck H. Influence of wearing masks on the density of airborne bacteria in the vicinity of the surgical wound. Eur J Surg. 1992;158(5):263–6.
  1. Tunevall TG. Postoperative wound infections and surgical face masks: a controlled study. World J Surg. 1991;15(3):383-7; discussion 387-8.
  1. Dineen P, Drusin L. Epidemics of postoperative wound infections associated with hair carriers. Lancet 1973;2(7839):1157–9.
  1. Humphreys H, Marshall RJ, Ricketts VE, Russell AJ, Reeves DS. Theatre over-shoes do not reduce operating theatre floor bacterial counts. J Hosp Infect. 1991;17:117–23.
  1. Weightman NC, Banfield KR. Protective over-shoes are unnecessary in a day surgery unit. J Hosp Infect. 1994;28:1–3.110
  1. Dewan PA, Van Rij AM, Robinson RG, Skeggs GB; Fergus M. The use of an iodophor-impregnated plastic incise drape in abdominal surgery—a controlled clinical trial. Aust N Z J Surg. 1987;57(11):859–63.
  1. Lewis DA, Leaper DJ, Speller DC. Prevention of bacterial colonization of wounds at operation: comparison of iodine impregnated (‘Ioban’) drapes with conventional methods. J Hosp Infect. 1984;5(4):431–7.
  1. Fairclough JA, Johnson D, Mackie I. The prevention of wound contamination by skin organisms by the preoperative application of an iodophor impregnated plastic adhesive drape. J Int Med Res. 1986;14(2):105–9.
  1. Blom A, Estela C, Bowker K, MacGowan A, Hardy JR. The passage of bacteria through surgical drapes. Ann R Coll Surg Engl. 2000;82(6):405–7.
  1. Davis N, Curry A, Gambhir AK, et al. Intraoperative bacterial contamination in operations for joint replacement. J Bone Joint Surg Br. 1999;81(5):886–9.
  1. Tokars JI, Culver DH, Mendelson MH, et al. Skin and mucous membrane contacts with blood during surgical procedures: risk and prevention. Infect Control Hosp Epidemiol. 1995;16(12):703–11.
  1. U.S. Department of Labor, Occupational Safety and Health Administration. Occupational exposure to bloodborne pathogens; final rule (29 CFR Part 1910.1030). Federal Register 1991;56:64004–182.
  1. Dalstrom DJ, Venkatarayappa I, Manternach AL, et al. Time-dependent contamination of opened sterile operating-room trays. J Bone Joint Surg Am. 2008;90(5):1022–5.
  1. Brown AR, Taylor GJ, Gregg PJ. Air contamination during skin preparation and draping in joint replacement surgery. J Bone Joint Surg Br. 1996;78(1):92–4.
  1. Anto B, McCabe J, Kelly S, et al. Splash basin bacterial contamination during elective arthroplasty. J Infect. 2006;52(3):231–2.
  1. Baird RA, Nickel FR, Thrupp LD, Rucker S, Hawkins B. Splash basin contamination in orthopedic surgery. Clin Orthop Relat Res. 1984;(187):129–33.111
  1. Glait SA, Schwarzkopf R, Gould S, Bosco J, Slover J. Is repetitive intraoperative splash basin use a source of bacterial contamination in total joint replacement? Orthopedics. 2011;34(9):e546–9.
  1. Givissis P, Karataglis D, Antonarakos P, Symeonidis PD, Christodoulou A. Suction during orthopedic surgery. How safe is the suction tip? Acta Orthop Belg. 2008;74(4):531–3.
  1. Mulcahy DM, McCormack D, McElwain JP. Intraoperative suction catheter tip contamination. J R Coll Surg Edinb. 1994;39(6):371–3.
  1. Robinson AH, Drew S, Anderson J, Bentley G, Ridgway GL. Suction tip contamination in the ultraclean-air operating theatre. Ann R Coll Surg Engl. 1993;75(4):254–6.
  1. Greenough CG. An investigation into contamination of operative suction. J Bone Joint Surg Br. 1986;68(1):151–3.
  1. Tejwani N, Immerman I. Myths and legends in orthopedic practice: are we all guilty? Clin Orthops Relat Res. 2008;466(11):2861–72.
  1. Gordon SM, Culver DH, Simmons BP, Jarvis WR. Risk factors for wound infections after total knee arthroplasty. Am J Epidemiol. 1990;131:905–16.
  1. Syahrizal AB, Kareem BA, Anbanadan S, Harwant S. Risk factors for infection in total knee replacement surgery at hospital Kuala Lumpur. Med J Malaysia. 2001;56(suppl D):5–8.
  1. Escalante A, Beardmore TD. Risk factors for early wound complications after orthopedic surgery for rheumatoid arthritis. J Rheumatol. 1995;22:1844–51.
  1. Morris CD, Sepkowitz K, Fonshell C, Margetson N, Eagan J, Miransky J, et al. Prospective identification of risk factors for wound infection after lower extremity oncologic surgery. Ann Surg Oncol. 2003;10:778–82.
  1. Wymenga AB, van Horn JR, Theeuwes A, Muytjens HL, Slooff TJ. Perioperative factors associated with septic arthritis after arthroplasty: prospective multicenter study of 362 knee and 2,651 hip operations. Acta Orthop Scand. 1992;63:665–71.
  1. Peersman G, Laskin R, Davis J, Peterson M. Infection in total knee replacement: a retrospective review of 6,489 total knee replacements. Clin Orthop Relat Res. 2001;392:15–23.112
  1. Sheffield CW, Sessler DI, Hopf HW, et al. Centrally and locally mediated thermoregulatory responses alter subcutaneous oxygen tension. Wound Repair Regen. 1997;4:339–45.
  1. Clardy CW, Edwards KM, Gay JC. Increased susceptibility to infection in hypothermic children: possible role of acquired neutrophil dysfunction. Pediatr Infect Dis. 1985;4: 379–82.
  1. Van Oss CJ, Absolom DR, Moore LL, et al. Effect of temperature on the chemotaxis, phagocytic engulfment, digestion and O2 consumption of human polymorphonuclear leukocytes. J Reticuloendothel Soc. 1980;27:561–5.
  1. Scott EM, Buckland R. A systematic review of intraoperative warming to prevent postoperative complications. AORN J. 2006;83(5):1090-1104, 1107-13.
  1. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med. 1996;334(19):1209–15.
  1. Melling AC, Ali B, Scott EM, Leaper DJ. Effects of preoperative warming on the incidence of wound infection after clean surgery: a randomised controlled trial. Lancet. 2001;358(9285):876–80.
  1. Memarzadeh F. Active warming systems to maintain perioperative normothermia in hip replacement surgery. J Hosp Inf 2010;75(4):332–3.
  1. Moretti B, et al. Active warming-systems to maintain perioperative normothermia in hip replacement surgery: a therapeutic aid or a vector of infection? J Hosp Inf. 2009;73:58–63.
  1. McGovern PD, Albrecht M, Belani KG, et al. Forced-air warming and ultra-clean ventilation do not mix: an investigation of theatre ventilation, patient warming and joint replacement infection in orthopedics. J Bone Joint Surg Br. 2011;93(11):1537–44.
  1. Sessler DI, Olmsted RN, Kuelpmann R. Forced-air warming does not worsen air quality in laminar flow operating rooms. Anesth Analg. 2011;113(6):1416–21.
  1. Huang JKC, Shah EF, Vinodkumar N, Hegarty MA, Greatorex RA. The Bair Hugger patient warming system in prolonged vascular surgery: an infection risk? Crit Care. 2003;7(3):R13–6.113
  1. Zink RS, Iaizzo PA. Convective warming therapy does not increase the risk of wound contamination in the operating room. Anesth Analg. 1993;76(1):50–3.
  1. Parvizi J, Karam JA. Do forced-air warming blankets increase surgical site infections? Available at: http://www.fawfacts.com/pdf/us/ff/ParviziStudy.pdf114

Incise Drapeschapter 14

Alvin Ong
 
Current Evidence

Rothman Institute Current Practices

  1. Incise drapes impregnated with iodophor are used in every total joint arthroplasty procedure.
  2. Incise drapes without antimicrobial agent are used when documented iodine allergy is present.
Plastic adhesive or incise drapes are designed to protect the surgical site from skin microbes and have been in use for over 50 years. When properly applied, the drape conforms to, and adheres tightly to, the skin. Air and fluid are prevented from gathering under the incised edge, thus protecting the surgical wound from contamination.1 French et al made a microbial evaluation of adhesive plastic surgical drapes, both during surgery and in the laboratory, and compared them with cloth surgical drapes. Deep wound cultures collected just prior to closing showed 60% contamination when cloth was used compared with 6% when plastic adhesive drape was used. The authors reported positive aseptic benefits afforded by plastic adhesive drapes.2 Fairclough et al3 reported a reduction in wound contamination from 15% to 1.6% in patients undergoing hip surgery in which a plastic adhesive drape was applied to the operation site prior to surgery. Other advantages of using incise draping include the following: (1) adherence directly to the wound edge, (2) transparency 116with minimal glare surface, (3) thin yet tear resistant, and (4) elasticity, allowing for limb mobilization with reduced skin tension.
Adhesion to the skin is most effective when the skin is prepared with an alcohol-based iodophor prep (iodine povacrylex) and allowed to dry completely before application of the incise drape. In a randomized controlled trial comparing the preoperative skin preparation of iodine povacrylex/alcohol and CHG/alcohol, incise drapes applied to the iodine povacrylex adhered significantly better than incise drapes applied to the CHG/alcohol prep.3a Improved adhesion of drape to the skin is hypothesized to reduce wound contamination.4
In summary, incise drapes provide a sterile operative surface at the onset of surgery, immobilizing bacteria beneath the drape and reducing the risk of surgical site contamination that may be associated with surgical site infections. Moreover, incise drapes impregnated with iodophor have been developed to provide antimicrobial protection to the skin and surgical site, thereby reducing contamination further.

Pitfalls

  1. Application of alcohol-based skin preparation is important to ensure that the incise drape will adhere tightly to the skin.
  2. Use of the incise drape is contraindicated in friable skin, which can easily tear when the drape is peeled off.
The effectiveness of incise drapes in preventing bacterial contamination of the surgical site has been called into question by multiple studies. The following are summaries of three studies that have shown a negative effect with incise drapes.
  • In 1993, Chiu et al5 reported on 120 patients with acute hip fracture treated operatively. The patients were randomized to two groups: an incise drape group 117(n = 65) and a no drape group (n = 55). The two groups were otherwise matched. Swabs for culture were taken from skin adjacent to the wound before closure. The incise drape group had four positive wound swabs. The no drape group had only one. No difference in the postoperative wound infection rates was observed. The authors question whether incise drapes can prevent wound contamination from skin flora.
  • Alexander et al6 reported on three consecutive controlled randomized clinical trials using 1,324 patients; the trials were conducted to assess the efficacy of incise drapes in preventing wound infections. When a polyester antimicrobial incise drape (loban 2 Antimicrobial Film) was applied to an operative area after a 1-minute skin preparation using either 70% alcohol or 2% iodine in 90% alcohol, the clean wound infection rate (1.3%) and overall wound infection rate (2.5%) were comparable to those following a standard 10-minute skin preparation with povidone-iodine (Betadine; 1.3% and 2.3%, respectively). Preliminary studies showed that separation of polyethylene antimicrobial incise drapes from the skin during operation was associated with a 6-fold increase in infection rate when compared with operations in which the incise drape did not lift. Design of the drape and technique of application are important considerations in preventing lift from the skin.
  • In 2007, the Cochrane database7 reviewed five studies, involving 3,082 participants, that compared adhesive drapes with no drapes and two studies, involving 1,113 participants, that compared iodine-impregnated adhesive drapes with no drapes. A significantly higher proportion of patients in the adhesive drape group developed a surgical site infection when compared with the no drape group. Moreover, iodine-impregnated 118adhesive drapes had no effect on the surgical site infection rate. The authors concluded that no evidence was found to support the idea that plastic adhesive drapes reduce the surgical site infection rate, and, indeed, some evidence that they increase infection rates was uncovered.
However, the studies included in the meta-analysis looking at the effect of antimicrobial incise drapes both used Ioban 2 antimicrobial incise drapes. There are a number of other iodine impregnated incise drapes on the market but no studies of these products were included in the review. Of the two studies included in the review, one study had ~1000 subjects and the other had ~50. The large study (Dewan) dominates the results and skews review conclusions to be based on one study, not a systematic review of multiple studies. The Dewan study found there was reduction in wound contamination in the iodine- impregnated drape group but that there was no difference in surgical site infection in the iodine-impregnated drape group compared to the group without the drape.
In addition the Cochrane review did not include a subset analysis of “clean and clean-contaminated procedures” and “contaminated and dirty procedures”. The pooling of data including different surgical wound classifications can confound results and conclusions. Ioban drapes impact organisms on the skin and would be expected to be more effective when used in the “clean and clean-contaminated” procedures. As might be expected, no benefit resulted from the use of drapes with dirty wounds.8
 
References
  1. Ha'eri GB. The efficacy of adhesive plastic incise drapes in preventing wound contamination. Int Surg. 1983;68(1):31–2.119
  1. French ML, Eitzen HE, Ritter MA. The plastic surgical adhesive drape: an evaluation of its efficacy as a microbial barrier. Ann Surg. 1976;184(1):46–50.
  1. Fairclough JA, Johnson D, Mackie I. The prevention of wound contamination by skin organisms by the preoperative application of an iodophor-impregnated plastic adhesive drape. J Int Med Res. 1986;14(2):105–9.
  1. Grove GL, Eyberg CI. Comparison of two preoperative skin antiseptic preparations and resultant surgical incise drape adhesion to skin in healthy volunteers. J Bone Surg Am 2012;94:1187–92.
  1. Jacobson C, Osmon DR, Hanssen A, et al. Prevention of wound contamination using DuraPrep solution plus Ioban 2 drapes. Clin Orthop Relat Res. 2005;439:32–7.
  1. Chiu KY, Lau SK, Fung B, Ng KH, Chow SP. Plastic adhesive drapes and wound infection after hip fracture surgery. Aust N Z J Surg. 1993;63(10):798–801.
  1. Alexander JW, Aerni S, Plettner JP. Development of a safe and effective one-minute preoperative skin preparation. Arch Surg. 1985;120(12):1357–61.
  1. Webster J, Alghamdi AA. Use of plastic adhesive drapes during surgery for preventing surgical site infection. Cochrane Database Syst Rev. 2007;(4):CD006353.
  1. Dewan PA, Van Rij AM, Robinson RG, et al. The use of an iodophor-impregnated plastic incise drape in abdominal surgery—a controlled clinical trial. Austral New Zealand J Surgery. Nov 1987;57(11):859–63.120

Antibiotic Prophylaxischapter 15

Nader Toossi
 
Current Evidence

Rothman Institute Current Practices

  1. All patients undergoing arthroplasty are given cefazolin approximately 30 minutes prior to skin incision.
  2. Vancomycin is given to patients with a prior history of MRSA, penicillin allergy, institutionalized patients, and health care workers.
  3. Prophylactic antibiotics are not continued beyond 24 hours after surgery.
  4. Dual antibiotics consisting of a cephalosporin and an aminoglycoside are given to patients with urinary tract symptoms.
Preoperative antibiotic prophylaxis is one of the most important strategies for prevention of infection and is considered essential in modern arthroplasty.1–3 The goal is for an adequate concentration of antibiotics to be present in the serum, tissue, and wound during the entire period when the incision is open and at risk for contamination.1 Systemic intravenous (IV) antibiotics are the best available prophylaxis method, as they allow rapid and predictable levels of antibiotic coverage. Cephalosporins are widely used because of their activity against Staphylococcus species and enteric pathogens. Currently, cefazolin or cefuroxime is the antibiotic of choice for prophylaxis in lower limb arthroplasty.4 These agents are bactericidal, provide superb tissue penetration, and have rapid and excellent bioavailability. 122Cefazolin should be given as a 1-g IV dose in patients weighing less than 80 kg and a 2-g IV dose in those weighing more than 80 kg (20–30 mg/kg), whereas cefuroxime should be infused at a dose of 50 mg/kg IV, up to a maximum dose of 1.5 g. The best time for administration varies; some studies have shown this to be 30–60 minutes before the skin incision,5 whereas others have suggested it to be within 30 minutes of the incision.6 However, timing is dependent on the type of antibiotic used and its pharmacokinetics. If a proximal tourniquet is used, the entire dose of antibiotic should be administered before inflation of the tourniquet.
The intraoperative dose of antibiotic should be repeated if operative time exceeds two times the half-life of antibiotic (four hours) or if increased blood loss (> 70% of circulating volume) occurs during the procedure.1,7
Dual antibiotic prophylaxis has been shown to have no advantage over single antibiotic prophylaxis.8 For us, an exception is made for the patient with a history of, or the presence of, a urinary tract infection with Gram-negative organisms; in this situation, we prefer to combine a cephalosporin antibiotic with an aminoglycoside.
 
Length of Coverage
Controversies abound regarding the duration of antibiotic coverage. In one study, four doses of intravenous antibiotics in total hip arthroplasty on the same day of operation were found to be more effective than fewer doses,9 whereas in another study, no difference was seen between the single- and 4-dose regimen.6 The latter study did, however, report an increased rate of aseptic loosening in patients receiving a single dose of antibiotic.
No evidence supports the continuation of prophylactic antibiotic therapy beyond 24 hours postoperatively.2,7,9 Even when a drain or urinary catheter is in place, the 123antibiotic should be stopped after 24 hours.1 Continued use of antibiotics beyond 24 hours probably leads to the emergence of resistant bacterial species10 and places the patient at risk of Clostridium difficile enteritis.11
 
Indications for Vancomycin
First-generation cephalosporins are adequate for the majority of patients undergoing elective total joint arthroplasty. However, in some cases, vancomycin may need to be administered. In our opinion, the following patients should be given vancomycin in addition to a first-generation cephalosporin:
  • Patients who are known carriers of methicillin-resistant S. aureus.
  • Patients from nursing homes, from dialysis units, or from centers with a known outbreak of methicillin-resistant S. aureus infections.
  • Health care workers.
  • Patients with proven penicillin allergy.4 Although clindamycin is also a reasonable alternative, the high association between administration of clindamycin and C. difficile enteritis has led us to use vancomycin in patients allergic to penicillin.
Two important points, however, must be remembered when using vancomycin. First, it cannot be administered rapidly; one needs to allow at least one hour for infusion. The lengthy infusion is required to prevent adverse reactions of the drug, such as hypotension, chest pain, and red neck or red man syndrome.12 Thus, infusion should be started at least 90 minutes prior to incision to allow completion of administration. Second, vancomycin does not have great coverage against methicillin-sensitive S. aureus and hence should be given in combination with a cephalosporin.2124
 
References
  1. Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis. 2004;38:1706–15.
  1. Antimicrobial prophylaxis in surgery. Med Lett Drugs Ther. 2001;43:92–7.
  1. AAOS recommendations for the use of intravenous antibiotic prophylaxis in primary total joint arthroplasty. 2004. Available at: www.aaos.org
  1. ASHP Therapeutic Guidelines on Antimicrobial Prophylaxis in Surgery. American Society of Health-System Pharmacists. Am J Health Syst Pharm. 1999;56:1839–88.
  1. Weber WP, Marti WR, Zwahlen M, et al. The timing of surgical antimicrobial prophylaxis. Ann Surg. 2008;247:918–26.
  1. van Kasteren ME, Mannien J, Ott A, Kullberg BJ, de Boer AS, Gyssens IC. Antibiotic prophylaxis and the risk of surgical site infections following total hip arthroplasty: timely administration is the most important factor. Clin Infect Dis. 2007;44:921–7.
  1. Page CP, Bohnen JM, Fletcher JR, McManus AT, Solomkin JS, Wittmann DH. Antimicrobial prophylaxis for surgical wounds. Guidelines for clinical care. Arch Surg. 1993;128:79–88.
  1. Sewick A, Makani A, Wu C, O'Donnell J, Baldwin KD, Lee GC. Does dual antibiotic prophylaxis better prevent surgical site infections in total joint arthroplasty? Clin Orthop Relat Res. 2012.
  1. Engesaeter LB, Lie SA, Espehaug B, Furnes O, Vollset SE, Havelin LI. Antibiotic prophylaxis in total hip arthroplasty: effects of antibiotic prophylaxis systemically and in bone cement on the revision rate of 22,170 primary hip replacements followed 0-14 years in the Norwegian Arthroplasty Register. Acta Orthop Scand. 2003;74:644–51.
  1. Harbarth S, Samore MH, Lichtenberg D, Carmeli Y. Prolonged antibiotic prophylaxis after cardiovascular surgery and its effect on surgical site infections and antimicrobial resistance. Circulation. 2000;101:2916–21.125
  1. Crabtree T, Aitchison D, Meyers BF, et al. Clostridium difficile in cardiac surgery: risk factors and impact on postoperative outcome. Ann Thorac Surg. 2007;83(4):1396–1402.
  1. Southorn PA, Plevak DJ, Wright AJ, Wilson WR. Adverse effects of vancomycin administered in the perioperative period. Mayo Clin Proc. 1986;61:721–4.126

Workup of Patients with Suspected Urinary Tract Infectionchapter 16

James McKenzie,
Jess H Lonner
 
Current Evidence
According to the American College of Physicians (ACP), urinary tract infection (UTI) is common in both the outpatient and the inpatient settings.1 Orthopedic studies have shown that UTIs are a predisposing risk factor for periprosthetic joint infection (PJI).2 Furthermore, the American Academy of Orthopedic Surgeons (AAOS), in conjunction with the American Urological Association, has released an advisory statement saying that UTI is a comorbid factor in hematogenous prosthetic seeding in PJI in the initial two years following total joint arthroplasty.3

Rothman Institute Current Practices

  1. Urinalysis and the dipstick test are performed at preoperative screening.
  2. A positive result is sent for culture and treated with a course of appropriate antibiotic.
  3. No clinical guidelines exist in our unit for canceling surgical procedures; each case is treated on an individual basis.
The Infectious Disease Society of America (IDSA) suggests that patients suspected of having UTI should be screened via urine culture. Furthermore, patients at 128high risk for contracting an intraoperative UTI, such as those with previous urological surgery, should receive prophylactic antibiotics before any surgical procedure.4 The ACP states that patients suspected of having a symptomatic UTI and who have a history of dysuria or frequent urination should be treated with the appropriate therapeutic antibiotic once the infectious agent has been identified via urine culture.
Currently, suspected UTI is diagnosed via urine culture, which requires time and appropriate sterile resources for an accurate culture result.5 Diagnosis of UTI can also be made via macroscopic and microscopic urinalysis, although species identification is not possible with urinalysis alone. Macroscopic urinalysis uses whole urine and detects the presence of the enzyme leukocyte esterase, an indication of infection, or nitrites, suggesting the presence of bacteria. Microscopic urinalysis inspects the centrifuged cellular content of the urine, counts erythrocytes and leukocytes if present, and detects the presence of bacteria.6

Pitfalls

  1. The culturing of “dirty” urine catches often reveals the presence of bacteria but tends to show mixed growth.
  2. The color of the nitrite or leukocyte esterase strip on dipstick testing can change with time, so the results must be quickly assessed so that a more quantitative and less qualitative interpretation can be accomplished.
The AAOS recommends a prophylactic 500-mg dose of ciprofloxacin 1 hour prior to surgery to help prevent UTI and further complications for patients with increased comorbid-based risk for PJI, such as immunocompromised patients or those with inflammatory arthropathies.7 For the treatment of UTI, several common antibiotic regimens can be used, including β-lactams, such as amoxicillin or cephalosporin, or trimethoprim-sulfamethoxazole 129(TMP-SMX). The typical duration of treatment ranges from three days for TMP-SMX to a week for a β-lactam antibiotic.8,9
At the Rothman Institute, a preoperative urinalysis is performed for each patient undergoing knee or hip arthroplasty. The laboratory automatically performs a culture on the urine specimen if the urinalysis is suspicious for infection. For example, a positive leukocyte esterase, elevated leukocyte count, and nitrites found on urinalysis should prompt culturing of the urine specimen. This approach reduces the common finding of contaminated urine specimens from “dirty” catches with mixed organisms and fewer than 10,000 leukocytes.
True positive urine cultures should be treated with oral antibiotics, and joint arthroplasty can proceed if treatment has commenced. Once in the hospital, the patient usually is not evaluated with urinalysis or urine culture unless he or she complains of urological pain or dysuria or is febrile. Appropriate antibiotics are given once an infectious agent is identified if a urine culture indicates the presence of UTI. Currently, no specific clinical guidelines for canceling surgery at Rothman Institute are available. Each case is evaluated individually. Certainly, significant and untreated UTIs may be an indication to postpone joint arthroplasty.
 
Controversies
Although the minimal level of bacteriuria required to diagnose and treat UTI has not been identified in the literature or microbiological laboratories, the commonly used threshold is 105 colony-forming units (CFU)/ml of urine.10 However, some sources suggest that as little as 102 CFU/ml of urine may be indicative of UTI in occasional situations and should not necessarily be dismissed as contaminant.11 Although low bacterial concentrations (102 CFU/ml) may be indicative of bacteriuria and 130subsequent UTI in rare situations, however, the physician should best determine whether UTI is a true clinical concern and how to optimally manage the patient, depending on the infectious agent, the presence or absence of symptoms, and the method used for urine culture.
Although less expensive and more rapid than urine culture, urinalysis for the diagnosis and clinical determination of bacteriuria and UTI can be complicated. The detection of nitrites in a urine sample can indicate bacteriuria, but this test does not have a high specificity and is less accurate in identifying Gram-positive organisms than Gram-negative bacteria. An accurate dipstick test also has a temporal dimension. The color of the nitrite or leukocyte esterase can change with time; therefore, results must be quickly assessed so a more quantitative and less qualitative interpretation can be accomplished. When clinical history and presentation suggest the presence of infection but the urine culture is negative, studies have shown that urinalysis can be most effective in ruling out UTI, especially when the dipstick test concurs with the microscopic urinalysis.12
Whereas older literature suggests that bacteriuria increases the risk for surgical wound infection and possibly deep PJI,13 more recent studies have found no correlation exists between preoperative UTI and deep wound infection following knee or hip arthroplasty, although these studies are often underpowered.14 This lack of correlation continues the ongoing debate over whether surgery should be postponed in patients with bacteriuria prior to their scheduled knee or hip arthroplasty. Nonetheless, common practice is to start an oral antibiotic upon detection of bacteriuria prior to surgery.131
 
References
  1. Gupta K, Trautner B. In the clinic. Urinary tract infection. Ann Intern Med. 2012;156(5):ITC3-1-ITC3-15.
  1. Pulido L, Ghanem E, Josh A, Purtill JJ, Parvizi J. Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res. 2008; 466(7):1710–5.
  1. Holtom P, Leveillee RJ, Patzakis MJ, Sharlip ID; Wiedel JD, Wolf JS Jr. Antibiotic prophylaxis for urological patients with total joint replacements. AAOS/AUA Advisory Statement, 2002.
  1. Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM; Infectious Diseases Society of America. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005;40:643–54.
  1. Nicolle LE. Catheter related urinary tract infection. Drugs Aging. 2005;22:627–39.
  1. Lachs MS, Nachamkin I, Edelstein PH, Goldman J, Feinstein AR, Schwartz JS. Spectrum bias in the evaluation of diagnostic tests: lessons from the rapid dipstick test for urinary tract infection. Ann Intern Med. 1992;117:135–40.
  1. Antibiotic prophylaxis for surgery. Med Lett. 2006;4(52):83–8.
  1. Little P, Moore MV, Turner S, et al. Effectiveness of five different approaches in management of urinary tract infection: randomised controlled trial. BMJ. 2010;340:c199.
  1. Rehmani, R. Accuracy of the urine dipstick test to predict urinary tract infections in the emergency department. J Ayub Med Coll Abbottabad. 2004;16(1):4–7.
  1. EAU (European Association of Urology) Guidelines on Urological Infections. European Association of Urology, 2010.
  1. Maderazo EG, Judson S, Pasternak H. Late infections of total joint prostheses: a review and recommendations for prevention. Clin Orthop Relat Res. 1988;229:131–42.
  1. Talan DA, Stamm WE, Hooton TM, et al. Comparison of ciprofloxacin (7 days) and trimethoprim sulfamethoxazole (14 days) for acute uncomplicated pyelonephritis in women: a randomized trial. JAMA. 2000;283:1583–90.132
  1. Koulovaris P, Sculco P; Finerty E, Sculco T, Sharrock, NE. Relationship between perioperative urinary tract infection and deep infection after joint arthroplasty. Clin Orthop Relat Res. 2009; 467(7):1859–67.
  1. Glynn M, Sheehan J. The significance of asymptomatic bacteriuria in patients Undergoing hip/knee arthroplasty. Clin Orthop Relat Res. 1984;185:151–4.

Irrigation Solutions in Total Joint Arthroplastychapter 17

Glenn J Kerr
 
Current Evidence

Rothman Institute Current Practices

  1. Irrigation with dilute povidone-iodine (Betadine), 3.5 ml/L, following placement of primary components.
  2. Irrigation and debridement of infected joints with a minimum of 9 L of saline.
No clear standards are established for the type of irrigation solution to be used for primary and revision total joint arthroplasty. Evidence for different solutions is largely based on bench work and trauma literature evaluating irrigation solutions for open fractures.1–6 Current literature would favor the use of either saline irrigation or povidone-iodine irrigation over solutions mixed with antibiotics, detergents, or other caustic agents.5,7 A cohort-based prospective study demonstrated a significant decrease in hip and knee arthroplasty infection during the first 90 days, using dilute povidone-iodine (Betadine) to soak wounds for a 3-minute period.7 This has also been supported in the spine and general surgery literature.8,9 Basic science research suggests chlorhexidine is the most effective solution for irrigation of titanium implants infected with methicillin-resistant Staphylococcus aureus.10 Unfortunately, this solution may be damaging to 134surrounding tissue when used in vivo, and further research is required.11 Other solutions such as hydrogen peroxide have been evaluated and noted to have a corrosive effect on titanium implants.12 Very little evidence supports the use of various antibiotic additives to irrigation solution for either primary or revision surgery.3,5 Table 17.1 contains a list of popular solution additives.
Table 17.1   Irrigation solutions used in total joint arthroplasty
Irrigations Solution
Pros
Cons
Povidine-iodine
Inexpensive
Effective against MRSA
Readily available in most ORs
Toxic to fibroblasts and osteoblasts at higher concentrations
Chlorhexidine
Broad spectrum bactericidal effect for skin preparation and with titanium implant
No validated orthopedic studies demonstrating safety in vivo. Case reports demonstrating cellular toxicity
Bacitracin/Neomycin/Polymixin + neomycin
No cellular or tissue toxicity has been demonstrated
Mixed results, with the majority of literature demonstrating lack of efficacy
Sodium hypochlorite (Dakin's solution)
Highly effective bactericidal agent
Paucity of support in the literature for arthroplasty application
Demonstrated toxicity at concentrations > 1/100135
Hydrogen peroxide
Highly effective bactericidal agent
Corrosive effect on titanium implants
Cellular toxicity
Castile soap
Nontoxic to surrounding tissue
As effective as saline controls
Some studies have demonstrated a superior effect to other solutions
Nonsterile delivery system
Absent support in the literature for use in arthroplasty cases
The delivery method of irrigation solutions either by bulb syringe or by pulsatile lavage has also been examined, along with the type of irrigant used. Anglen et al13 demonstrated 100-fold increase in bacterial removal from metallic implants with the use of power irrigation instead of bulb syringe. The same study failed to demonstrate that adding antibiotics to the solution had any value in decreasing the bioburden. In a laboratory study evaluating low-pressure versus high-pressure lavage on infected canine tibiae, it was found that low-pressure lavage may be superior to high-pressure lavage.6 The stated rationale behind choosing low-pressure over high-pressure lavage is to decrease tissue damage and cause less dispersion of bacteria into noncontaminated areas. The application in joint arthroplasty is unclear, and powered lavage (high or low pressure) is recommended over lavage with a bulb syringe.
 
Controversies
  • Solutions containing antibiotics have not been effective according to the current literature, and although 136routinely used in orthopedic surgery, these additives are not supported by current available evidence for irrigation in primary or revision arthroplasty cases.
  • Soaps have met with mixed success in the trauma literature but have no demonstrated efficacy in arthroplasty cases and currently lack sterile delivery systems, which limits their application.3–5,10
  • Irrigation solutions used in general surgery are often applied to total joint arthroplasty, and some may affect bone in growth or wound healing. These solutions should be used with caution.1,2,5,9,11
 
References
  1. Kaysinger KK, Nicholson NC, Ramp WK, Kellam JF. Toxic effects of wound irrigation solutions on cultured tibiae and osteoblasts. J Orthop Trauma. 1995;9(4):303–11.
  1. Lineaweaver W, McMorris S, Soucy D, Howard R. Cellular and bacterial toxicities of topical antimicrobials. Plast Reconstr Surg. 1985;75(3):394–6.
  1. Anglen JO. Comparison of soap and antibiotic solutions for irrigation of lower-limb open fracture wounds. A prospective, randomized study. J Bone Joint Surg Am. 2005;87(7):1415–22.
  1. Conroy BP, Anglen JO, Simpson WA, et al. Comparison of castile soap, benzalkonium chloride, and bacitracin as irrigation solutions for complex contaminated orthopedic wounds. J Orthop Trauma. 1999;13(5):332–7.
  1. Crowley DJ, Kanakaris NK, Giannoudis PV. Irrigation of the wounds in open fractures. J Bone Joint Surg Br. 2007;89(5):580–5.
  1. Bhandari M, Adili A, Schemitsch EH. The efficacy of low-pressure lavage with different irrigating solutions to remove adherent bacteria from bone. J Bone Joint Surg Am. 2001;83-A(3):412-9.
  1. Brown NM, Cipriano CA, Moric M, Sporer SM, Della Valle CJ. Dilute Betadine lavage before closure for the prevention of acute postoperative deep periprosthetic joint infection. J Arthroplasty. 2012;27(1):27–30.137
  1. Cheng MT, Chang MC, Wang ST, Yu WK, Liu CL, Chen TH. Efficacy of dilute Betadine solution irrigation in the prevention of postoperative infection of spinal surgery. Spine. 2005;30(15):1689–93.
  1. Chundamala J, Wright JG. The efficacy and risks of using povidone-iodine irrigation to prevent surgical site infection: an evidence-based review. Can J Surg. 2007;50(6):473–81.
  1. Schwechter EM, Folk D, Varshney AK, Fries BC, Kim SJ, Hirsh DM. Optimal irrigation and debridement of infected joint implants: an in vitro methicillin-resistant Staphylococcus aureus biofilm model. J Arthroplasty. 2011;26(suppl 6):109–13.
  1. Douw CM, Bulstra SK, Vandenbroucke J, Geesink RG, Vermeulen A. Clinical and pathological changes in the knee after accidental chlorhexidine irrigation during arthroscopy. Case reports and review of the literature. J Bone Joint Surg Br. 1998;80(3):437–40.
  1. Shigematsu M, Kitajima M, Ogawa K, Higo T, Hotokebuchi T. Effects of hydrogen peroxide solutions on artificial hip joint implants. J Arthroplasty. 2005;20(5):639–46.
  1. Anglen JO, Apostoles S, Christensen G, Gainor B. The efficacy of various irrigation solutions in removing slime-producing Staphylococcus. J Orthop Trauma. 1994;8(5):390–6.138

Bone Cement and Antibioticschapter 18

Claudio Diaz-Ledezma
 
Current Evidence
 
Rationale for Antibiotic-Impregnated Bone Cement Use
The use of antibiotic-impregnated bone cement (AIBC) in total joint arthroplasty (TJA) may be separated into two categories: (1) prophylaxis of periprosthetic joint infection (PJI) and (2) treatment of PJI. Although the use of AIBC is well accepted in PJI treatment, its use as a preventive intervention remains controversial with regard to possible emergence of bacterial resistance and cost-effectiveness.

Rothman Institute Current Practices

  1. AIBC is often used in primary procedures.
  2. Two-stage revision is used for the majority of PJIs.
  3. Vancomycin, 3 g, and tobramycin, 3.6 g, in 40 g of PMMA (PALACOS R®, Zimmer) are the most common combinations for spacers.
  4. THA reimplantation is performed with noncemented components in most cases. TKA reimplantation is performed with AIBC fixation whenever possible.
Polymethyl methacrylate (PMMA), or bone cement, is effective for delivering antibiotics locally in bone and joint infections.1 Antibiotics are eluted from the cement surface, pores, and microcracks.2 Successful use of antibiotics with PMMA depends on (1) stability during the exothermic 140reaction of cement curing; (2) antibiotic capability to diffuse in water; (3) low allergenic potential;2 (4) possibility of combined use with other antibiotics; and (5) ideally, a sustained antibiotic release over time.
 
Suitable Antibiotics for Use in PMMA
Different antibiotics can be mixed with PMMA. Examples include the following : gentamicin, tobramycin, cefuroxime,3 vancomycin, piperacillin/tazobactam,4 and clindamycin.5 Potentially, other antibiotics can be added to PMMA: cefazolin, ciprofloxacin, gatifloxacin, levofloxacin, linezolid, and rifampin.6 An animal model compared different combinations: cefazolin (Ancef; 4.5 g/40 g cement powder), ciprofloxacin (Cipro; 6 g/40 g powder), clindamycin (Cleocin; 6 g/40 g powder), ticarcillin (Ticar; 12 g/40 g powder), tobramycin (Nebcin; 9.8 g/40 g powder), and vancomycin (Vancocin; 4 g/40 g powder). Clindamycin, vancomycin, and tobramycin demonstrated the best elution into bone and granulation tissue.7
Manufactured AIBCs approved by the Food and Drug Administration (FDA) and commercially available in the United States are presented in Table 18.1. It is necessary to remark that the FDA has approved it only for second stage reimplantation after an eliminated infection.
The technique for hand-mixed AIBC is detailed in Figures 18.1A to F.
The antibacterial properties of AIBC depend on various factors, namely, the type of antibiotic used, the organism, and so forth. Some of these factors are under the surgeon's control (e.g. the use of a vacuum system in the mixing process).
 
AIBC in Primary Cemented TJA
Evidence from registry data supports the use of AIBC in primary cemented TJA.8 Despite this, it has not become the standard of care.9141
Table 18.1   AIBC (including spacers) in premarket notification
Product
Company
Approval Date
510 (K) Number
Antibiotic
PALACOS R Bone Cement with Gentamicin
Biomet
12/17/2003
K030086
Gentamicin
SmartSet GHV Gentamicin Bone Cement
DePuy Orthopedics
2/5/2004
K033563
Gentamicin
VERSABOND AB Bone Cement
Smith & Nephew
4/29/2004
K022688
Gentamicin
Cemex Genta Bone Cement; Cemex Genta System Bone Cement
Exactech
5/10/2004
K033596
Gentamicin
Refobacin—PALACOS G
Heraeus Kulzer
5/25/2004
K031673
Gentamicin
Modification to Depuy 1 Gentamicin Bone Cement and SmartSet GMV Endurance Gentamicin Bone Cement
DePuy Orthopaedics
7/1/2004
K041656
Gentamicin
SmartMix Pre-filled Mixing System
DePuy Orthopedics
10/22/2004
K042591
Gentamicin
PALACOS LV+G
Heraeus Kulzer
7/7/2005
K050854
Gentamicin
Palamed G
Heraeus Kulzer
7/7/2005
K050855
Gentamicin142
DePuy CMW 1 Gentamicin Bone Cement
DePuy Orthopaedics
11/22/2005
K053002
Gentamicin
SmartMix Cemvac Pre-filled with SmartSet HV Bone Cement
DePuy Orthopaedics
1/6/2006
K053445
Gentamicin
DePuy CMW 2 and CMW 3 Gentamicin Bone Cement
DePuy Orthopaedics
6/8/2006
K061144
Gentamicin
Simplex P SpeedSet with Tobramycin Bone Cement
Howmedica Osteonics
2/26/2007
K063857
Tobramycin
SmartSet GMV Gentamicin Bone Cement
DePuy Orthopaedics
5/14/2008
K081163
Gentamicin
Cobalt MV with Gentamicin (AKA Cobalt G-MV) Bone Cement
Biomet.
10/27/2009
K092150
Gentamicin
Cemex Genta System and Genta System Fast
Tecres S.P.A.
11/24/2009
K092773
Gentamicin
Spacer-K, Spacer-G, Spacer-S
Tecres S.P.A.
9/20/2011
K101356
Gentamicin
510(k) Database by the FDA. Available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm?start_search=1&Panel=&ProductCode=MBB&KNumber=K&Model=&Applicant=&DeviceName=&Type=&ThirdPartyReviewed=off&ClinicalTrials=off&ExpeditedReview=&Decision=&DecisionDateFrom=&DecisionDateTo=&IVDProducts=off&CombinationProducts=off&PAGENUM=25. Accessed March 13, 2012.
According to a Markov model published 143by Cummins et al,10 the use of AIBC is cost-effective when the treated population is young (< 71 years) and the cost of the cement is low (< $650 US). They also reported that if the use of antibiotic-impregnated bone cement does not reduce the risk of deep infection by at least 70%, it is no longer a cost-effective intervention.10
Figures 18.1A to D: Antibiotic-loaded bone cement (ALBC) preparation. (A) Materials used for cement ALBC preparation. In our institution, our choice is 40 g of cement (1 pack) + vancomycin (3 g) + tobramycin (2.4 g). Usually, for a knee spacer, we use 3 packs of cement. (B) Open the cement powder sachet in a plastic bowl, using sterile technique. (C) An external assistant opens and adds the antibiotic powder to the plastic bowl. (D) Add the polymer liquid content to the antibiotic/cement powder mix
144
Figures 18.1E and F: (E) Mix the powder and polymer to achieve a uniform consistency. Take into account that time of application and setting differs between vacuum technique and manual mixing technique (see cement provider specifications). (F) Finish the mixing process by hand. The result should be a green homogeneous dough, which can be molded when it no longer adheres to the surgical gloves
In 1 report investigating AIBC use in primary THA, it was found to decrease the infection rate by approximately 50%.11 In primary TKA, the evidence supports AIBC use, especially in diabetics.3,12 Reports also show no benefit to using AIBC in primary TJA.13,14 McDonald et al are conducting a randomized controlled trial comparing the use of Simplex P with Tobramycin versus Simplex P in 8,800 patients with primary TKA (Study NCT01079559; http://clinicaltrials.gov/ct2/show/record/NCT01079559) to provide evidence about risk of infection after six weeks and 3, 12, and 24 months postoperatively. One of the secondary endpoints is cost-effectiveness. The results of this trial probably will generate more solid evidence.145
 
AIBC for PJI Treatment
The use of AIBC is advocated by most authors, both in one-stage and in two-stage revisions for PJI. In one-stage revisions, the antibiotic added to PMMA depends on the organism profile (after determination of antibiotic resistance).15 For two-stage revision, AIBC can be inserted as a spacer (static or articulated) or beads. The use of spacers has better interim and post-reimplantation performance,16 and is the most commonly recommended practice (although it has been reported that beads elute greater amount of antibiotics).17 Most surgeons at the Rothman Institute use PALACOS (Zimmer) cement, as it offers a more effective vehicle for local drug delivery.18

Pitfalls

  1. A great proportion of antibiotic-impregnated PMMA preparations currently used are “off-label”.
  2. No global consensus has been reached regarding the use of antibiotic-impregnated PMMA in primary procedures.
  3. The evidence of cemented fixation for reimplantation procedure using the potential advantage of antibiotic is not conclusive.
Different ways to fashion a spacer, both commercial and handmade, are available. Anagnostakos et al19 advise the following: (1) Commercial spacers appear to be superior to handmade spacers; (2) if the surgeon wants to use a combination of aminoglycoside and glycopeptide, the latter must be added at a higher dose owing to its inferior release characteristics; and (3) the total dose of the two antibiotics must not exceed 10% of the PMMA by weight to maintain the spacer's mechanical properties.19
For the reimplantation procedure in two-stage revisions, the surgeon must decide between a cemented 146or noncemented fixation, keeping in mind the possibility of adding local antibiotic protection. Although no definite evidence has been published, existing data support a good eradication rate with the use of noncemented implants in THA.20 However, in reimplantation following two-stage revisions of previously infected hips, AIBC has been shown to lower infection rates by approximately 40%.11 Similarly, in TKA, the current evidence is in favor of using AIBC at reimplantation surgery.21
 
Disadvantages of Routine Use of AIBC
Some disadvantages have been reported: (1) lower mechanical properties of PMMA when antibiotics are added;22 (2) acute renal failure;23 and (3) hypersensitivity reactions.4
Springer et al26 demonstrated that high doses of vancomycin and gentamicin in cement spacers for infected TKA (average total dose of 10.5 g of vancomycin [range, 3-16 g] and 12.5 g of gentamicin [range, 3.6–19.2 g]) were safe in a sample of 34 patients, with no major systemic side effects. At our institution, however, there have been some cases of systemic toxicity with the use of antibiotic spacers. This problem may relate to the use of Palacos, with better elution properties than Simplex, at our institution. Our series includes all comers with some patients having impaired renal function who may be more prone to this problem.
Antibiotic resistance is a major concern.22 Vancomycin should not be used as a primary agent for prophylaxis because of the potential emergence of resistant organisms.24
 
Controversies
  • Two antibiotics (gentamicin and tobramycin) have been approved by the FDA for commercial combination with PMMA. The use of other antibiotics is called “off-label”.147
  • The use of vacuum technology to mix antibiotics and PMMA appears to be superior to hand mixing for some commercial brands.25
  • The use of AIBC in primary procedures is supported by the international registry data. Geographic variations in the use of this modality are observed; it does not correspond to the standard of care in 2012.
  • No conclusive evidence for the best fixation modality in the second stage (reimplantation) after THA infections has been published. The use of noncemented fixation lacks the possibility of local antibiotic protection. In the reimplantation surgery of TKA, the use of AIBC appears to be a reasonable management.
 
References
  1. Wenke JC, Owens BD, Svoboda SJ, Brooks DE. Effectiveness of commercially-available antibiotic-impregnated implants. J Bone Joint Surg Br. 2006;88(8):1102–4.
  1. Jaeblon T. Polymethyl methacrylate: properties and contemporary uses in orthopedics. J Am Acad Orthop Surg. 2010;18(5):297–305.
  1. Chiu FY, Chen CM, Lin CF, Lo WH. Cefuroxime-impregnated cement in primary total knee arthroplasty: a prospective, randomized study of three hundred and forty knees. J Bone Joint Surg Am. 2002;84-A(5):759-62.
  1. Song EK, Seon JK, Jeong MS. Delayed-type hypersensitivity reaction to piperacillin/tazobactam in a patient with an infected total knee replacement. J Bone Joint Surg Br. 2010;92:1596–9.
  1. Fink B, Vogt S, Reinsch M, Buchner H. Sufficient release of antibiotic by a spacer six weeks after implantation in two-stage revision of infected hip prostheses. Clin Orthop Relat Res. 2011;469(11):3141–7.
  1. Anguita-Alonso P, Rouse MS, Piper KE, Jacofsky DJ, Osmon DR, Patel R. Comparative study of antimicrobial release kinetics from polymethyl methacrylate. Clin Orthop Relat Res. 2006;445:239–44.148
  1. Adams K, Couch L, Cierny G, Calhoun J, Mader JT. In vitro and in vivo evaluation of antibiotic diffusion from antibiotic-impregnated polymethyl methacrylate beads. Clin Orthop Relat Res. 1992(278):244-52.
  1. Dunbar MJ. Antibiotic bone cements: their use in routine primary total joint arthroplasty is justified. Orthopedics. 2009;32(9):ii.
  1. SooHoo NF, Lieberman JR, Farng E, Park S, Jain S, Ko CY. Development of quality of care indicators for patients undergoing total hip or total knee replacement. BMJ Qual Saf. 2011;20(2):153–7.
  1. Cummins JS, Tomek IM, Kantor SR, Furnes O, Engesaeter LB, Finlayson SR. Cost-effectiveness of antibiotic-impregnated bone cement used in primary total hip arthroplasty. J Bone Joint Surg Am. 2009;91(3):634–41.
  1. Parvizi J, Saleh KJ, Ragland PS, Pour AE, Mont MA. Efficacy of antibiotic-impregnated cement in total hip replacement. Acta Orthop. 2008;79(3):335–41.
  1. Chiu FY, Lin CF, Chen CM, Lo WH, Chaung TY. Cefuroxime-impregnated cement at primary total knee arthroplasty in diabetes mellitus. A prospective, randomised study. J Bone Joint Surg Br. 2001;83(5):691–5.
  1. Gandhi R, Razak F, Pathy R, Davey JR, Syed K, Mahomed NN. Antibiotic bone cement and the incidence of deep infection after total knee arthroplasty. J Arthroplasty. 2009;24(7):1015–8.
  1. Namba RS, Chen Y, Paxton EW, Slipchenko T, Fithian DC. Outcomes of routine use of antibiotic-loaded cement in primary total knee arthroplasty. J Arthroplasty. 2009;24(suppl 6):44–7.
  1. Sofer D, Regenbrecht B, Pfeil J. [Early results of one-stage septic revision arthroplasties with antibiotic-laden cement. A clinical and statistical analysis]. Orthopade. 2005;34(6):592–602.
  1. Hsieh PH, Shih CH, Chang YH, Lee MS, Shih HN, Yang WE. Two-stage revision hip arthroplasty for infection: comparison between the interim use of antibiotic-loaded cement beads and a spacer prosthesis. J Bone Joint Surg Am. 2004;86-A(9):1989-97.149
  1. Anagnostakos K, Wilmes P, Schmitt E, Kelm J. Elution of gentamicin and vancomycin from polymethyl methacrylate beads and hip spacers in vivo. Acta Orthop. 2009;80(2):193–7.
  1. Stevens CM, Tetsworth KD, Calhoun JH, Mader JT. An articulated antibiotic spacer used for infected total knee arthroplasty: a comparative in vitro elution study of Simplex and Palacos bone cements. J Orthop Res. 2005;23(1):27–33.
  1. Anagnostakos K, Furst O, Kelm J. Antibiotic-impregnated PMMA hip spacers: Current status. Acta Orthop. 2006;77(4):628–37.
  1. Fink B, Grossmann A, Fuerst M, Schafer P, Frommelt L. Two-stage cementless revision of infected hip endoprostheses. Clin Orthop Relat Res. 2009;467(7):1848–58.
  1. Leone JM, Hanssen AD. Management of infection at the site of a total knee arthroplasty. Instr Course Lect. 2006;55:449–61.
  1. Jiranek WA, Hanssen AD, Greenwald AS. Antibiotic-loaded bone cement for infection prophylaxis in total joint replacement. J Bone Joint Surg Am. 2006;88(11):2487–500.
  1. Dovas S, Liakopoulos V, Papatheodorou L, et al. Acute renal failure after antibiotic-impregnated bone cement treatment of an infected total knee arthroplasty. Clin Nephrol. 2008;69(3):207–12.
  1. Hanssen AD, Osmon DR. The use of prophylactic antimicrobial agents during and after hip arthroplasty. Clin Orthop Relat Res. 1999(369):124-38.
  1. Meyer J, Piller G, Spiegel CA, Hetzel S, Squire M. Vacuum-mixing significantly changes antibiotic elution characteristics of commercially available antibiotic-impregnated bone cements. J Bone Joint Surg Am. 2011;93(22):2049–56.
  1. Springer BD, Lee GC, Osmon D, Haidukewych GJ, Hanssen AD, Jacofsky DJ. Systemic safety of high-dose antibiotic-loaded cement spacers after resection of an infected total knee arthroplasty. Clin Orthop Rel Res 2004;(427):47–51.150

Blood Conservationchapter 19

Mohammad R Rasouli
 
Current Evidence
Blood conservation strategies have been developed to reduce patient exposure to allogenic blood. Transfusion of allogenic blood has been shown to adversely affect outcome in surgical patients. Blood conservation strategies can be broadly classified as preoperative, intraoperative and postoperative.
Screening patients for bleeding disorders, administration of erythropoietin and iron supplement, administration of hemostatic agents and preoperative autologous blood donation (PAD) are considered the main preoperative blood conservation strategies. Use of an intraoperative blood salvage system (cell saver), regional anesthesia, expeditious and minimally invasive operations, application of tourniquet, and acute normovolemic hemodilution are the main intraoperative blood conservation strategies. Blood salvage systems can also be used postoperatively.

Rothman Institute Current Practices

  1. Preoperative autologous blood donation is used only for patients who are at high risk of requiring post-operative transfusion.
  2. Tourniquet use is routinely employed for TKA in patients who have no evidence of peripheral vascular disease.
  3. Some surgeons use Tranexamic acid routinely in patients undergoing total joint arthroplasty. The administered dose of Tranexamic acid in our center is 15 mg/kg which is administered intravenously 20 minutes before surgery.
152
 
Minimally Invasive Techniques and Expeditious Surgery
In a systematic review, Vavken and Dorotka1 pooled data from 13 studies to investigate the benefits of minimally invasive approaches in joint replacement. They found that blood loss was significantly lower using minimally invasive approaches for both hip and knee arthroplasty. In a meta-analysis of both randomized and nonrandomized studies, Smith et al2 included 28 studies in the final analysis, and found that perioperative blood loss is significantly lower in patients undergoing hip arthroplasty that uses minimally invasive techniques. However, no significant difference was found between minimally invasive and conventional approaches with respect to total blood loss and transfusion rate.2 Expeditious joint arthroplasty may also reduce the amount of blood loss and consequently the need for allogenic blood transfusion.3
 
Tourniquet Use
Data from eight randomized controlled trials and three high-quality prospective studies on tourniquet use in total knee arthroplasty (TKA) were pooled in a meta-analysis by Tai et al.4 Their findings showed that tourniquet use in TKA does not reduce blood loss. They also showed a higher risk of thromboembolic complications.4 In another meta-analysis, Smith and Hing5 also found that using a tourniquet during TKA did not reduce blood transfusions. In contrast, another meta-analysis of 10 randomized controlled trials by Alcelik et al6 showed that application of a tourniquet during TKA does reduce blood loss without posing a greater risk for thromboembolic complications. Regarding the time of tourniquet release, 153in a meta-analysis of randomized controlled trials, Rama et al7 showed that in primary TKA, early tourniquet release for hemostasis increases the blood loss, whereas deflation of the tourniquet after wound closure will increase the risk of early postoperative complications, necessitating reoperation.
 
Tranexamic Acid

Pitfalls

  1. Use of an intraoperative blood salvage system in patients undergoing revision of a TJA is not recommended.
  2. Use of fibrin glues has disadvantages related to its cost, risk of contamination, and required availability of trained personnel.
  3. Use of tourniquet may increase risk of thromboembolic events.
  4. Oral dosing of TXA may be associated with nausea, diarrhea, and abdominal cramping. Rapid intravenous administration of TXA can cause hypotension, and there are potential concerns about increasing the risk of thromboembolic events and renal toxicity after use of TXA; however, this has not yet been definitely confirmed.17
Tranexamic acid (TXA) is a synthetic derivative of the amino acid lysine with antifibrinolytic properties,8 and it has been used widely in the field of total joint arthroplasty. It can be administered intravenously, by intra-articular injection as well as orally or by topical application. Intravenous TXA reduces amount of blood loss and need for allogenic blood transfusion in both hip and knee arthroplasty.9–11 Alshryda et al10 included 19 studies in a meta-analysis (18 studies used intravenous, one also used oral dosing, and one study evaluated topical TXA) and showed that administration of high-dose TXA (> 4 g) in TKA reduces allogenic blood transfusion. This meta-analysis also showed that there is no evidence suggesting that TXA increases the risk 154of thromboembolic complications. The role of TXA in primary total hip arthroplasty (THA) was evaluated in a meta-analysis performed by Sukei et al.11 They included 11 clinical trials. Their results showed that administration of TXA significantly diminishes blood loss and the need for allogenic blood transfusion. The pooled data analysis didn't show any increased risk of thromboembolic events, infection, or other complications. In a study by Noordin et al,12 use of TXA was associated with lower rate of transfusion in patients undergoing revision THA. Phillips et al13 also showed that the combination of intraoperative salvage and TXA is associated with a significantly lower rate of transfusion in revision THA.
Even in the setting of minimally invasive TKA,14 or use of other blood conservation strategies,15 administration of TXA has been shown to reduce the amount of blood loss and need for blood transfusion. Moreover, intra-articular injection of TXA (500 mg/5 ml TXA) can also decrease blood loss and transfusion following unilateral TKA.16
The TXA should be given preoperatively to effectively reduce blood loss and need for allogenic blood transfusion in total joint arthroplasty.17 Contraindications of TXA use are severe renal failure, active intravascular clotting, thromboembolic disorders (including previous thromboembolic stroke, myocardial infarction, or venous thromboembolism), color vision disorders, or subarachnoid bleeding.
 
Controversies
  • Although a tourniquet is used routinely in patients undergoing revision TKA, as mentioned earlier, conclusions regarding efficacy of tourniquet application in decreasing blood loss and need for allogenic blood transfusion are mixed.
  • Fibrin glue, which is also known as fibrin sealant, has been used as a hemostatic agent in various operations; 155however, its role has not yet been precisely determined in orthopedic surgeries, including joint arthroplasty.18 Fibrin sealants facilitate formation of a stable fibrin clot and subsequent hemostasis.19 Fibrin glue and platelet preparations have been used in different studies on patients undergoing joint arthroplasty. Results of studies on the efficacy of fibrin glue and platelet products in reducing blood loss and transfusion in joint arthroplasty are mixed.19 Although most studies have shown efficacy of fibrin glue as a blood conservation strategy in joint arthroplasty,20–24 some other authors failed to show a beneficial effect of these products.25
  • Safety of the second-generation fibrin sealants has improved owing to lack of animal source proteins while these products keep their hemostatic properties. Efficacy of these products has been confirmed in patients having THA or TKA.26–28
  • It has not yet been definitely determined whether minimally invasive joint replacement is able to reduce blood loss and transfusion requirements in patients undergoing joint arthroplasty.
 
References
  1. Vavken P, Dorotka R. Modeling the “minimally invasive surgery effect” in total joint replacement. Surg Innov. 2011;18:268–78.
  1. Smith TO, Blake V, Hing CB. Minimally invasive versus conventional exposure for total hip arthroplasty: a systematic review and meta-analysis of clinical and radiological outcomes. Int Orthop. 2011;35:173–84.
  1. Macaulay W, Salvati EA, Sculco TP, Pellicci PM. Single-stage bilateral total hip arthroplasty. J Am Acad Orthop Surg. 2002;10:217–21.
  1. Tai TW, Lin CJ, Jou IM, Chang CW, Lai KA, Yang CY. Tourniquet use in total knee arthroplasty: a meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2011;19:1121–30.156
  1. Smith TO, Hing CB. Is a tourniquet beneficial in total knee replacement surgery? A meta-analysis and systematic review. Knee. 2010;17:141–7.
  1. Alcelik I, Pollock RD, Sukeik M, Bettany-Saltikov J, Armstrong PM, Fismer P. A comparison of outcomes with and without a tourniquet in total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. J Arthroplasty. 2012;27:331–40.
  1. Rama KR, Apsingi S, Poovali S, Jetti A. Timing of tourniquet release in knee arthroplasty. Meta-analysis of randomized, controlled trials. J Bone Joint Surg Am. 2007;89:699–705.
  1. Dunn CJ, Goa KL. Tranexamic acid: a review of its use in surgery and other indications. Drugs 1999;57:1005–32.
  1. Ho KM, Ismail H. Use of intravenous tranexamic acid to reduce allogeneic blood transfusion in total hip and knee arthroplasty: a meta-analysis. Anaesth Intensive Care. 2003;31:529–37.
  1. Alshryda S, Sarda P, Sukeik M, Nargol A, Blenkinsopp J, Mason JM. Tranexamic acid in total knee replacement: a systematic review and meta-analysis. J Bone Joint Surg Br. 2011;93:1577–85.
  1. Sukeik M, Alshryda S, Haddad FS, Mason JM. Systematic review and meta-analysis of the use of tranexamic acid in total hip replacement. J Bone Joint Surg Br. 2011;93:39–46.
  1. Noordin S, Waters TS, Garbuz DS, Duncan CP, Masri BA. Tranexamic acid reduces allogenic transfusion in revision hip arthroplasty. Clin Orthop Relat Res. 2011;469:541–6.
  1. Phillips SJ, Chavan R, Porter ML, Kay PR, Hodgkinson JP, Purbach B, et al. Does salvage and tranexamic acid reduce the need for blood transfusion in revision hip surgery? J Bone Joint Surg Br. 2006;88:1141–2.
  1. Lin PC, Hsu CH, Chen WS, Wang JW. Does tranexamic acid save blood in minimally invasive total knee arthroplasty? Clin Orthop Relat Res. 2011;469:1995–2002.
  1. Alvarez JC, Santiveri FX, Ramos I, Vela E, Puig L, Escolano F. Tranexamic acid reduces blood transfusion in total knee arthroplasty even when a blood conservation program is applied. Transfusion. 2008;48:519–25.157
  1. Roy SP, Tanki UF, Dutta A, Jain SK, Nagi ON. Efficacy of intra-articular tranexamic acid in blood loss reduction following primary unilateral total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2012 Mar 15. [Epub ahead of print]
  1. Mahdy AM, Webster NR. Perioperative systemic haemostatic agents. Br J Anaesth. 2004;93:842–58.
  1. Patel S, Rodriguez-Merchan EC, Haddad FS. The use of fibrin glue in surgery of the knee. J Bone Joint Surg Br. 2010;92:1325–31.
  1. Thoms RJ, Marwin SE. The role of fibrin sealants in orthopaedic surgery. J Am Acad Orthop Surg. 2009;17:727–36.
  1. Gardner MJ, Demetrakopoulos D, Klepchick PR, Mooar PA: The efficacy of autologous platelet gel in pain control and blood loss in total knee arthroplasty: An analysis of the haemoglobin, narcotic requirement and range of motion. Int Orthop. 2007;31:309–13.
  1. Berghoff WJ, Pietrzak WS, Rhodes RD: Platelet-rich plasma application during closure following total knee arthroplasty. Orthopedics. 2006;29:590–8.
  1. Everts PA, Devilee RJ, Brown Mahoney C, Eeftinck-Schattenkerk M, Box HA, Knape JT, et al. Platelet gel and fibrin sealant reduce allogeneic blood transfusions in total knee arthroplasty. Acta Anaesthesiol Scand. 2006;50:593–9.
  1. Everts PA, Devilee RJ, Oosterbos CJ, Mahoney CB, Schattenkerk ME, Knape JT, et al. Autologous platelet gel and fibrin sealant enhance the efficacy of total knee arthroplasty: improved range of motion, decreased length of stay and a reduced incidence of arthrofibrosis. Knee Surg Sports Traumatol Arthrosc. 2007;15:888–94.
  1. Mawatari M, Higo T, Tsutsumi Y, Shigematsu M, Hotokebuchi T. Effectiveness of autologous fibrin tissue adhesive in reducing postoperative blood loss during total hip arthroplasty: a prospective randomised study of 100 cases. J Orthop Surg (Hong Kong). 2006;14:117–21.
  1. Lassen MR, Solgaard S, Kjersgaard AG, Olsen C, Lind B, Mittet K, et al. A pilot study of the effects of Vivostat patient-derived fibrin sealant in reducing blood loss in primary hip arthroplasty. Clin Appl Thromb Hemost. 2006;12:352–7.158
  1. Levy O, Martinowitz U, Oran A, Tauber C, Horoszowski H. The use of fibrin tissue adhesive to reduce blood loss and the need for blood transfusion after total knee arthroplasty: a prospective, randomized, multicenter study. J Bone Joint Surg Am. 1999;81:1580–8.
  1. Wang GJ, Hungerford DS, Savory CG, Rosenberg AG, Mont MA, Burks SG, et al. Use of fibrin sealant to reduce bloody drainage and hemoglobin loss after total knee arthroplasty: a brief note on a randomized prospective trial. J Bone Joint Surg Am. 2001;83-A:1503-5.
  1. Wang GJ, Goldthwaite CA Jr, Burks S, Crawford R, Spotnitz WD; Orthopaedic Investigators Group. Fibrin sealant reduces perioperative blood loss in total hip replacement. J Long Term Eff Med Implants. 2003;13:399–411.

Wound Closurechapter 20

Carl Deirmengian
 
Current Evidence
The importance of wound closure is likely the most underestimated aspect of joint arthroplasty. Given the interest and attention received by implant design, materials, approaches, alignment techniques, and new technologies, it is no surprise that wound closure has historically been a relatively uninteresting and usually undesirable aspect of surgery. However, because of the increasing awareness of infection prevention, and the emergence of several new wound closure technologies, techniques related to wound closure have received increasing and deserved recent attention. A proper wound closure after arthroplasty is necessary to avoid postoperative infection.

Rothman Institute Current Practices

  1. Layered, watertight closure with absorbable sutures is used by all arthroplasty surgeons.
  2. Final skin closure is at the discretion of the operating surgeon.
  3. Monofilament suture is used in all infected cases in effort to reduce bacterial adherence.
 
Absorbable Versus Nonabsorbable Sutures
Absorbable sutures are made of materials, usually polymeric, which can be broken down in the body enzymatically or through hydrolysis. By varying the polymeric structure, absorbable sutures can be made to retain strength for varying amounts of time after use. 160For example, Vicryl, a copolymer of glycolide and lactide, goes through a hydrolytic process, resulting in loss of 50% of its original strength by three weeks, loss of almost all strength by five weeks, and complete absorption by three months. In contrast, polydioxanone (PDS) loses about 50% of its strength by four weeks, and is completely absorbed at about six months. Absorbable sutures have the advantage of fully hydrolyzing, minimizing the chances of chronic tissue irritation and foreign body reaction. They are the most commonly used suture in arthroplasty, as they generally provide enough strength to allow for tissue healing.
Nonabsorbable sutures are used when long-term strength is necessary to ensure appropriate tissue healing. Nonabsorbable sutures are most common in arthroplasty when retention suture technique is used to approximate compromised, high-tension wounds. The main disadvantage of nonabsorbable sutures is that they will cause a foreign body reaction in tissues, often becoming encapsulated. Furthermore, a theoretical possibility exists that because they do not absorb, nonabsorbable sutures are more likely to become chronically seeded with bacteria.
Very few studies in the literature compare absorbable with nonabsorbable sutures. Al-Abdullah et al1 performed a meta-analysis of seven randomized controlled trials comparing absorbable with nonabsorbable sutures for the closure of traumatic lacerations and surgical wounds. They found no statistically significant differences between suture types when considering infection, wound dehiscence, or cosmesis.
 
Monofilament Versus Polyfilament Sutures
Monofilament sutures are made from one solid strand of material. They are smooth and pass through tissues with low friction and relative ease. Furthermore, because of their simplified external structure, monofilament sutures exhibit a relative resistance to the harboring of bacteria. 161However, many surgeons consider monofilament sutures difficult to handle. They retain significant structural memory and do not bend easily. Furthermore, given their decreased flexibility and lower friction, monofilament sutures generally require more knots to prevent slipping.
Polyfilament sutures are braided from multiple strands of suture material. This construction provides for increased tensile strength and improved flexibility. Surgeons generally prefer the handling properties of polyfilament sutures, as their increased friction and improved handling provide a perceived ease in knot tying. However, the more complex surface structure of the polyfilament suture makes it more likely to harbor bacteria. For this reason, many surgeons will avoid polyfilament suture when the surgical site is possibly infected or contaminated.
Though few studies in the literature comparing monofilament with polyfilament sutures have considered their differing propensity to harbor bacteria. Both Shuhaiber et al2 and Henry-Stanley et al3 demonstrated a statistically significant increase in bacterial adherence onto polyfilament suture when compared with monofilament suture. Biofilm formation can be observed on suture material, with 3 – 10 times greater bacterial counts found on polyfilament suture material. For this reason, many surgeons prefer to use monofilament suture for all tissue layers in the clinical setting of infection.
 
Antibiotic-Impregnated Sutures
Antibiotic-impregnated polyfilament suture has been manufactured with the hope of reducing wound infections. Vicryl Plus (Ethicon) is coated with triclosan to protect against bacterial adherence and colonization. Several in vitro4 and animal studies5,6 have shown that triclosan-coated suture is indeed able to prevent the adherence, colonization, and growth of bacteria.162
However, clinical studies evaluating the efficacy of antibiotic-coated sutures have demonstrated mixed results. Prospective randomized studies assessing the efficacy of antibiotic-coated sutures during hepatobiliary surgery7 and open abdominal surgery8 have demonstrated statistically significant reductions in the postoperative infection rate. In other studies focusing on colorectal surgery9 and cardiac surgery,10 triclosan-coated sutures were not found to alter the postoperative infection rate when compared with traditional sutures. As yet, data are insufficient to recommend the regular use of antibiotic-coated sutures for wound closure after arthroplasty.
 
Barbed Sutures
The use of running, knotless, barbed sutures has recently gained popularity in the closure of wounds after arthroplasty. Barbed sutures are manufactured to have a series of barbs protruding at an angle from the suture axis. The barbs are created to allow for tissue penetration, which prevents the suture from sliding backward within the tissue layers. Furthermore, the increased number of suture fixation points theoretically distributes the tissue tension more evenly. Advocates of barbed sutures tout its exceptional tissue manipulation capabilities and increases in operative efficiency. Opponents of barbed sutures have concerns that a running suture may compromise the integrity and durability of wound closure.
Nett et al11 utilized cadaveric knees to demonstrate with statistical significance that a bidirectional barbed suture for arthrotomy closure was more “watertight” than conventional suture. Eickmann and Quane12 retrospectively demonstrated a 10-minute decrease in operative time, with no complications, when comparing the use of bidirectional barbed suture with that of conventional suture for the closure of 178 knee arthroplasties. Levin et al13 also demonstrated the efficiency and safety of a bidirectional 163barbed suture when used to close wounds in 940 primary and revision knee arthroplasties. However, Wright et al14 suggested exercising caution, as they experienced three arthrotomy dehiscences in the first 161 primary knee arthroplasties in which barbed sutures were used.
Barbed sutures appear to have several advantages over conventional sutures, including decreased operative time, with few reports of complications in the setting of arthroplasty. It must be emphasized, though, that the use of barbed sutures requires specific alterations in closure technique that may not be obvious. It is recommended that surgeons be trained in appropriate barbed suture technique before they use these sutures during arthroplasty.

Pitfalls

  1. Failure to achieve watertight closure can lead to wound drainage, which has been linked to the development of periprosthetic joint infection.
  2. The use of bidirectional barbed suture requires a specific technique that can lead to wound dehiscence if not watched.
 
References
  1. Al-Abdullah T, Plint AC, Fergusson D. Absorbable versus nonabsorbable sutures in the management of traumatic lacerations and surgical wounds: a meta-analysis. Pediatr Emerg Care. May 2007;23(5):339–44.
  1. Shuhaiber H, Chugh T, Burns G. In vitro adherence of bacteria to sutures in cardiac surgery. J Cardiovasc Surg (Torino). 1989;30(5):749–53.
  1. Henry-Stanley MJ, Hess DJ, Barnes AM, Dunny GM, Wells CL. Bacterial contamination of surgical suture resembles a biofilm. Surg Infect (Larchmt). Oct 2010;11(5):433–9.
  1. Masini BD, Stinner DJ, Waterman SM, Wenke JC. Bacterial adherence to suture materials. J Surg Educ. 2011;68(2):101–4.
  1. Marco F, Vallez R, Gonzalez P, Ortega L, de la Lama J, Lopez-Duran L. Study of the efficacy of coated Vicryl plus antibacterial suture in an animal model of orthopedic surgery. Surg Infect (Larchmt). 2007;8(3):359–65.164
  1. Ming X, Rothenburger S, Nichols MM. In vivo and in vitro antibacterial efficacy of PDS plus (polidioxanone with triclosan) suture. Surg Infect (Larchmt). 2008;9(4):451–7.
  1. Justinger C, Schuld J, Sperling J, Kollmar O, Richter S, Schilling MK. Triclosan-coated sutures reduce wound infections after hepatobiliary surgery—a prospective non-randomized clinical pathway driven study. Langenbecks Arch Surg. 2011;396(6):845–50.
  1. Justinger C, Moussavian MR, Schlueter C, Kopp B, Kollmar O, Schilling MK. Antibacterial [corrected] coating of abdominal closure sutures and wound infection. Surgery. 2009;145(3):330–4.
  1. Baracs J, Huszar O, Sajjadi SG, Horvath OP. Surgical site infections after abdominal closure in colorectal surgery using triclosan-coated absorbable suture (PDS Plus) vs. uncoated sutures (PDS II): a randomized multicenter study. Surg Infect (Larchmt). 2011;12(6):483–9.
  1. Isik I, Selimen D, Senay S, Alhan C. Efficiency of antibacterial suture material in cardiac surgery: a double-blind randomized prospective study. Heart Surg Forum. 2012;15(1):E40–5.
  1. Nett M, Avelar R, Sheehan M, Cushner F. Water-tight knee arthrotomy closure: comparison of a novel single bidirectional barbed self-retaining running suture versus conventional interrupted sutures. J Knee Surg. 2011;24(1):55–9.
  1. Eickmann T, Quane E. Total knee arthroplasty closure with barbed sutures. J Knee Surg. 2010;23(3):163–7.
  1. Levine BR, Ting N, Della Valle CJ. Use of a barbed suture in the closure of hip and knee arthroplasty wounds. Orthopedics. 2011;34(9):e473–5.
  1. Wright RC, Gillis CT, Yacoubian SV, Raven RB III, Falkinstein Y. Extensor mechanism repair failure with use of bidirectional barbed suture in total knee arthroplasty. J Arthroplasty. 2012;27(7):1413.e1-4.

Drainschapter 21

Mohammad R Rasouli
 
Current Evidence
Surgical drains are used to prevent hematoma formation, fluid accumulation and provide egress in the case of infected wounds.1,2 Although there are several types of surgical drains available, they can be broadly categorized to open and closed suction drains. An open drain is an artificial conduit which is inserted and left in the wound to provide a port for drainage of fluids to the outside of the wound. In closed suction drains, a perforated drainage tube is inserted within the wound and connected to a drainage bottle. The pressure gradient facilitates drainage of fluids from the wound.3

Rothman Institute Current Practices

  1. Some surgeons use drains in PJI cases (both hips and knees) during revision surgery. The drain may be inserted in either superficial or deep tissues.
  2. Identifying patients who may benefit from placement of drains is based on the surgeon's judgment. As a simple rule, patients who need extensive soft tissue dissection and who are prone to the formation of wound hematoma are considered appropriate candidates for drain insertion.
  3. Drains are removed usually 24 to 48 hours after surgery.
A meta-analysis performed by Parker et al4 evaluated the effect of wound drainage in patients undergoing hip and knee arthroplasty; it analyzed 18 studies including 3495 166patients with 3689 wounds. The pooled data showed no significant difference between drained and nondrained wounds in regard to development of wound infection, formation of wound hematoma, or reoperation for wound complications. The transfusion rate was greater in patients whose wounds were treated with drains. Reinforcement of wound dressings was also required more frequently in the drained wounds. No significant difference was observed between the 2 groups with respect to limb swelling, venous thrombosis, or length of hospital stay.
Another systematic review by Parker et al3 evaluated the role of closed suction drains in orthopedic operations. In that systematic review, 36 studies with 5464 patients (5697 surgical wounds) were pooled. The results of the study failed to show a statistically significant difference between wounds managed with drains and those managed without drains in regard to the incidence of wound infection, hematoma formation, wound dehiscence, or reoperation. Similar to previous metaanalyses, this systematic review also indicated a greater blood transfusion rate in the group with drains.
In spite of these meta-analysis, controversy still exists regarding the use of drains in patients undergoing hip and knee arthroplasty. In a randomized trial, Omonbude et al5 evaluated joint effusion and hematoma in 78 patients after total knee replacement. They used ultrasound to detect joint effusion and wound hematoma on the fourth postoperative day. The results did not show a significant difference between the two groups regarding joint effusion; however, the findings indicated that drain insertion reduces hematoma formation. No wound infection was observed in either group during the six-week follow-up.
The majority of available studies have focused on primary joint replacement, and information about the efficacy and safety of drains in revision surgeries, 167particularly revisions in patients with periprosthetic joint infection (PJI), is lacking.
In summary, little evidence is available to support the routine use of drains after lower limb arthroplasty. Although, a subgroup of patients with the high probability of postoperative hematoma formation may benefit from placement of drains, no evidence-based recommendations can be made in this regard.
 
Controversies
  • The optimal time for removing the drains is not clear. Theoretically, drains should be removed when the wound drainage stops, which is usually 24 to 48 hours after insertion.1,6 However, shorter periods have been suggested by some authors.7

    Pitfalls

    1. Drains may work as a port for entrance of infection. Using a longer drain and leaving a drain in place for a longer period may increase risk of infection.
    2. Malfunction of drains can occur owing to obstruction and kinking.
    3. If the drain is left in place for a long-time, formation of granulation tissue may make drain removal difficult.
  • The role of drainage-clamping methods in reducing blood loss following joint arthroplasty is controversial. A meta-analysis of randomized controlled trials by Tai et al8 showed that temporary drainage clamping after total knee replacement can reduce the amount of drainage, but clamping should be done for at least 4 hours to reduce true blood loss. No significant differences were found with respect to the transfusion rate, postoperative range of motion, incidence of thromboembolic events, and wound complications. The authors suggested that 168no evidence supports drainage clamping. However, a recent randomized controlled trial of 100 patients who underwent total knee arthroplasty showed that using three-hour intervals for clamping can reduce postoperative bleeding.9
  • It seems that low-pressure (50 mm Hg) drains do not have any advantage over high-pressure (700 mm Hg) ones with respect to reducing blood loss following knee arthroplasty.10
 
References
  1. Walker J. Patient preparation for safe removal of surgical drains. Nurs Stand. 2007;21:39–41.
  1. Gaines RJ, Dunbar RP. The use of surgical drains in orthopedics. Orthopedics. 2008;31:702–5.
  1. Parker MJ, Livingstone V, Clifton R, McKee A. Closed suction surgical wound drainage after orthopaedic surgery. Cochrane Database Syst Rev. 2007;(3):CD001825.
  1. Parker MJ, Roberts CP, Hay D. Closed suction drainage for hip and knee arthroplasty. A meta-analysis. J Bone Joint Surg Am. 2004;86-A:1146-52.
  1. Omonbude D, El Masry MA, O'Connor PJ, Grainger AJ, Allgar VL, Calder SJ. Measurement of joint effusion and haematoma formation by ultrasound in assessing the effectiveness of drains after total knee replacement: A prospective randomised study. J Bone Joint Surg Br. 2010;92:51–5.
  1. Drinkwater CJ, Neil MJ. Optimal timing of wound drain removal following total joint arthroplasty. J Arthroplasty. 1995;10:185–9.
  1. Ares O, Seijas R, Hernandez A, Castellet E, Sallent A. Knee arthroplasty and bleeding: when to remove drainages. Knee Surg Sports Traumatol Arthrosc. 2012. [Epub ahead of print]
  1. Tai TW, Yang CY, Jou IM, Lai KA, Chen CH. Temporary drainage clamping after total knee arthroplasty: a meta-analysis of randomized controlled trials. J Arthroplasty. 2010;25:1240–5.169
  1. Pornrattanamaneewong C, Narkbunnam R, Siriwattanasakul P, Chareancholvanich K. Three-hour interval drain clamping reduces postoperative bleeding in total knee arthroplasty: a prospective randomized controlled trial. Arch Orthop Trauma Surg. 2012;132:1059–63.
  1. Calvo R, Martínez-Zapata MJ, Urrútia G, Gich I, Jordán M, Del Arco A, et al. Low- vs high-pressure suction drainage after total knee arthroplasty: a double-blind randomized controlled trial. J Adv Nurs. 2012;68:758–66.170

Postarthroplasty Antibiotic Prophylaxischapter 22

Fabio Orozco
 
Current Evidence
Postarthroplasty joint infections can occur at different time intervals. They are classified as early-onset, delayed-onset, and late-onset infections. Early-onset infection occurs within three months after surgery, delayed-onset occurs between 3 and 24 months, and late-onset occurs after 24 months. Joint infections can arise owing to direct contamination of the surgical wound or by bacteremia secondary to dental, urinary tract, skin, and soft tissue infections.1 Certain medical procedures have a high risk of causing bacteremia. This increases the threat of joint infections in patients who underwent arthroplasty. The American Academy of Orthopaedic Surgeons (AAOS) currently recommends prophylaxis in patients undergoing dental, vascular, gastrointestinal (GI), head and neck, obstetric and gynecological, and genitourinary procedures for the rest of their lives.2

Rothman Institute Current Practices

Prophylaxis, for the rest of the patient's life, with 2 g of amoxicillin or 2 g of cephalexin or 600 mg of clindamycin (if PNC allergy) 1 to 2 hours before dental procedures that place the patient at risk of bacteremia.
172
When dental prophylaxis is warranted and the patient is not allergic to penicillin (PNC), 2 g of cephalexin, cephradine, or amoxicillin can be taken orally one hour before the procedure. If the patient is not allergic to PNC but is unable to take medications orally, order 1 g of cefazolin or 2 g of ampicillin administered intramuscularly (IM) or intravenously (IV) one hour before the procedure. If the patient is allergic to PNC, order 600 mg of clindamycin to be administered orally or IV one hour before the procedure. The following are dental procedures considered to increase the risk of bacteremia: dental extractions, periodontal procedures, dental implant placement and replantation of avulsed teeth, endodontic instrumentations or surgery only below the apex, initial placement of orthodontic bands but not brackets, intraligamentary and intraosseous local anesthetic injections, and prophylactic cleaning of teeth or implants during which bleeding may occur.2,3
The AAOS also states the following recommendations. Patients undergoing vascular surgery should receive a dose of cefazolin 1 to 2 g IV or vancomycin 1 g IV an hour before the start of the procedure. Patients undergoing orthopedic surgery should receive a dose of cefazolin 1 to 2 g IV, cefuroxime 1.5 g IV, or vancomycin 1 g IV one hour before the procedure. Patients undergoing esophageal, gastroduodenal, or biliary tract procedures should receive a dose of cefazolin 1 to 2 g IV one hour before the start of the procedure. Patients undergoing colorectal surgery should receive 1 g of metronidazole. The AAOS recommends a GI consult to determine the start of antibiotics before any colorectal procedure. In procedures involving the head and neck, a dose of cefazolin 1 to 2 g IV or clindamycin 600 to 900 mg IV with gentamicin 1.5 mg/kg IV should be given one hour before the procedure. In patients undergoing obstetric and gynecological procedures, patients should receive a dose of cefoxitin 1 to 2 g IV, cefazolin 1 to 2 g IV, or ampicillin/sulbactam 3 g IV one hour before the procedure. 173Finally, the AAOS recommends in patients undergoing genitourinary procedures one dose of ciprofloxacin 500 mg by mouth or 400 mg IV one hour before the start of the procedure.2
 
Controversies
In 2003, the American Dental Association (ADA) and AAOS shared the same recommendations for antibiotic prophylaxis. The AAOS changed its recommendations in 2011, but the ADA continued to follow the same guidelines. The ADA recommends that all patients who have undergone arthroplasty receive, within the first two years, antibiotic prophylaxis before dental procedures that carry high risk of bacteremia. After two years, prophylaxis is indicated only in patients who are immunocompromised, have had previous prosthetic joint infections, are considered malnourished, and have a medical history of hemophilia, insulin-dependent diabetes, and malignancy.3 The ADA states that the AAOS has no clinical evidence to support the lifelong use of antibiotics for all postarthroplasty patients. It argues that the continued use of antibiotics may lead to increased resistance among the population.4
The American Society for Gastrointestinal Endoscopy does not recommend antibiotic prophylaxis in postarthroplasty patients undergoing GI endoscopic procedures. The society states that only two cases of pyogenic arthritis were reported in their review of studies and concluded that prosthetic joint infections are extremely rare.5
 
References
  1. Shurman EK, Urquhart A, Malani P. Management and prevention of prosthetic joint infection. Infect Dis Clin North Am 2012;26(1):29–38.174
  1. American Academy of Orthopaedic Surgeons. Information Statement: Antibiotic prophylaxis for bacteremia in patients with joint replacements. Available at: www.aaos.org/about/papers/advistmt/1033.asp. Accessed March 31, 2012.
  1. Antibiotic prophylaxis for dental patients with total joint replacements. American Dental Association and American Academy of Orthopaedic Surgeons. J Am Dent Assoc. 2003;134;895–8.
  1. Garg A. Debate rages over antibiotic prophylaxis in patients with total joint replacements. Dent Implantol Update. 2011;22(5):33–5.
  1. Banerjee S, Shen B. Antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc. 2008;67(6):791–8.
Section 3
175Diagnosis
Carlos A Higuera

AAOS Clinical Practice Guidelines: Diagnosis of Periprosthetic Joint Infections in Hip and Kneechapter 23

Carlos A Higuera,
Javad Parvizi
 
Summary
In June 2010, the American Academy of Orthopaedic Surgeons (AAOS) released its clinical practice guidelines to diagnose periprosthetic joint infection (PJI).1 These guidelines are based on a systematic review of the published literature ranging from 1970 to August 2009. They were developed to improve clinical practice, using evidence-based recommendations. This evidence was selected and analyzed using the AAOS Clinical Practice Guidelines.

Rothman Institute Current Practices

The AAOS recommendations for diagnosing PJI are followed at the Rothman Institute.
By no means are these guidelines designed to replace clinical judgment, and each patient should be 178evaluated and treated according to the individual situation. These guidelines are designed to be updated every five years.
The following recommendations were made for the diagnosis of PJI:

Pitfalls

Clinical judgment is paramount in using these clinical guidelines. The clinical guidelines establish a simple and concise workflow to diagnose PJI.
Recommendation 1: In the absence of reliable evidence about risk stratification of patients with a potential PJI, it is the opinion of the work group that testing strategies be planned according to whether there is a higher or lower probability that a patient has PJI. (Strength of recommendation: Consensus)
Recommendation 2: Test erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels to assess patients with PJI. When both the ESR and CRP level are negative, PJI is unlikely (negative likelihood ratio 0 to 0.06). When both tests are positive, PJI must be considered (positive likelihood ratio 4.3 to 12.1), and this result warrants further investigation. These tests are highly sensitive (> 90%) in ruling out PJI. Unfortunately, other inflammatory conditions or infections may elevate these markers and cause false-positive results for PJI. The specificity of these tests to diagnose PJI is low. (Strength of recommendation: Strong)
Recommendation 3: Perform knee aspiration in patients with abnormal ESR and/or CRP level results. The aspirated fluid should be sent for microbiologic culture, synovial fluid white blood cell (WBC) count, and differential WBC count. Studies suggest that either a synovial fluid WBC count higher than1700 cells/μL (range, 1100–3000 cells/μL) or a neutrophil percentage higher than 65% (range, 64–80%) is highly suggestive of chronic periprosthetic 179infection.2–4 In the case of an acute infection, a threshold for WBC count was not determined at that time. (Strength of recommendation: Strong)
Recommendation 4: Use a selective approach to aspirate the hip based on the patient's probability of PJI and the results of the ESR and CRP levels. The aspirated fluid should be sent for microbiologic culture, synovial fluid WBC count, and differential WBC count. There was no reliable evidence at that time on the diagnostic performance of hip aspirations in patients who were not undergoing reoperation, and the hip aspirations increased the risk of potential false-positive results, the possibility of introducing bacteria into the joint during the procedure, and patient pain or discomfort during the procedure. Therefore, universal hip aspiration was not indicated. Aspiration was indicated only when ESR and/or CRP levels were elevated regardless of the probability of PJI. (Strength of recommendation: Strong)
Recommendation 5: Repeat hip aspiration when a discrepancy exists between the probability of PJI and the initial aspiration culture result. Currently, the use of synovial WBC count and differential may aid in the diagnosis of PJI in these situations. (Strength of recommendation: Moderate)
Recommendation 6: Re-evaluate for infection within 3 months when there is a lower probability of PJI in hip arthroplasty patients who do not have planned reoperation and who do have abnormal ESR or abnormal CRP levels. If the patient is asymptomatic, further testing may be unnecessary. (Strength of recommendation: Consensus)
Recommendation 7: Repeat knee aspiration when there is discrepancy between the probability of PJI and initial aspiration culture results. If the probability of PJI is low and the initial cultures are positive, or if the probability of PJI is high and the initial cultures are negative, a repeat 180knee aspiration is warranted. The use of synovial WBC count and differential may aid in diagnosing PJI in these situations. (Strength of recommendation: Consensus)
Recommendation 8: Patients should discontinue taking antibiotics at least two weeks prior to obtaining intraarticular cultures. Although the exact antibiotic-free time needed to allow washout of antibiotics from systemic circulation and the joint is not known, the work group has accepted two weeks as the minimum time required. (Strength of recommendation: Moderate)
Recommendation 9: Nuclear imaging (labeled-leukocyte imaging combined with bone or bone marrow imaging, F-18 fluorodeoxyglucose-positron emission tomography [FDG-PET] imaging, gallium imaging, or labeled-leukocyte imaging) is an option in patients in whom diagnosis of PJI has not been established and who are not scheduled for reoperation. Patients in whom diagnosis of infection has not been established include those with a higher probability of infection who have abnormal ESR and/or CRP levels but whose aspiration results are inconclusive. (Strength of recommendation: Weak)
Recommendation 10: Unable to recommend for or against CT or MRI for the diagnosis of PJI. The evidence is insufficient in this matter. (Strength of recommendation: Inconclusive)
Recommendation 11: Intraoperative Gram stain should not be used in the diagnosis of PJI. Negative likelihood ratios suggest Gram stain is not a good rule-out test (LR- values > 0.5). Comparatively, negative likelihood ratios for synovial fluid WBC count and differential tests are much lower (LR- values < 0.1). Thus, Gram stain is not a useful test for ruling out PJI. (Strength of recommendation: Strong)181
Recommendation 12: Use of frozen sections of peri-implant tissues in patients who are undergoing reoperation for whom the diagnosis of PJI has not been established or excluded. The studies used to support this recommendation based the histological diagnosis of probable infection on the tissue concentration of neutrophils, usually defined by two variables: (1) the number of neutrophils in a high-magnification (400×) microscopic field, and (2) the minimum number of fields containing that concentration of neutrophils.5–7 Insufficient information exists to distinguish five from 10 neutrophils per high-power field as the best threshold needed for diagnosis. Insufficient information is available to determine the efficacy of frozen sections in patients with an underlying inflammatory arthropathy. (Strength of recommendation: Strong)
Recommendation 13: Multiple cultures should be obtained at the time of reoperation. This increases the chances of identifying infection, decreases the chances of obtaining false-negative results, and may assist in the clarification of false-positive test results. (Strength of recommendation: Strong)
Recommendation 14: Do not initiate antibiotic treatment in patients with suspected PJI until cultures from the joint are obtained. Antibiotic treatment affects the sensitivity of the cultures.8 (Strength of recommendation: Strong)
Recommendation 15: Prophylactic preoperative antibiotics should not be withheld in patients at lower probability for PJI and those with an established diagnosis of PJI who are undergoing reoperation. The studies evaluated did not address whether preoperative antibiotics interfere with intraoperative cultures. However, the important role of antibiotic prophylaxis in helping to 182prevent postoperative infection outweighs the potential risk. (Strength of recommendation: Moderate)
 
Controversies
  • Evidence has changed recently in some of these topics. More current evidence in the diagnosis of PJI is discussed in other chapters.
  • Thresholds of synovial WBC count and differential in the knee and the hip may be different from the ones proposed in these guidelines, using the new definition of PJI.
  • Thresholds of synovial WBC count and differential in inflammatory conditions are described in further chapters.
 
References
  1. Della Valle C, Parvizi J, Bauer TW, et al. Diagnosis of periprosthetic joint infections of the hip and knee. J Am Acad Orthop Surg. 2010;18(12):760–70.
  1. Della Valle CJ, Sporer SM, Jacobs JJ, Berger RA, Rosenberg AG, Paprosky WG. Preoperative testing for sepsis before revision total knee arthroplasty. J Arthroplasty. 2007;22(6 suppl 2):90–3.
  1. Ghanem E, Parvizi J, Burnett RS, et al. Cell count and differential of aspirated fluid in the diagnosis of infection at the site of total knee arthroplasty. J Bone Joint Surg Am. 2008;90(8):1637–43.
  1. Trampuz A, Hanssen AD, Osmon DR, Mandrekar J, Steckelberg JM, Patel R. Synovial fluid leukocyte count and differential for the diagnosis of prosthetic knee infection. Am J Med. 2004;117(8):556–62.
  1. Fehring TK, McAlister JA Jr. Frozen histologic section as a guide to sepsis in revision joint arthroplasty. Clinical Orthop Relat Res. 1994;(304):229–37.
  1. Ko PS, Ip D, Chow KP, Cheung F, Lee OB, Lam JJ. The role of intraoperative frozen section in decision making in revision hip and knee arthroplasties in a local community hospital. J Arthroplasty. 2005;20(2):189–95.183
  1. Schinsky MF, Della Valle CJ, Sporer SM, Paprosky WG. Perioperative testing for joint infection in patients undergoing revision total hip arthroplasty. J Bone Joint Surg Am. 2008;90(9):1869–75.
  1. Trampu z A, Piper KE, Jacobson MJ, et al. Sonication of removed hip and knee prostheses for diagnosis of infection. TN Engl J Med. 2007;357(7):654–63.184

Available Diagnostic Laboratory Testschapter 24

Vinay Aggarwal,
Alexander Brothers
 
Introduction
Diagnosis of periprosthetic joint infection (PJI) can be fraught with challenges and pitfalls, and despite best efforts, a true gold standard diagnostic test remains elusive. As such, the 2011 Musculoskeletal Infection Society (MSIS) work group devised a new definition for PJI consisting of a combination of clinical and laboratory diagnostic parameters. Many of these tests are either mainstays for current diagnosis or newer endeavors to improve diagnostic yield and will be reviewed in this and in subsequent chapters.

Rothman Institute Current Practices

  1. Check ESR (nL < 30 mm/h) and serum CRP (nL < 0.8 mg/dL) in any patient undergoing revision surgery.
  2. Do not use CBC or differential in diagnosis.
  3. Do not use Gram stain in diagnosis.
  4. We do not use intraoperative frozen sections owing to lack of pathologist experience at our institution.
 
Current Evidence
 
Erythrocyte Sedimentation Rate and C-Reactive Protein
Erythrocyte sedimentation rate (ESR) and serum C-reactive protein (CRP) have long been the initial diagnostic 186screening tools for suspected PJI, and are strongly recommended by the AAOS for initial workup.1 In addition to being cost effective and easily performed, they show hig h sensitivity for the detection of deep tissue infection, which is of great importance in the initial process of risk stratification and treatment.2
Although it is advised that the two markers be tested in combination in order to “rule out” PJI, limited evidence suggests that CRP is a more reliable indicator and perhaps better than ESR at “ruling in” infection.1,3,4 According to two of the only studies examining the combined use of ESR and CRP to diagnose PJI, the sensitivity when at least one of the tests was positive ranged from 96% to 100%, whereas the specificity when both of the tests were positive ranged from 79% to 93%.5,6 In total knee arthroplasty patients with suspected PJI, either an abnormal ESR or CRP warrants joint aspiration under AAOS guidelines.1 For patients who have undergone total hip arthroplasty, however, the algorithm after serological study becomes somewhat more complex based on whether preoperative probability of PJI is high or low and whether reoperation has already been planned.1
The shortcoming of these markers of inflammation lies in their relatively lower specificity, as they are affected by age and gender, and are frequently elevated in other concurrent inflammatory or infectious states.4,7 For example, in patients who underwent total joint arthroplasty (TJA) owing to an inflammatory arthropathy such as rheumatoid arthritis, clinicians should recognize that the diagnostic utility of serum markers ESR and CRP may be impaired because of the persistent baseline elevation in this population.7,8 Although it is well known that a variety of medical comorbidities may affect ESR and CRP, literature is scarce regarding how best to interpret serum values in this small subset of TJA patients suspected of having PJI. Furthermore, the normal thresholds of ESR 187(mm/h) and CRP (mg/dL) may vary widely between clinical laboratories, and no consensus cutoff has been reached for these values in diagnosing PJI.1
A current topic of serious interest is determining the utility of these serum markers in optimizing the timing of prosthesis reimplantation in patients undergoing two-stage exchange arthroplasty for PJI. Thus far, only a couple of studies have explored this issue, concluding that ESR and CRP are poor indicators of infection remission and do not play any role in predicting success after PJI treatment with two-stage exchange.9,10 A major reason for this deficiency is that ESR and CRP have been found to be elevated in all TJA patients for upto two months postoperatively, and thus are difficult to interpret in the acute postsurgical patient suspected of having PJI.11,12
 
White Blood Cells and Polymorphonuclear Cells
Serum white blood cell (WBC) count and polymorphonuclear cell (PMN) percentage, although useful in the diagnosis of many systemic and local infections, have been found to lack any value in the diagnosis of PJI. Elevations in serum WBC count occur in as few as 15% of patients with prosthesis-related deep joint infection and have been shown to have very low sensitivity and specificity for PJI.13,14 As such, many experts are now recommending that these parameters no longer be used to aid in the diagnosis of PJI.
 
Controversies
 
Gram Stain and Frozen Sections
Although intraoperative tests for the diagnosis of PJI maintain the theoretical advantage of allowing for real-time decisions regarding treatment strategies in the operating room, much literature has called the reliability of these tests into question. The Gram stain and frozen histological sections are two such available tests. The AAOS 188strongly recommends against the routine use of Gram stain during revision surgery to rule out PJI, based on the analysis of several studies.1,15,16 These studies have shown very poor sensitivity of less than 50% in diagnosing PJI. In contrast, the AAOS guidelines strongly recommend the use of frozen sections of peri-implant tissues in revision surgeries when the diagnosis of PJI remains uncertain at the time of surgery.1 This includes the particularly difficult cases in which prior diagnostic workup of ESR/CRP, joint aspiration culture, and synovial fluid WBC count and PMN percentage are equivocal. As mentioned previously, the rapid interpretation of these sections may aid surgeons in the operating room, especially during reimplantation procedures. The MSIS has recommended that when used, the test be considered positive if more than five neutrophils per high-power field in five high-power fields (400×) are present.17 Frozen sections can be disadvantageous, however, because not only are some institutions not equipped to perform them, but also they rely heavily on the variable interpretations of sometimes untrained pathologists.
 
References
  1. Parvizi J, Della Valle CJ. AAOS Clinical Practice Guideline: diagnosis and treatment of periprosthetic joint infections of the hip and knee. J Am Acad Orthop Surg. 2010;18(12):771–2.
  1. Spangehl MJ, Masri BA, O'Connell JX, Duncan CP. Prospective analysis of preoperative and intraoperative investigations for the diagnosis of infection at the sites of two hundred and two revision total hip arthroplasties. J Bone Joint Surg Am. 1999;81(5):672–83.
  1. Sanzén L, Carlsson AS. The diagnostic value of C-reactive protein in infected total hip arthroplasties. J Bone Joint Surg Br. 1989;71(4):638–41.189
  1. Osei-Bimpong A, Meek JH, Lewis SM. ESR or CRP? A comparison of their clinical utility. Hematology. 2007;12(4):353–7.
  1. Schinsky MF, Della Valle CJ, Sporer SM, Paprosky WG. Perioperative testing for joint infection in patients undergoing revision total hip arthroplasty. J Bone Joint Surg Am. 2008;90(9):1869–75.
  1. Greidanus NV, Masri BA, Garbuz DS, et al. Use of erythrocyte sedimentation rate and C-reactive protein level to diagnose infection before revision total knee arthroplasty. A prospective evaluation. J Bone Joint Surg Am. 2007;89(7):1409–16.
  1. Shih LY, Wu JJ, Yang DJ. Erythrocyte sedimentation rate and C-reactive protein values in patients with total hip arthroplasty. Clin Orthop Relat Res. 1987;(225):238–46.
  1. Fink B, Makowiak C, Fuerst M, et al. The value of synovial biopsy, joint aspiration and C-reactive protein in the diagnosis of late peri-prosthetic infection of total knee replacements. J Bone Joint Surg Br. 2008;90(7):874–8.
  1. Mortazavi SMJ, Vegari D, Ho A, Zmistowski B, Parvizi J. Two-stage exchange arthroplasty for infected total knee arthroplasty: predictors of failure. Clin Orthop Relat Res 2011;469(11):3049–54.
  1. Kusuma SK, Ward J, Jacofsky M, Sporer SM, Della Valle CJ. What is the role of serological testing between stages of two-stage reconstruction of the infected prosthetic knee? Clin Orthop Relat Res. 2011;469(4):1002–8.
  1. Bilgen O, Atici T, Durak K, Karaeminoğullari, Bilgen MS. C-reactive protein values and erythrocyte sedimentation rates after total hip and total knee arthroplasty. J Int Med Res. 2001;29(1):7–12.
  1. Larsson S, Thelander U, Friberg S. C-reactive protein (CRP) levels after elective orthopedic surgery. Clin Orthop Relat Res. 1992;(275):237–42.
  1. Jahoda D. Clinical strategy for the treatment of deep infection of hip arthroplasty. In: Knienapfel H, Kühn KD, eds. The Infected Implant. Berlin, Germany: Springer Medizin Verlag Heidelberg;  2009:27-42.190
  1. Toossi N, Adeli B, Rasouli MR, Huang R, Parvizi J. Serum white blood cell count and differential do not have a role in the diagnosis of periprosthetic joint infection. J Arthroplasty. 2012;(May 17). [Epub ahead of print].
  1. Ghanem E, Ketonis C, Restrepo C, et al. Periprosthetic infection: where do we stand with regard to Gram stain? Acta Orthop. 2009;80(1):37–40.
  1. Spangehl MJ, Masterson E, Masri BA, O'Connell JX, Duncan CP. The role of intraoperative Gram stain in the diagnosis of infection during revision total hip arthroplasty. J Arthroplasty. 1999;14(8):952–6.
  1. Parvizi J, Zmistowski B, Berbari EF, et al. New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res. 2011;469(11):2992–4.

Aspirationchapter 25

Pouya Alijanipour
 
Current Evidence
Aspiration of the prosthetic joint is one of the most important available diagnostic tests for investigating periprosthetic joint infection (PJI).1 According to the clinical practice guidelines of the American Academy of Orthopaedic Surgeons (AAOS), prosthetic knees should be aspirated if ESR and/or CRP levels are elevated. Given the considerable morbidity and higher false-positive results of hip aspiration, a more selective approach is recommended for suspected PJI in hips.2 Nevertheless, in both hips and knees, aspiration should be repeated if any discrepancy exists between the probability of PJI and the initial aspiration culture result.1

Rothman Institute Current Practices

  1. Hip aspiration is performed usually through an anterior approach under fluoroscopic or ultrasound guidance.
  2. Blind, unguided hip aspiration is not recommended.
 
Techniques
Several techniques for hip and knee aspiration or injection have been described. Every technique has its own advantages and risks.3 Aspiration is performed under aseptic conditions. For hip aspiration, the needle is advanced under fluoroscopic guidance, most commonly through an anterior approach. A lateral approach following standard 192arthroscopic portals can also be used.3 Local anesthetic is administered, but not too deeply, in order to avoid its probable bactericidal effect4 (potential cause for a false-negative result). Injection of any contrast should be avoided owing to its probable bactericidal activity (potential reason for a false-negative result).2 The most common approach to knee aspiration is the lateral patellofemoral approach.5 Prompt transportation of the aspirated specimen to the laboratory is vital. When delivery to the laboratory is not accomplished appropriately, it may lead to loss of sensitive bacteria like anaerobes, if they are not inoculated into the specific media immediately after the aspiration.2

Pitfalls

  1. Aspiration should not be performed through overlying cellulitis.
  2. If an organism of questionable clinical significance is isolated or if discrepancy is noted between the probability of infection and the initial aspiration culture result, repeat aspiration should be considered.
  3. False-positive aspiration despite strictly sterile conditions can occur.
  4. Patients should remain without antibiotics for at least 2 weeks before the aspiration procedure.
Dry tap is not an uncommon problem during aspiration. The best approach in this situation has yet to be defined. Recommendations in the literature include redirecting the needle and trying multiple passes;6,7 and flexing, internally rotating, and abducting the hip.6 Some technical tips have been reported to improve the yield of synovial fluid.8 Lavage by saline solution has been proposed,9 although some authors do not believe the aspirated saline is consistently representative of the joint fluid and therefore do not advocate this approach.7,10
Recently, ultrasound-guided hip aspiration has been reported to be superior to fluoroscopy-guided aspiration 193and is gaining more popularity. Ultrasound technique does not expose the patient to radiation, is cheaper, and allows the radiologist to precisely target the joint fluid. One recent prospective randomized study has reported that ultrasound, in comparison with fluoroscopy, provides an aspiration test with improved sensitivity, specificity, and accuracy.11 However, more evidence is required to confirm this claim.
 
Tests
Synovial fluid is routinely analyzed for white blood cell (WBC) count, differential, and microbiologic culture. Other tests of synovial fluid that can be helpful in the diagnosis of PJI are leukocyte esterase, C-reactive protein (CRP) level, or molecular techniques such as polymerase chain reaction (PCR).12 Adding capsular biopsy does not offer any advantage to hip aspiration.13
 
Cell Count
The WBC count is a low-cost test and can be performed manually without any specialized equipment or by automated analyzers. It has been described as the most predictive perioperative test when combined with the preoperative erythrocyte sedimentation rate (ESR) and CRP.14 The leukocyte count cutoff values in PJI are substantially lower than those in native joint septic arthritis (50,000 WBCs/mL).
 
Threshold for Chronic PJI
Hip: Cutoff points of 3000 WBCs/mL and 80% for polymorphonuclear leukocyte (PMN) percentage have been proposed for chronic hip PJI when the ESR and CRP levels are both elevated. When either ESR or CRP (but not both) is elevated, a cutoff point of 9000 WBCs/mL has been consistent with a diagnosis of PJI.14194
Knee: In chronic knee PJI, the cutoff points for WBC count and differential have been reported to be between 1100 and 4000 WBCs/mL and 64% and 69%, respectively.12
 
Threshold for Acute PJI
In patients with acute knee PJI infections (as defined within 3 months after index arthroplasty15), the levels of synovial cell count and PMN percentage are much higher (approximately 20,000/mL and 89%, respectively). Values for acute hip infections have not yet been described.
 
How to Adjust for Blood-Stained Fluid
The WBC count may be falsely elevated if the obtained synovial fluid is bloody owing to traumatic arthrocentesis. A corrective equation, traditionally used for cerebrospinal fluid analysis, has been verified and found helpful to avoid false-positive results in the PJI setting.16 These adjusted results should be interpreted in the context of other available data, especially when they are not consistent with the patient's scenario as a whole.
 
Manual Versus Automated
An automated count of synovial fluid by different analyzers has been demonstrated to be faster and more precise than manual count, especially at higher cell counts.17–19 Ethylenediamine-tetraacetic acid (EDTA) is the preferred anticoagulant to be added to synovial fluid samples.17,19 It has been suggested that addition of hyaluronidase to the synovial fluid specimen improves the precision of automated cell counting19 because it prevents formation of aggregates that can falsely be interpreted as WBCs by the analyzer.
 
Culture
Synovial fluid is routinely sent for aerobic and anaerobic cultures. Fungal and mycobacterial media should be 195considered whenever any clinical suspicion exists or previous cultures have been negative, but not as a matter of routine. Inoculation of aspirated fluid into a blood-culture bottle has been suggested for optimal sensitivity and specificity of the culture.19 This method is discussed in detail in chapter 28.
 
Controversies
  • Cutoff values for synovial WBC count and differential for acute PJI in hips have not yet been investigated.
  • The role of adjuvant tests, such as synovial fluid CRP, in the diagnosis of PJI has yet to be established.
  • Evidence is still lacking for stratifying the risk and estimating the probability of PJI in different patients. This information would be particularly helpful in assessing the appropriate indication for, or repetition of, arthrocentesis in borderline clinical situations.
 
References
  1. Della Valle C, Parvizi J, Bauer TW, et al. American Academy of Orthopaedic Surgeons clinical practice guideline on: the diagnosis of periprosthetic joint infections of the hip and knee. J Bone Joint Surg Am. 2011;93(14):1355–7.
  1. Ali F, Wilkinson JM, Cooper JR, et al. Accuracy of joint aspiration for the preoperative diagnosis of infection in total hip arthroplasty. J Arthroplasty. 2006;21(2):221–6.
  1. Malfair D. Therapeutic and diagnostic joint injections. Radiol Clin North Am. 2008;46(3):439–53.
  1. Schmidt RM, Rosenkranz HS. Antimicrobial activity of local anesthetics: lidocaine and procaine. J Infect Dis 1970;121(6):597–607.
  1. Jackson DW, Evans NA, Thomas BM. Accuracy of needle placement into the intra-articular space of the knee. J Bone Joint Surg Am. 2002;84-A(9):1522-7.196
  1. Tigges S, Stiles RG, Meli RJ, Roberson JR. Hip aspiration: a cost-effective and accurate method of evaluating the potentially infected hip prosthesis. Radiology. 1993;189(2):485–8.
  1. Lachiewicz PF, Rogers GD, Thomason HC. Aspiration of the hip joint before revision total hip arthroplasty. Clinical and laboratory factors influencing attainment of a positive culture. J Bone Joint Surg Am. 1996;78(5):749–54.
  1. Brandser EA, El-Khoury GY, FitzRandolph RL. Modified technique for fluid aspiration from the hip in patients with prosthetic hips. Radiology. 1997;204(2):580–2.
  1. Spangehl MJ, Masri BA, O'Connell JX, Duncan CP. Prospective analysis of preoperative and intraoperative investigations for the diagnosis of infection at the sites of two hundred and two revision total hip arthroplasties. J Bone Joint Surg Am. 1999;81(5):672–83.
  1. Barrack RL, Harris WH. The value of aspiration of the hip joint before revision total hip arthroplasty. J Bone Joint Surg Am. 1993;75(1):66–76.
  1. Battaglia M, Vannini F, Guaraldi F, et al. Validity of preoperative ultrasound-guided aspiration in the revision of hip prosthesis. Ultrasound Med Biol. 2011;37(12):1977–83.
  1. Parvizi J, Zmistowski B, Berbari EF, et al. New definition for periprosthetic joint infection: From the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res. 2011;469(11):2992–4.
  1. Williams JL, Norman P, Stockley I. The value of hip aspiration versus tissue biopsy in diagnosing infection before exchange hip arthroplasty surgery. J Arthroplasty. 2004;19(5):582–6.
  1. Schinsky MF, Della Valle CJ, Sporer SM, Paprosky WG. Perioperative testing for joint infection in patients undergoing revision total hip arthroplasty. J Bone Joint Surg Am. 2008;90(9):1869–75.
  1. Bedair H, Ting N, Jacovides C, et al. The Mark Coventry Award: Diagnosis of Early Postoperative TKA Infection Using Synovial Fluid Analysis. Clin Orthop Relat Res. 2010. Available at: http://www.ncbi.nlm.nih.gov.proxy1.lib.tju.edu:2048/pubmed/20585914. Accessed August 30, 2010.197
  1. Ghanem E, Houssock C, Pulido L, et al. Determining “true” leukocytosis in bloody joint aspiration. J Arthroplasty. 2008;23(2):182–7.
  1. Salinas M, Rosas J, Iborra J, Manero H, Pascual E. Comparison of manual and automated cell counts in EDTA preserved synovial fluids. Storage has little influence on the results. Ann Rheum Dis. 1997;56(10):622–6.
  1. de Jonge R, Brouwer R, Smit M, et al. Automated counting of white blood cells in synovial fluid. Rheumatology (Oxford). 2004;43(2):170–3.
  1. Sugiuchi H, Ando Y, Manabe M, et al. Measurement of total and differential white blood cell counts in synovial fluid by means of an automated hematology analyzer. J Lab Clin Med. 2005;146(1):36–42.198

Molecular Markers in Periprosthetic Joint Infectionchapter 26

Carl Deirmengian,
Joseph A Karam
 
Current Evidence
The diagnosis of periprosthetic joint infection (PJI) still poses a significant challenge, and no consensus on the most appropriate diagnostic tests has been reached. The tests most used are suboptimal: Systemic markers of inflammation, including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), have very low specificity; and synovial fluid culture yields a high false-negative rate. Other tests, such as the synovial fluid white blood cell count, the differential cell count, and frozen-section analysis, are subjective and potentially variable because they rely on the interpretation of the technician or physician.

Rothman Institute Current Practices

  1. The Musculoskeletal Infection Society (MSIS) criteria are the gold standard in confirming the diagnosis of PJI at our institution.
  2. Synovial fluid leukocyte esterase is being trialled and optimized for use after knee aspiration to rule out infection.
With significant progress in the area of molecular biology, various strategies have been developed to enhance diagnostic accuracy, with the ultimate goal 200of producing a quick and reliable molecular assay for diagnosing PJI. Some of those strategies aim at identifying the organisms themselves, whereas others try to quantify the host response.

Pitfalls

  1. To be used routinely in the hospital setting, biomarker immunoassays still need standardization and validation.
  2. PCR testing is susceptible to contamination, and this should be always kept in mind when interpreting results.
Among the available molecular methods to detect bacteria, polymerase chain reaction (PCR) assays have yielded the best results, and have been suggested as compensating for the high false-negative rates of synovial fluid culture. They carry, however, a notoriously increased false-positive rate from the amplification of contaminating genetic material. After several successful results in the early 1990s,1–3 Mariani et al4 further developed the technique with a methodology adapted to the synovial fluid.
Broad-range PCR targets a DNA region universally preserved in all bacterial species, which increases the chances that bacteria will be identified. Even though it is able to identify infecting organisms in culture-negative cases, it is difficult to recommend its systematic use owing to the increased rate of false-positive results.5,6 Consequently, several strategies have been introduced to counter this effect, among which multiplex PCR, which makes use of multiple sets of primers, each set being specific for a certain bacterial species. Achermann et al7 found this method to yield an extremely high identification rate, even in patients with concurrent antibiotic treatment. Specific primers targeting the MecA gene of MRSA have also been developed and have yielded very promising results.8,9 Finally, some authors have suggested that reverse transcriptase PCR (RT-PCR) would yield better accuracy because it targets RNA sequences, which are rapidly 201destroyed after the death of the organism, hence leading to a lower likelihood of detecting free genetic material.10,11 Although these experimental techniques have revealed promise, they have not made their way to clinical use owing to the methodological complexity and required expertise.
More recently, our group has run preliminary experiments with the new IBIS T5000 universal biosensor, which combines broad-range PCR with high-performance mass spectrometry. Ongoing investigations at our institution are trying to validate its role in PJI diagnosis, especially in culture-negative cases.
Overall, PCR assays have demonstrated promise in diagnosing PJI. However, they are technically cumbersome and cannot be currently implemented for routine diagnosis of PJI in the hospital setting. Thus, further research efforts should focus on facilitating the methodology, while at the same time maximizing its performance.
Host inflammatory reaction markers, such as CRP and ESR, are widely used to identify infection. Unfortunately, these systemic blood tests are notoriously nonspecific and yield elevated values in various inflammatory conditions, including nonsynovial infections. In an effort to avoid these systemic confounders, several groups have reported on the measurement of synovial fluid biomarkers to detect PJI.
In 2005, Deirmengian et al12 demonstrated a dramatic differential gene expression in the synovial fluid neutrophils responding to staphylococcal infection versus gout, thus demonstrating the concept of a specific local response to infection. Even though the microarray technology used in that study would be too tedious to be routinely applied in the clinical setting, it was able to identify several genes whose up-regulation would be potentially diagnostic for synovial infection. Indeed, in a follow-up study, Deirmengian et al13 translated this concept into a more clinically applicable configuration using immunoassays. 202These have a low cost, provide quick results, and already constitute the basis of diagnosis and follow-up for many diseases. Synovial fluid levels of interleukin-6, interleukin-1b, granulocyte colony stimulating factor (G-CSF), and an antimicrobial peptide were found to have better sensitivity, specificity, and accuracy in diagnosing PJI than systemic ESR and CRP. Moreover, multiple other synovial fluid biomarkers, such as interleukin-8, interleukin-17, vascular endothelial growth factor (VEGF), and interleukin-1a, were found to have extremely high accuracy.
The value of local synovial fluid biomarkers has also been corroborated in other studies. Jacovides et al14 identified several proteins with good diagnostic value for PJI. Three of their five best biomarkers corresponded to those identified in previous studies, thus further supporting the role of synovial fluid biomarkers in reliably diagnosing PJI. Another study from the same institution assessed synovial fluid CRP as a diagnostic tool for PJI.15 This was found to be more specific and sensitive than serum CRP testing, indicating that local inflammation elicits a stronger response than does systemic inflammation detected in the serum.
Recent efforts by Parvizi et al16 have also identified leukocyte esterase as a strong biomarker of synovial fluid infection. They used urine dipsticks that routinely test for this enzyme in the diagnosis of urinary tract infections. After joint aspiration, one drop of synovial fluid is sufficient for this test and results are read in one minute. The authors demonstrated encouraging accuracy when using a ‘2+’ reading as a positive result. The most attractive aspects of this dipstick test are its ease of use, low cost, and real-time results. The most limiting factor of its use is the confounding nature of bloody aspirates, which interfere with colorimetric readings. Furthermore, some subjectivity exists in the visual interpretation of the colorimetric assay. Ongoing research is addressing these problems.203
Biomarker immunoassays are reliable and quick, thus constituting a valuable test for the diagnosis of PJI. Initial studies have yielded encouraging results that clearly surpass those of systemic markers. Major attributes of local biomarkers include decreased susceptibility to bacterial contamination, compared with PCR, and reduced distortion by conditions eliciting systemic inflammation, compared with systemic markers. However, one principal drawback resides in their inability to identify the infecting organism.
 
Controversies
Various molecular markers have been evaluated to address the deficiency of the tests currently used for diagnosing PJI. To be used routinely in the clinical setting, these immunoassays have to be further validated and standardized. However, PCR has been shown to outperform synovial fluid cultures because it is independent of culture media, growth conditions, and previous antibiotic treatment. Indeed, PCR assays are the most robust genetic tests currently available, but they are greatly susceptible to bacterial contamination. Interestingly, the combination of PCR testing with biomarker assays to confirm infection may potentially provide the optimal strategy for diagnosing PJI.
 
References
  1. Nocton JJ, Dressler F, Rutledge BJ, et al. Detection of Borrelia burgdorferi DNA by polymerase chain reaction in synovial fluid from patients with Lyme arthritis. N Engl J Med. 1994;330:229–34.
  1. Liebling MR, Arkfeld DG, Michelini GA, et al. Identification of Neisseria gonorrhoeae in synovial fluid using the polymerase chain reaction. Arthritis Rheum. 1994;37:702–9.
  1. Poole ES, Highton J, Wilkins RJ, Lamont IL. A search for Chlamydia trachomatis in synovial fluids from patients with reactive arthritis using the polymerase chain reaction and antigen detection methods. Br J Rheumatol. 1992;31:31–4.204
  1. Mariani BD, Levine MJ, Booth RE Jr, Tuan RS. Development of a novel, rapid processing protocol for polymerase chain reaction-based detection of bacterial infections in synovial fluids. Mol Biotechnol. 1995;4:227–37.
  1. Panousis K, Grigoris P, Butcher I, et al. Poor predictive value of broad-range PCR for the detection of arthroplasty infection in 92 cases. Acta Orthop. 2005;76:341–6.
  1. Tunney MM, Patrick S, Curran MD, et al. Detection of prosthetic hip infection at revision arthroplasty by immunofluorescence microscopy and PCR amplification of the bacterial 16S rRNA gene. J Clin Microbiol. 1999;37:3281–90.
  1. Achermann Y, Vogt M, Leunig M, et al. Improved diagnosis of periprosthetic joint infection by multiplex PCR of sonication fluid from removed implants. J Clin Microbiol. 2010;48:1208–14.
  1. Tarkin IS, Henry TJ, Fey PI, et al. PCR rapidly detects methicillin-resistant staphylococci periprosthetic infection. Clin Orthop Relat Res. 2003;(414):89–94.
  1. Kobayashi N, Inaba Y, Choe H, et al. Rapid and sensitive detection of methicillin-resistant Staphylococcus periprosthetic infections using real-time polymerase chain reaction. Diagn Microbiol Infect Dis. 2009;64:172–6.
  1. Birmingham P, Helm JM, Manner PA, Tuan RS. Simulated joint infection assessment by rapid detection of live bacteria with real-time reverse transcription polymerase chain reaction. J Bone Joint Surg Am. 2008;90:602–8.
  1. Bergin PF, Doppelt JD, Hamilton WG, et al. Detection of periprosthetic infections with use of ribosomal RNA-based polymerase chain reaction. J Bone Joint Surg Am. 2010;92:654–63.
  1. Deirmengian C, Lonner JH, Booth RE Jr. The Mark Coventry Award: white blood cell gene expression: a new approach toward the study and diagnosis of infection. Clin Orthop Relat Res. 2005;440:38–44.
  1. Deirmengian C, Hallab N, Tarabishy A, et al. Synovial fluid biomarkers for periprosthetic infection. Clin Orthop Relat Res. 2010; 468:2017–23.205
  1. Jacovides CL, Parvizi J, Adeli B, Jung KA. Molecular markers for diagnosis of periprosthetic joint infection. J Arthroplasty. 20112699–10. e1.
  1. Parvizi J, Jacovides C, Adeli B, et al. The Mark Coventry Award: synovial C-reactive protein: a prospective evaluation of a molecular marker for periprosthetic knee joint infection. Clin Orthop Relat Res. 2012;470:54–60.
  1. Parvizi J, Jacovides C, Antoci V, Ghanem E. Diagnosis of periprosthetic joint infection: the utility of a simple yet unappreciated enzyme. J Bone Joint Surg Am. 2011; 93:2242–8.206

Imaging for Diagnosis of Periprosthetic Joint Infectionchapter 27

Zachary D Post
 
Current Evidence
The usefulness of imaging for the diagnosis of prosthetic joint infection (PJI) has been controversial at best. The controversy lies in the effectiveness and the accompanying cost, both monetary and otherwise, associated with each test. Pathologic changes, including infection, in the tissues that surround a joint implant are unfailingly accompanied by inflammation. The specific changes associated with infection are predictable, but not specific.

Rothman Institute Current Practices

  1. Plain film X-rays are evaluated on all patients presenting with complaints of pain after TJA.
  2. Bone scintigraphy is not routinely used, as its diagnostic value is questionable when infection is a consideration.
  3. FDG-PET is used when the diagnostic picture is confusing. Typically this occurs when the ESR and CRP are equivocal and intra-articular fluid was not obtained with aspiration.
  4. MRI is not currently used for the evaluation of possible infection in the setting of TJA.
Each of the imaging modalities discussed in this chapter attempts to exploit a unique attribute of the 208inflammatory process to thereby identify an infection or other pathologic process.
 
Plain X-Ray and Computed Tomography Scan
Part of the work up for any painful total joint arthroplasty (TJA) should begin with a series of appropriate films. An X-ray can identify changes to the bone that indicate infection. Endosteal scalloping and new periosteal bone formations are typical X-ray findings associated with osteomyelitis. While they are specific, these findings often are not present, even in the setting of advanced infection.1 Plain X-rays are essential, but often are not helpful.
Computed tomography (CT) scans give a much more detailed picture of the bone surrounding the implant. However, CT scans are limited to the identification of the same boney changes marking infection for plain X-ray. One study estimated the frequency of periosteal reaction in the presence of infection at only 16%.2 Given the cost and radiation exposure associated with CT scanning, it is typically not utilized in the work up for infection around a joint replacement.
 
Scintigraphic Studies
Scintigraphy (bone scan) involves the placement of a radioactive marker into the bloodstream of the patient, allowing that marker to find a target, and then visualizing the location of the marker from outside the body. Bone scan has been used for the diagnosis of bone disease, including infection, for several years. Markers are attached to a carrier with specificity for the pathologic process under investigation.
A common marker used in bone scan is Technetium Tc-99m labeled diphosphonates. These compounds have an affinity for processes where bone turnover is occurring as the diphosphonates are taken up by active bone cells. Gallium Ga-67 scanning is also used, as gallium tends to 209localize to areas of inflammation. Most bone scans are done as “triple phase” scans The 3 phases are (1) immediately after the marker is injected. (2) Five minutes after injection. (3) Two to four hours after the marker is injected. The three-phase approach helps to differentiate an infectious process in the soft tissues from one in the bone. It is the final scan which will identify the active bone turnover process in the body.
The Tc-99m diphosphonate scintigraphy has an overall accuracy of 75.5% according to meta-analysis with a sensitivity of 85.4% and specificity of 75.2%.3,4 Some studies show that the addition of the triple phase component in combination with use of Ga-67 scanning improves accuracy of bone scan, but it is still substandard to that of other modalities.5,6 The trouble lies in differentiating between loosening (and other inflammatory process (that may surround a TJA) and infection. As a screening tool, a negative bone scan can help rule out infection, but a positive test does not add to the work up.
Another bone scan method involves attachment of a radioactive marker (Tc-99m or indium) to autologous white blood cells (tagged white cell scan). The marked white cells are reintroduced into the patient and then travel to and congregate around the site of active infection. Six to 24 hours after injection of the tagged cells, scanning is done to visualize the areas of increased white cell concentration. Unfortunately, accuracy is often diminished by unpredictable blood flow to regions of chronic infection surrounding a joint component.4 Literature reports sensitivity to be as low as 43.5%.7
 
Flourine-18-Fluorodeoxyglucose Positron Emission Tomography
Positron emission tomography (PET) uses tracers that are associated with increased metabolic activity. The most commonly used tracer is fluorine-18-fluorodeoxyglucose 210(FDG), in which uptake is related to cellular glucose metabolism.

Pitfalls

  1. Plain film X-ray rarely demonstrates changes diagnostic of infection.
  2. CT scan is not substantially more diagnostic than plain film X-ray.
  3. Bone scintigraphy involves substantial cost, and radiation exposure and is less accurate than other available tests.
  4. Tagged white cell scan has a sensitivity less than 50%.
  5. FDG-PET has limited availability and involves substantial cost (approximately three times the cost of an MRI).
This particular marker is useful in identifying infection as the inflammation associated with infection involves increased glucose metabolism. The fluorine component of FDG is also well taken up by bone and tends to show areas of high bone turnover. After introduction of the tracer, PET scanners are used to localize and identify areas of increased tracer concentration. Because it is three-dimensional in nature, FDG-PET is especially useful for identifying infection surrounding orthopedic implants. A recent meta-analysis found a sensitivity of 94.1% and specificity of 87.3% among studies the authors evaluated.3 FDG-PET has also been found to be much more accurate than tagged white cell scan or triple phase bone scan.7–8 However, in spite of superior detection when compared to other nuclear studies, the clinical practice guideline approved by the American Association of Orthopaedic Surgeons (AAOS) gave FDG-PET a weak recommendation. In fact, the guideline gives all nuclear medicine studies a weak recommendation for the detection of periprosthetic joint infection.9
 
Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) has been found to be very successful for diagnosis of infection in the musculoskeletal system.3 Most studies find MRI to be more 211accurate than scitigraphy, but less so than FDG-PET in the presence of metallic implants.3 In truth, the available literature on MRI evaluation of periprosthetic infection is limited. As metal artifact reduction sequence (MARS) MRI becomes more available, further investigation of its use for diagnosis of infection will be required. As of 2010, the AAOS work group on periprosthetic infection was unable to give a recommendation for MRI due to a lack of evidence.9
 
Controversies
  • Scintigraphy involves the introduction of a radioactive substance into the body. For most patients the amount of radiation exposure associated with this test is equivalent to a standard CT without contrast. Tagged white cell scan also involves the introduction of radioactive substances. In addition to the radiation exposure, it can take up to 24 hours to obtain a result. As the diagnostic value of bone scintigraphy is questionable, most surgeons find the risk and delay unacceptable. In addition, the cost of a bone scan is significant, comparable to that of an MRI or CT. In light of less invasive and less expensive tests that are more accurate (see ESR and CRP) bone scan as a diagnostic tool for periprosthetic infection has largely been abandoned.
  • The FDG-PET is a highly specialized test that requires the expertise of an experienced nuclear radiologist for accurate interpretation. Additionally the availability of scanners is primarily limited to tertiary care centers. The cost of PET is also a significant barrier, estimated to be approximately three times that of bone scan or MRI.4 For these reasons FDG-PET is limited in its use for diagnosis of TJA infection. If it is available, PET scan can be helpful in the setting of mixed ESR and CRP results and inability to obtain intra-articular fluid.
212
 
References
  1. Callaghan JJ, Rosenberg AG, Rubash HE, eds. The Adult Hip. Second edition. P 1263: Lippincott Williams & Wilkins,  2006.
  1. Cyteval C, Hamm V, Sarrabère MP, et al. Painful infection at the site of hip prosthesis: CT imaging. Radiology. 2002(224):477-83.
  1. Prandini N, Lazzeri N, Rossi B, et al. Nuclear medicine imaging of bone infections. Nuclear Med Commun. 2006(27): 633–4.
  1. Hsu W, Hearty TM. Radionuclide imaging in the diagnosis and management of orthopaedic disease. J Am Ortho Surg 2012(20):151-9.
  1. Nagoya S, Kaya M, Sasaki M, et al. Diagnosis of peri-prosthetic infection at the hip using triple-phase bone scintigraphy. H Bone Joint Surg. (90-B):140-4.
  1. Levitsky K, Hozack WJ, Balderston RA, et al. Evaluation of the painful prosthetic joint: relative value of bone scan, sedimentation rate, and joint aspiration. J Arthroplasty. 1991(6): 237–44.
  1. Pill SG, Parvizi J, Nelson CL, et al. The role of FDG-PET imaging in diagnosing periprosthetic infection after total hip arthroplasty. J Arthroplasty. 2006;(21):308.
  1. Reinartz P. Radionuclide imaging of the painful hip arthroplasty: Positron-emission tomography versus triple-phase bone scanning. J Bone Joint Surgery. 2005(87-B): 465-70.
  1. Della Valle C, Parvizi J, Bauer TW, et al. Diagnosis of periprosthetic joint infections of the hip and knee. J Am Acad Orthop Surg 2010(18):760-70.

Culture Principleschapter 28

Anthony Tokarski,
Bahar Adeli,
Gregory K Deirmengian
 
Current Evidence
Microbial cultures play a critical role in the diagnosis of periprosthetic joint infection (PJI). Identification of the organism responsible for the infection and determination of its antibiotic sensitivities are cirtical elements for succesful treatment of PJI.
Sample Acquistition: Three main samples are used to obtain deep cultures for the purpose of diagnosing PJI: synovial fluid, intraoperative swabs of deep tissues, and deep tissue samples. When there is high clinical suspicion, radiologic evidence, or elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels preoperatively, synovial fluid should be aspirated from the affected joint and cultured.1,2 The accuracy of joint aspiration is uncertain, with studies reporting sensitivities between 0.50 and 0.93 in hip aspirations.3–5 Therefore, results of a cultured aspiration are best used to confirm the presence of an infection and should not be used as a screening test.1,3,6 The sensitivity of aspirations rises significantly when used only in the presence of elevated serology.7 Aspiration also allows for the identification of the infectious organism and its antibiotic sensitivities, knowledge that is crucial for the successful treatment of PJI. Antibiotics should be withheld for a minimum of two weeks prior to aspiration in order to maximize culture yield.2,3
At our institution, aspirations of the knee are performed under a semisterile manner in the office. Hip aspirations 214are preformed using fluoroscopic or ultrasound guidance. The skin is first decolonized by the use of alcohol wipes or sprays. Betadine solution is then applied to the skin and allowed to dry. The bottle tops are cleaned with alcohol wipes prior to transfer of synovial fluid in order to minimize the potential for contamination. The needle used to puncture the skin is also changed to a new sterile needle before injection into the tubes. This will also minimize the chance for contamination and lower the false-positive rate.

Rothman Institute Current Practices

  1. When CRP and ESR levels are elevated, the affected joint is aspirated preoperatively and the fluid is cultured.
  2. Anaerobic, aerobic, AFB, and fungal cultures are ordered for all patients.
  3. Thioglycate broth, blood agar, chocolate agar, and MacConkey agar are used for aerobic cultures.
  4. Brucella Laked Blood agar, phenylethyl alcohol blood agar, Bacteroides Bile Esculin agar, and Laked blood with kanamycin and vancomycin are used for anaerobic cultures.
  5. AFB cultures are grown using Lowenstein-Jensen growth medium, Middlebrook agar, and BBL Mycobacteria growth indicator tube (BBL MGIT) vials.
  6. Cultures are incubated for five days. In the absence of growth, the incubation will be increased up to 14 days.
  7. The BBL MGIT vials are for rapid use and can detect growth in 4 to 10 days. Samples can be incubated for up to 8 weeks.
  8. Fungal cultures are grown using sheep's blood agar, sabourad agar, and brain heart infusion agar.
  9. One plate of sheep's blood agar is incubated at 37° for 1–3 days for the detection of yeast. All other samples are incubated at 30° for up to 4–8 weeks.
Intraoperative deep tissue sampling is critical for optimizing the identification of the causative organism in cases of PJI. Atkins et al8 found that up to six samples were required to obtain an accurate diagnosis. Others have suggested that only three samples are necessary.9 The Musculoskeletal Infection Society (MSIS) guideline recommends obtaining between three and five culture samples.10 Swabs 215of the skin or deeper tissues are not recommended. Swab samples have a number of disadvantages when compared to tissue or fluid samples. Certain microorganism cannot survive on swabs as well as they can in synovial fluid, and others adhere to the swab and cannot be transferred to the plate for Gram staining. Swabs are also more likely to be contaminated and also may inhibit the growth of different pathogens, leading to more false-positive and false-negative results.11 A study within our institution has shown that deep tissue samples have a lower false-negative and false-positive rate than swab samples (unpublished data). We recommend that intraoperatively, three tissue samples are obtained and sent for aerobic, anaerobic, acid-fast bacilli (AFB), and fungal cultures.
Length of Incubation: The optimal length of incubation time for the diagnosis of PJI is a topic of debate. Typically, cultures are incubated for five days.12 However, studies have shown that a longer incubation period may lead to a more accurate diagnosis. Schafer et al13 reported that 26.4% of patients who were classified as being infected based on culture results when the incubation time was 14 days would have been classified as aseptic at the seven-day point. This study also showed that contamination of the cultures is not affected by longer incubation times. Using shorter incubation times may also make it more difficult to diagnose PJI caused by fastidious bacteria. Butler-Wu et al12 showed that an incubation period of 13 days was necessary to detect Propionibacterium acnes in patients undergoing revision arthroplasty. By increasing the length of incubation with both aerobic and anaerobic cultures, they were able to identify significantly more infected patients than the ones with increased incubation length in anaerobic cultures alone.
Blood Culture Vials for Culturing Synovial Fluid: While cultures obtained from periprosthetic tissue and 216synovial fluid samples are commonly grown on blood agar plates and in broth media, some advocate for the use of blood culture flasks or vials to inoculate synovial fluid collected intraoperatively and have reported increased sensitivities.14, 15 The reported advantages of synovial fluid inoculated in blood culture vials over swab and tissue cultures may be attributable to the inherent differences in the way each sample is handled. Synovial fluid can be injected directly into the vials immediately after collection, minimizing both the opportunity for contamination as well as exposure to an aerobic environment. Even though some studies have demonstrated more accurate culture results using blood culture vials, the increased cost associated with them must be weighed against the utility of conventional culturing methods.14,16
Organism Identification: Staphylococcus aureus and Staphylococcus epidermidis are responsible for nearly 70% of all cases of PJI. Streptococci and enterococci species cause as much as 20% of cases. The remaining cases can be attributed to gram-negative and anaerobic bacteria. When the explanted prosthesis is cultured, up to 60% of PJIs are associated with multimicrobial infections.17 The variability in the biology of infecting organisms makes it necessary to perform both aerobic and anaerobic cultures when diagnosing PJI. While staphylococci account for the majority of infections, atypical organisms such as fungi and mycobacteria are the causative organisms in approximately 1% of cases.18 These infectious organisms are difficult to detect with routine anaerobic and aerobic cultures and require specialized media. AFB cultures can be used to detect the presence of mycobacteria. A separate fungal culture should be ordered to test for the presence of infectious fungi. Some literature suggests that these tests should only be performed when routine cultures are negative and the patient has appropriate epidemiologic context.19 217At our institution, both AFB and fungal cultures are routinely checked for all patients, a practice that has been observed in other studies.20 The reasoning behind this is twofold: to ensure that all patients with these rare infections are identified and to streamline the protocol for the hospital staff. By routinely ordering AFB and fungal cultures for all patients rather than only when there are signs of infection and negative aerobic and anaerobic cultures, the hospital staff is better acquainted with the process allowing for the early detection of atypical infectious organisms.
 
Controversies
  • Tissue versus swab culture samples: swabs are inexpensive and easy to use but have inherent disadvantages that lead to less accurate results.
  • Some studies suggest that as many as six samples are necessary to correctly identify an infection and rule out the possibility of contamination, while others report that three samples are sufficient. What is accepted is that multiple samples (at least two) must be taken and show positive growth of the same organism to diagnose PJI.
  • It is common practice to incubate cultures for five days. Studies have shown that certain organisms, including P. acnes require a longer incubation period to identify all infected patients. It is debatable that incubations times longer than 14 days can lead to an increase in contamination.
 
References
  1. Parvizi J, Ghanem E, Menashe S, et al. Periprosthetic infection: what are the diagnostic challenges? J Bone Joint Surg Am. 2006;88 Suppl 4:138–47.218
  1. Toms AD, Davidson D, Masri BA, et al. The management of peri-prosthetic infection in total joint arthroplasty. J Bone Joint Surg Br. 2006;88(2):149–55.
  1. Ali F, Wilkinson JM, Cooper JR, et al. Accuracy of joint aspiration for the preoperative diagnosis of infection in total hip arthroplasty. J Arthroplasty. 2006;21(2):221–6.
  1. Rosenthal VD, Maki DG, Jamulitrat S, et al. International Nosocomial Infection Control Consortium (INICC) report, data summary for 2003–2008, issued June 2009. Am J Infect Control. 2010;38(2):95–104.e2.
  1. Tigges S, Stiles RG, Meli RJ, Roberson JR. Hip aspiration: a cost-effective and accurate method of evaluating the potentially infected hip prosthesis. Radiology. 1993;189(2):485–8.
  1. Spangehl MJ, Masri BA, O'Connell JX, et al. Prospective analysis of preoperative and intraoperative investigations for the diagnosis of infection at the sites of two hundred and two revision total hip arthroplasties. J Bone Joint Surg Am. 1999;81(5):672–83.
  1. Barrack RL, Jennings RW, Wolfe MW, et al. The Coventry Award. The value of preoperative aspiration before total knee revision. Clin Orthop Relat Res. 1997;(345):8–16.
  1. Atkins BL, Athanasou N, Deeks JJ, et al. Prospective evaluation of criteria for microbiological diagnosis of prosthetic-joint infection at revision arthroplasty. The OSIRIS Collaborative Study Group. J Clin Microbiol. 1998;36(10):2932–9.
  1. Parvizi J, Azzam K, Ghanem E, et al. Periprosthetic infection due to resistant staphylococci: serious problems on the horizon. Clin Orthop Relat Res. 2009;467(7):1732–9.
  1. Parvizi J. New definition for periprosthetic joint infection. Am J Orthop. 2011;40(12):614–5.
  1. Wilson ML, Winn W. Laboratory diagnosis of bone, joint, soft-tissue, and skin infections. Clin Infect Dis. 2008;46(3):453–7.
  1. Butler-Wu SM, Burns EM, Pottinger PS, et al. Optimization of periprosthetic culture for diagnosis of Propionibacterium acnes prosthetic joint infection. J Clin Microbiol. 2011;49(7):2490–5.
  1. Schäfer P, Fink B, Sandow D, et al. Prolonged bacterial culture to identify late periprosthetic joint infection: a promising strategy. Clin Infect Dis. 2008;47(11):1403–9.219
  1. Font-Vizcarra L, García S, Martínez-Pastor JC, et al. Blood culture flasks for culturing synovial fluid in prosthetic joint infections. Clin Orthop Relat Res. 2010;468(8):2238–43.
  1. Levine BR, Evans BG. Use of blood culture vial specimens in intraoperative detection of infection. Clin Orthop Relat Res. 2001;(382):222–31.
  1. Patel R, Osmon DR, Hanssen AD. The diagnosis of prosthetic joint infection: current techniques and emerging technologies. Clin Orthop Relat Res. 2005;(437):55–8.
  1. Lentino JR. Prosthetic joint infections: bane of orthopedists, challenge for infectious disease specialists. Clin Infect Dis 2003;36(9):1157–61.
  1. Shuman EK, Urquhart A, Malani PN. Management and prevention of prosthetic joint infection. Infect Dis Cli. North Am. 2012;26(1):29–39.
  1. Marculescu CE, Berbari EF, Cockerill FR 3rd, et al. Fungi, mycobacteria, zoonotic and other organisms in prosthetic joint infection. Clin Orthop Relat Res. 2006;451:64–72.
  1. Schinsky MF, Della Valle CJ, Sporer SM, et al. Perioperative testing for joint infection in patients undergoing revision total hip arthroplasty. J Bone Joint Surg Am. 2008;90(9):1869–75.220

Culture-Negative Periprosthetic Joint Infectionchapter 29

Carlos A Higuera
 
Current Evidence
Cultures of tissue and synovial fluid from an affected joint are an essential element of the diagnosis and treatment of periprosthetic joint infection (PJI). According to the new definition of PJI, the sole isolation of a pathogen by culture from two separate tissue or fluid samples that are obtained from the affected joint make the diagnosis of PJI.1 Additionally, the identification of a pathogen tailors the antibiotic treatment using specific sensitivity. Unfortunately, in 7% to 12% of cases, cultures may be negative even in the presence of clear signs of infection.2,3 A negative culture is defined as an appropriate sample of fluid or tissue from the affected joint that has been incubated in the appropriate media for at least 5 days and has shown no pathogen growth.4

Rothman Institute Current Practices

  1. In the presence of negative cultures and inconclusive aspiration with a high suspicion of PJI and elevated inflammatory markers, an aspiration is repeated.
  2. It is our practice to call the microbiology department and inform them of the challenge of isolating the infecting organism and “warn” them about the sample being sent.
222
Negative cultures have different causes including the use of antimicrobial therapy prior to the collection of fluid or tissue; inappropriate collection of tissue samples (i.e. excessive cauterization); and the use of short periods of incubation, especially when low virulence pathogens cause the infection. Some pathogens are difficult to identify using traditional tissue cultures, particularly if they are encapsulated in a biofilm, or when fungi or mycobacteria are the culprits and a specific medium culture for these pathogens is not used. Malekzadeh et al5 reported that the use of prior antimicrobial therapy and postoperative wound drainage after index arthroplasty were associated with increased odds of PJI being culture negative. They believed that wound drainage was a possible confounder, given the tendency of the general practitioner to prescribe antibiotics when such situation is encountered after arthroplasty. Furthermore, Schafer et al6 described how standard culture techniques, including maintenance of incubation periods between 4 and 7 days do not meet the requirements for reliable identification of slowly growing organisms.

Pitfalls

  1. It is imperative to hold antibiotic treatment for at least two weeks prior to obtaining intra-articular samples for culture.
  2. Cultures are used to confirm and not to screen for PJI.
  3. In the presence of negative cultures a multidisciplinary approach with the infectious disease and microbiology team can make a difference to identify the final pathogen and establish the final antibiotic treatment.
Negative cultures limit the tailoring of the antibiotic treatment and moreover hinder the justification for revision surgery if other components of the PJI definition are not present. This may jeopardize a successful outcome because patients with culture-negative PJI had less stage procedures and more irrigation and debridement only as a 223surgical intervention, and the average length of antibiotic therapy is shorter than in patients with positive cultures.2
 
Strategies to Isolate Organism
In general, to decrease the incidence of negative cultures (or false-negative results), it is recommended that representative samples of tissue are obtained, that antibiotics are withheld for at least two weeks prior to the collection of samples, and that the incubation period is increased. In cases that involve inconclusive preoperative aspiration, negative cultures with elevated inflammatory markers, and high suspicion of PJI, a repeat aspiration is recommended.7 In these cases, communication with the microbiology department is paramount to have an appropriate manipulation of the sample. The sample should be transported and processed immediately after collection. The main strategies to improve isolation of the pathogen is to hold antibiotics for at least two weeks prior to the collection of the sample and once this period is reached, the incubation period should be increased. Schafer et al6 described how prolonged incubation periods of at least 14 days increased yields of identifying pathogens that initially were culture negative, in specific for low-virulence organisms such as Propionibacterium species. The appropriate use of culture media is fundamental to obtain accurate positive cultures. If fungi or mycobacteria infection is suspected, the proper media should be used. (See chapters 35 and 36 for more information.)
Pathogens are commonly present in a biofilm on the surface of the prosthesis. Trampuz et al reported the use of sonication of explanted prostheses to dislodge adherent bacteria in patients undergoing revision arthroplasty.8 They prospectively compared the use of conventional cultures from tissue with cultures obtained using sonication. They found a significant improvement of the 224sensitivity of cultures obtained using sonication when compared with conventional cultures (from 61 – 78.5%). The improvement of sensitivity was more significant in patients who received antibiotic therapy within 14 days of the sample culture collection. Such results were obtained by employing a few key elements in the methodology. For example, solid containers were used to transport the explanted prostheses and a vortexing step was added before sonication. As a result, it appears that vortexing increased the concentration of air bubbles and thus enhanced the cavitation effect of subsequent sonication. Additionally, the sensitivity of the sonication fluid culture may have improved by an additional centrifugation step of the fluid and cultivation of the sediment with concentrated bacteria only. This sonication method preserved the microbial viability. Some advantages of this technique include the fact that it is simple, reproducible, and it yields viable microorganisms that can be subjected to antimicrobial-susceptibility testing. The sonication fluid typically yields a high number of organisms, which may help to distinguish between infected and contaminated prostheses. Disadvantages are related to the improved, yet limited, sensitivity (< 80%), and the lack of capacity to identify microorganisms in some cases. Multiple molecular markers can be used in addition to these strategies, but this topic is also discussed in chapter 26.
 
Controversies
  • Withholding prophylactic antibiotics does not interfere with the sensitivity of intraoperative cultures.
  • Obtaining mycobacteria and fungal cultures should not be done routinely unless the initial cultures are negative.
225
 
References
  1. Parvizi J, Zmistowski B, Berbari EF, et al. New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res. 2011;469(11):2992–4.
  1. Berbari EF, Marculescu C, Sia I, et al. Culture-negative prosthetic joint infection. Clin Infect Dis. 2007;45(9):1113–9.
  1. Parvizi J, Ghanem E, Menashe S, Barrack RL, Bauer TW. Periprosthetic infection: what are the diagnostic challenges? J Bone Joint Surg Am. 2006;88 Suppl 4:138–47.
  1. Higuera CP, J. Culture negative PJI periprosthetic joint infection: Strategies to improve yield. Orthopedics today 2012.
  1. Malekzadeh D, Osmon DR, Lahr BD, Hanssen AD, Berbari EF. Prior use of antimicrobial therapy is a risk factor for culture-negative prosthetic joint infection. Clin Orthop Relat Res. 2010;468(8):2039–45.
  1. Schafer P, Fink B, Sandow D, et al. Prolonged bacterial culture to identify late periprosthetic joint infection: a promising strategy. Clin Infect Dis. 2008;47(11):1403–9.
  1. Della Valle C, Parvizi J, Bauer TW, et al. Diagnosis of periprosthetic joint infections of the hip and knee. J Am Acad Orthop Surg. 2010;18(12):760–70.
  1. Trampuz A, Piper KE, Jacobson MJ, et al. Sonication of removed hip and knee prostheses for diagnosis of infection. N Engl J Med. 2007;357(7):654–63.226

Diagnosis of Prosthetic Joint Infection in Inflammatory Conditionschapter 30

Bahar Adeli,
Ibrahim J Raphael
 
Current Evidence
Total joint arthroplasty (TJA) patients with inflammatory arthritis are at an elevated risk for periprosthetic joint infection (PJI).1,2 A report from the Norwegian Arthroplasty Register mentions a 1.6 times higher risk for total knee revision due to infection in patients with rheumatoid arthritis (RA) compared to patients with osteoarthritis (OA).3 Moreover, Bongartz et al1 reported a twofold increased risk for infection after TJA in RA patients. Patients with RA may have a higher risk of infection for multiple reasons, including diseased skin and connective tissue, impaired healing ability, and immunosuppressive therapy including disease-modifying antirheumatic drugs (DMARDs) such as methotrexate and sulfadiazine.

Rothman Institute Current Practices

Patients with inflammatory conditions and suspicion of PJI are evaluated in an individual basis following the same criteria than in patients without history of inflammatory conditions.
A high 228dose of steroids and continuous tumor necrosis factor (TNF) α-blocker therapy within 1 year perioperatively have been described as potential risk factors for infection.4

Pitfalls

  1. In patients with inflammatory arthritis and suspicion of PJI, elevated ESR and CRP should warrant an aspiration and should not be interpreted as part of the inflammatory condition.
  2. Synovial WBC count and differential are the most useful tests to differentiate periprosthetic joint sepsis from nonsepsis in patients with inflammatory conditions.
Many studies have reported the usefulness of inflammatory biomarkers such as ESR, CRP, and synovial fluid WBC count and differential in the diagnosis of PJI.2 These markers have also been included in the most recent diagnostic criteria for PJI.5 However, their use in the presence of inflammatory conditions is controversial owing to elevated basal levels that potentially can increase false-positive diagnosis. Baseline elevations in the levels of inflammatory biomarkers can be found in patients with inflammatory arthritis such as RA, ankylosing spondylitis, or systemic lupus erythematosus (SLE).2 The question arises whether clinicians should resort to different reference levels or different biomarkers.
Cipriano et al2 reported a 31% and 18% incidence of late PJI in patients with inflammatory and noninflammatory arthritis after TJA. The PJI was the most common cause of revision surgery in the group of patients with inflammatory arthritis. The levels of ESR, CRP, and synovial WBC count and differential were similar in both patient groups (Table 30.1). In both groups, the synovial leukocyte count and differential were the most accurate tests to differentiate between septic and aseptic cases. In contrast, a study by Dizdaveric et al6 compared ESR and CRP levels in infected RA and OA patients and found a significantly higher 229mean values for ESR and CRP in patients with RA.
Table 30.1   Optimal inflammatory biomarker cutoff levels in inflammatory and nonInflammatory arthritis2
Inflammatory arthritis
Noninflammatory arthritis
ESR (mm/hr)
30
32
CRP (mg/L)
17
15
Synovial WBC count (count/μL)
3444
3450
Synovial WBC differential (%PMN)
75
78
These thresholds have variability and can be affected by multiple factors including time of aspiration, effect of DMARDs, and stage of the inflammatory condition (flared versus controlled disease). Finally, to date, the synovial WBC and differential are the most useful test to diagnose PJI in patients with inflammatory conditions.
 
Controversies
  • There is a lack of establishment of baseline levels of inflammatory markers in inflammatory arthropathies.
  • The effect of DMARDs on inflammatory markers has not been established.
  • The diagnosis of PJI in the presence of inflammatory conditions should be assessed on an individual basis.
  • The use of more specific biomarkers for PJI may increase the accuracy of the diagnosis.
 
References
  1. Bongartz T, Halligan CS, Osmon DR, et al. Incidence and risk factors of prosthetic joint infection after total hip or knee replacement in patients with rheumatoid arthritis. Arthritis Rheumatism. 2008;59(12):1713–20.230
  1. Cipriano CA, Brown NM, Michael AM, Moric M, et al. Serum and synovial fluid analysis for diagnosing chronic periprosthetic infection in patients with inflammatory arthritis. J Bone Joint Surg Am. 2012;94(7):594–600.
  1. Schrama JC, Espehaug B, Hallan G, et al. Risk of revision for infection in primary total hip and knee arthroplasty in patients with rheumatoid arthritis compared with osteoarthritis: a prospective, population-based study on 108,786 hip and knee joint arthroplasties from the Norwegian Arthroplasty Register. Arthritis Care Res. 2010;62(4):473–9.
  1. Gilson M, Gossec L, Mariette X, et al. Risk factors for total joint arthroplasty infection in patients receiving tumor necrosis factor alpha-blockers: a case-control study. Arthritis Res Ther. 2010;12(4):R145.
  1. Parvizi J, Zmistowski B, Berbari EF, et al. New definition for periprosthetic joint infection: from the workgroup of the musculoskeletal infection society. Clinical Orthop Rel Rres. 2011;469(11):2992–4.
  1. Dizdaveric IA, Cashman B, Parvizi J. ESR and CRP serology in inflammatory and non-inflammatory arthtitis patients undergoing joint revision surgery. Eastern Orthopaedic Association 42nd Annual Meeting. Williamsburg, VA, 2011.

Conditions Mimicking Periprosthetic Joint Infectionchapter 31

William V Arnold
 
Current Evidence
Patients with painful metal-on-metal (MOM) hip arthroplasty, trunion corrosion, or crystalline deposition disease (CDD) following total joint arthroplasty can present with symptoms that mimic periprosthetic joint infection (PJI). Physicians are faced with the challenging prospect of deciding between treating a culture-negative infection versus treating these noninfection entities. The ultimate choice is not without consequences, since the former can involve a two-stage procedure while the latter often involves single-stage revision surgery or even just simple medical treatment.

Rothman Institute Current Practices

  1. Do not hesitate to aspirate affected hips in patients with painful MOM arthroplasties. Ask for a manual cell count of the aspirate.
  2. Ask for a crystal analysis of aspirated joint arthroplasties to evaluate for the possibility of CDD.
This diagnostic dilemma can be especially challenging in treating symptomatic patients with MOM hip arthroplasties or trunion corrosion cases. In diagnosing PJI, physicians are 232encouraged to use the diagnostic criteria recently published and endorsed by the Musculoskeletal Infection Society.1

Pitfalls

  1. Results of diagnostic tests such as ESR and CRP can be elevated in cases of noninfected painful MOM arthroplasties.
  2. Automated cell counts can be falsely elevated in cases of MOM arthroplasties.
  3. Like acute infection, CDD can complicate a previously well-functioning joint arthroplasty and be accompanied by acute symptoms as well as abnormal studies such as elevated ESR, CRP, synovial cell count, and synovial neutrophil percentage.
Unfortunately, even this diagnostic tool is not always definitive in distinguishing between PJI and adverse reactions to metal particles. Case reports2,3 have noted elevated ESR and CRP levels in patients with noninfected painful MOM arthroplasties. Additionally, the development of a draining fistula has been reported one year following a noninfected MOM arthroplasty.4 Aspirated fluid can often be cloudy. Furthermore, erroneously elevated automated cell counts have been reported from aspirations of MOM arthroplasties.5 Additionally, adverse reactions to metal-on-metal may not be limited solely to MOM arthroplasties, as such reactions have also been postulated to occur from trunion wear in non-MOM cases.6 In working up painful MOM arthroplasty cases, physicians are still encouraged to use the usual diagnostic tools for diagnosing PJI. Physicians must keep in mind the pitfalls mentioned herein. If a joint aspiration is done, a manual cell count should be requested, as this will avoid the potential for an erroneous automated count. A truly elevated manual cell count with a high neutrophil percentage (> 80%) would direct suspicion more toward infection. In planning for surgery, preparations should be made for both prosthesis removal with placement of an antibiotic cement spacer 233versus a single-stage revision with the understanding that a final decision might depend upon intraoperative findings. Frozen sections taken at the time of surgery can be helpful because MOM adverse reactions seem to be dominated by a lymphocytic tissue response while PJI is dominated by a neutrophilic response. Ultimate treatment may finally rely on clinical suspicion when laboratory data is equivocal.
Patients with crystalline deposition disease (CDD) can present with acute pain, inflammation, and erythema in a previously well-functioning joint arthroplasty. While the diagnostic dilemma in painful MOM arthroplasties often involves a differentiation from chronic infection, the dilemma in CDD involves ruling out acute infection. There are few reports of CDD in total joint arthroplasty.7–10 However, these reports are generally consistent in describing an acute onset of symptoms accompanied by an elevated ESR and CRP. Aspiration of the affected joint often yields cloudy fluid. The synovial cell count can be elevated with a preponderance of neutrophils. The diagnosis of CDD in these cases, as with native joints, relies upon the identification of crystals in the aspirated synovial fluid or in synovial tissue. The correct diagnosis has clear implications, since CDD can often be treated conservatively with anti-inflammatory medications. While most reports of CDD in joint arthroplasty involve gout, pseudogout has also been reported after total knee arthroplasty.11 The presence of crystals in a culture-negative aspiration from a joint replacement in a patient with symptoms that respond to medical treatment is essentially the definition of CDD in joint arthroplasty.
 
Controversies
  • It has been suggested that the damage to tissue that occurs from the inflammatory processes related to adverse reactions in MOM arthroplasties, trunion 234corrosion, or CDD-affected arthroplasties may predispose this tissue to infection.
 
References
  1. Parvizi J, Zmistowski B, Berbari EF, et al. New definition for periprosthetic joint infection: from the Workgroup of the musculoskeletal Infection Society. Clin Orthop Rel Res. 2011;469:2992–4.
  1. Blumenfield TJ, Bargar WL, Campbell PA. A painful metal-on-metal total hip arthroplasty. A diagnostic dilemma. J Arthroplasty. 2010;25:1168.e1-4.
  1. Campbell P, Shimmin A, Walter L, et al. Case report: metal sensitivity as a cause of groin pain in metal-on-metal resurfacing. J Arthroplasty. 2008:23:1080-5.
  1. Earll MD, Earll PG, Rougeux RS. Case report: wound drainage after metal-on-metal hip arthroplasty secondary to presumed delayed hypersensitivity reaction. J Arthroplasty. 2011;26:338.e5-7.
  1. Berend KR. Symposium S: Metal-on-metal hip replacement: current status and recommendations for patient management. 2012 AAOS Annual Meeting, San Francisco.
  1. Lindgren JU, Brismar BH, Wikstrom AC. Adverse reaction to metal release from a modular metal-on-polyethylene hip prosthesis. J Bone Joint Surg Br. 2011;93:1427–30.
  1. Archibeck MJ, Rosenberg AG, Sheinkop MB, et al. Gout-induced arthropathy after total knee arthroplasty. A report of two cases. Clin Orthop Rel Res. 2001;392:377–82.
  1. Crawford I, Kumar A, Shepherd GJ. Gouty synovitis after total knee arthroplasty: a case report. J Orthop Surg. 2007;15:384–5.
  1. Freehill MT, McCarthy EF, Khanuja HS. Case report: total knee arthroplasty failure and gouty arthropathy. J Arthroplasty. 2010;25:658.e7-10.
  1. Ortman BL, Pack LL. Aseptic loosening of a total hip prosthesis secondary to tophaceous gout. A case report. J Bone Joint Surg Am. 1987;69:1096–9.
  1. Sonsale PD, Philipson MR. Case report: pseudogout after total knee arthroplasty. J Arthroplasty. 2007;22:271–2.
Section 4
235Treatment of Periprosthetic Joint Infection
Erik N Hansen

Total Joint Arthroplasty in Patients with Prior Septic Arthritischapter 32

Joseph A Karam,
Carl Deirmengian
 
Current Evidence
 
Introduction
Total joint arthroplasty (TJA) in adult patients with a history of septic arthritis presents a clinical challenge for the treating orthopedic surgeon. Along with the greater complexity of surgical technique required when operating on severely damaged joints with extensive scarring of the soft tissues, the increased risk of infection is a concern for both patient and physician. In addition to the resurgence of dormant organisms potentially remaining from the index infection, soft tissue scarring and compromised vascular supply are major predisposing factors for periprosthetic joint infection (PJI).1 Because of the limited number of patients presenting with this situation and the few relevant studies available in the literature, evidence is currently insufficient to support clear guidelines about the measures that should be undertaken to prevent the occurrence of PJI. Nevertheless, certain strategies at both the preoperative and the intraoperative stages seem to be crucial in minimizing the risk of infection and will be discussed in this chapter.
Septic arthritis is a known cause of early-onset osteoarthritis. The degradative enzymes released by both 238the infecting bacteria and the neutrophils of the host immune response result in direct chondrotoxicity. Most patients undergoing total knee arthroplasty (TKA) with a prior history of a septic knee had their infection as an adult,2,3 whereas most patients undergoing total hip arthroplasty (THA) for end-stage hip arthritis as a sequela of a prior septic hip had their infection in childhood or infancy, and present for surgery at an earlier time, usually in their fourth or fifth decade.4 However, Bauer et al3 reported on patients undergoing TJA for sequelae of septic arthritis of the hip, all of whom had onset of their index infection in adulthood.

Rothman Institute Current Practices

  1. All candidates for TJA who have a history of septic arthritis receive preoperative CRP and ESR tests and undergo joint aspiration for synovial fluid analysis and culture.
  2. Between three to five tissue cultures are taken intraoperatively and sent for microbiologic culture. Most of our physicians do not perform frozen-section analysis owing to prior difficulties in interpreting data provided by the pathology department.
  3. We currently use antibiotic impregnated cement in all TKAs and this same protocol is followed in patients with a history of septic arthritis.
  4. Most of our surgeons currently recommend uncemented arthroplasty in candidates for THA with a prior history of septic arthritis of the hip.
  5. Our perioperative antibiotic protocol is not altered in these specific patients (cf. chapter 15 for details about antibiotic prophylaxis protocols).
 
Preoperative Evaluation
To minimize the occurrence of PJI in patients with a history of prior septic arthritis, a thorough preoperative evaluation is apparently the single most important aspect of patient management. In addition to performing a thorough history 239and physical examination, basic laboratory tests should be ordered, including serum C-reactive protein (CRP) levels and erythrocyte sedimentation rate (ESR) to rule out an indolent infection. Several authors also suggest performing a joint aspiration for synovial fluid analysis (total white blood cell count and leukocyte differential) and synovial fluid culture.2,4,5 Kim et al5 systematically performed a hip aspiration eight weeks preoperatively in their patients with prior history of childhood septic arthritis of the hip. In the case of dry aspirations, they performed a lavage of the joint with saline and cultured the retrieved fluid.

Pitfalls

  1. Patients should stop taking antibiotics before surgery (and aspiration) to prevent any interference with culture results.
  2. Between three to five tissue cultures should be taken for culture at the time of surgery.
 
Intraoperative Strategies
During the surgical procedure, several diagnosis- and treatment-related steps should be followed to maximize the chances of a successful outcome. To make the diagnosis of occult infection, in contrast to an uncomplicated primary joint replacement, multiple intraoperative tissue samples should be sent for culture. Bauer et al3 identified ongoing infection in seven of 23 cases of presumably cured septic arthritis, on the basis of positive intraoperative cultures. All of those patients received appropriate antibiotic therapy postoperatively and none developed PJI as of the latest follow-up. Kim et al5 found negative culture results in all 170 hips in patients with a history of childhood septic arthritis. Intraoperative frozen-section analysis is also advocated by some authors, as long as pathologists are comfortable with analyzing these samples.2 Kim et al5 recommended this analysis when finding suspicious-looking tissue at the time of surgery. Regarding treatment-related 240measures, extensive debridement is crucial, and Bauer et al3 advocated systematic total synovectomy. Many surgeons use antibiotic-loaded cement for cemented implants, even though no clear proof of its benefit exists.2
 
Clinical Outcomes
The incidence of PJI in this specific patient population varies among reported series, with very encouraging results in the recent literature (Table 32.1). Jerry et al1 found a 7.7% risk of PJI in their 65 patients who had a history of septic arthritis and underwent TKA. This risk was found to be increased in patients with a history of infection of both bone and joint compared with an infection of the joint only, which led the authors to contraindicate TJA in patients with prior osteomyelitis. The authors also report a drastically elevated rate of infection after revision arthroplasty in their cohort, which reached 17%. In a more recent study from the same institution, which included a series of 19 patients, Lee et al2 reported only one case of PJI. They postulated that this observed decrease in the rate of PJI was due to thorough preoperative evaluation, advances in knee designs over those used by their predecessors, and the use of antibiotic-loaded cement. The one patient who had a recurrence suffered from diabetes and rheumatoid arthritis and was receiving chronic corticosteroid treatment, all of which had actually convinced the treating physician to perform the arthroplasty in two stages in his particular case. Bauer et al3 also report a rate of 5%, with one infection in their cohort of 23 patients, even though they do not mention using antibiotic-loaded cement. The authors attempted to identify possible predictors of PJI in these patients but failed to show any significant predisposing factor. In Kim et al's5 cohort, recurrence occurred only in one patient (two hips) and that was the only case in which the interval between the septic arthritis episode and 241arthroplasty was less than 10 years.
Table 32.1   Summary of cited studies
Paper
Year
N
Population
Average Follow-up (y)
No. (%) of PJI
Other Major Complications (%)
AB in Cement?
Jerry et al1
1988
65
TKA in patients with prior SA
6.1
5 (7.7)
PJI after revision TKA: 17
Superficial infection: 7.7
Hematoma: 6.2
Manipulation under anesthesia: 41.5
No
Lee et al2
2002
16
TKA in patients with prior SA
5
1 (6.3)
Skin necrosis: 12.5
Hematoma: 6.3
Skin bridge compromise: 6.3
Superficial infection: 6.3
Yes
Kim et al5
2003
161
THA in patients with childhood septic arthritis
Cemented: 9.8
Uncemented: 10.8
1 (0.6)
Osteolysis: 57.1 of hips
Trochanteric nonunion: 5.3
Heterotopic ossification: 8.4
Peroneal nerve palsy: 1.2
Periprosthetic fracture (all uncemented): 1.8
No242
Park et al4
2005
75*
THA in patients with childhood septic arthritis
5.8
1 (1.3)*
Sciatic nerve palsy: 1.3
PPFx: 1.3
N/A
Bauer et al3
2010
23†
TKA/THA in patients with history of adult-onset septic arthritis2
5
1 (4.3)
N/A
No
* This study population included patients with a history of tuberculous arthritis, and in the 1 patient who developed PJI, the infection was of tuberculous origin.
† This study reported on 30 patients with active SA who underwent TJA.
AB, antibiotic; N/A, not applicable; PJI, periprosthetic joint infection; PPFx, periprosthetic fracture; SA, septic arthritis; THA, total hip arthroplasty; TKA, total knee arthroplasty.
243
They thus confirmed their previously stated recommendation that TJA should be undertaken a minimum of 10 years after septic arthritis.6 Park et al4 reported a series of 75 hips that underwent uncemented arthroplasty, and in only one case—that of a patient with a history of tuberculous arthritis—did PJI develop.4
 
Controversies
Even though resorting to a two-stage procedure is standard in patients with active septic arthritis in whom conservative medical management has failed, most authors advocate one-stage procedures in patients with a remote history of infection in their joint.3 However, Lee et al2 report two cases of remote septic arthritis in which the treating physician opted for a two-stage procedure with placement of an antibiotic-loaded cement spacer.
Many authors recommend the use of antibiotic-loaded cement for cemented arthroplasty in this specific population, although no clear proof of its benefit has been shown.2 However, recent studies indicate that antibiotic-loaded cement helps prevent PJI even in patients with no history of infection.7 Hence, its use should be encouraged even more in patients with remote infection of the joint. Nevertheless, reports of nonantibiotic-loaded cement have yielded very encouraging outcomes.3 Regarding THA, uncemented arthroplasty has led to a very good outcome, and the need for cemented THA simply for the sake of guaranteeing local antibiotic delivery through antibiotic-loaded cement does not seem justified.4,6
Perioperative systemic antibiotic administration also stands out as a subject of controversy. Bauer et al3 initiated systemic antibiotic therapy after obtaining operative samples for culture and maintained it until the definitive results of those cultures were available. Antibiotics were 244first based on the organism identified at the time of the index infectious event, and in the case of positive cultures, they were tailored according to microbiologic sensitivities. Lee et al2 did not administer postoperative oral antibiotics, whereas Kim et al6 administered intravenous cephalosporins for two days postoperatively.
 
Conclusion
Overall, definitive data are lacking with regard to the optimal way to manage adult patients with a prior history of septic arthritis who are undergoing TJA. The incidence of PJI in these patients is acceptable according to available current literature, and arthroplasty should not be withheld for fear of an increased risk of infection.2–4 Extensive preoperative evaluation is of utmost importance to confirm complete eradication of the initial infection. Intraoperative cultures are also essential and help tailor eventual postoperative antibiotic therapy. The use of antibiotic cement in TKA and in cemented THA, even though lacking a clearly proven benefit, should be recommended. Uncemented THA in patients with history of septic arthritis of the hip seems to yield very good results.4,5 Apart from the risk of PJI, this patient population has a particularly increased risk of other postoperative complications, such as wound healing problems, hematomas, and the need for manipulation under general anesthesia because of extensive scarring, and should be counseled accordingly.1,2
 
References
  1. Jerry GJ Jr, Rand JA, Ilstrup D. Old sepsis prior to total knee arthroplasty. Clin Orthop Relat Res. 1988;(236):135–40.
  1. Lee GC, Pagnano MW, Hanssen AD. Total knee arthroplasty after prior bone or joint sepsis about the knee. Clin Orthop Relat Res. 2002;(404):226–31.245
  1. Bauer T, Lacoste S, Lhotellier L, et al. Arthroplasty following a septic arthritis history: a 53 cases series. Orthop Traumatol Surg Res. 2010;96:840–3.
  1. Park YS, Moon YW, Lim SJ, et al. Prognostic factors influencing the functional outcome of total hip arthroplasty for hip infection sequelae. J Arthroplasty. 2005;20:608–13.
  1. Kim YH, Oh SH, Kim JS. Total hip arthroplasty in adult patients who had childhood infection of the hip. J Bone Joint Surg Am. 2003;85-A:198-204.
  1. Kim YH. Total arthroplasty of the hip after childhood sepsis. J Bone Joint Surg Br. 1991;73:783–6.
  1. Parvizi J, Saleh KJ, Ragland PS, et al. Efficacy of antibiotic-impregnated cement in total hip replacement. Acta Orthop. 2008;79:335–41.246

Joint Arthroplasty in Patients with Hardware In Situchapter 33

William V Arnold
 
Current Evidence
The performance of hip or knee replacement in the setting of previous fracture surgery with retained hardware can present a challenging scenario for the arthroplasty surgeon. The subsequent surgery can be as straightforward as a routine primary arthroplasty procedure or as difficult and perhaps more complex than a revision procedure. Careful preoperative planning with appropriate preoperative radiographic evaluation can help to predict which of these disparate scenarios the surgeon will likely face.

Rothman Institute Current Practices

  1. As with revision arthroplasties, preoperative workup for infection in these patients is recommended.
  2. Only hardware interfering with placement of the prosthesis is removed.
  3. Consider approaching difficult cases as a staged procedure, with removal of hardware, as a first stage. When satisfactory healing has occurred, then arthroplasty can be considered as a second stage. If infection is suspected, then an antibiotic cement spacer may be placed as part of the first stage.
 
One-Stage or Two-Stage Procedure
As a general rule, arthroplasty can be performed as a single stage, with previous hardware removed only if it interferes 248with the placement of the arthroplasty components. Removal of the entire hardware is recommended only in patients with prior history of infection at the site of hardware. In these patients arthroplasty should be performed as a two-stage procedure. During the initial stage, the hardware is removed, bony cuts are made, extensive debridement is done, and possibly an antibiotic spacer is inserted. Reimplantation is then performed at a later stage when the wound and soft tissue have healed, which usually takes three to six weeks. Another scenario requiring the two-stage approach is that of patients in whom the hardware has to be removed through a separate incision from the planned arthroplasty incision.
 
Surgical Strategy

Pitfalls

  1. Bypass stress risers that may occur from hardware removal.
  2. The greatest risk encountered when knee arthroplasty is performed following previous fracture treatment may not involve hardware removal, but rather may involve the exposure and subsequent healing of the wound and soft tissue.
Hip: On the femoral side of hip arthroplasty, surgeons may encounter hardware from treatment of a previous hip fracture,1 femur fracture, hip dysplasia, or slipped capital femoral epiphysis (SCFE). Such hardware either can be removed and the generated bone defects bypassed with the use of a long-stemmed femoral component or left in place as long as the hardware does not interfere with the use of conventional components. In the younger patient population, removal of “interfering” hardware may still allow the use of proximally coated stems thereby avoiding future loss of proximal bone sometimes seen with stems that had a more distal fixation (Fig. 33.1). Removal of screws from the femoral head, such as those used for treatment of SCFE or subcapital 249fractures, can easily be accomplished. It is critical that the hip be dislocated prior to removal of the screw to prevent fracture of the shaft at the screw site. Occasionally, screws heads may be difficult to find or may be stripped. In these circumstances, the neck cut should be performed first and the head removed piecemeal, which allows tapping the screw out through the lateral cortex.
Special attention may need to be paid to the greater trochanter if this has been involved in previous surgery. If hardware from around the trochanter needs to be removed, weakening and subsequent fracture of the trochanter may result. One may consider performing an extended osteotomy to protect the trochanter and obtain better fixation. The presence of a significant proximal femoral deformity or malunion can also present a challenge. In these cases, an extended trochanteric osteotomy or realignment osteotomy may be required.
Figure 33.1: Stem with distal fixation
In patients with intramedullary hardware in place that either cannot be removed (some old devices such as a Judet nail 250are extremely difficult to remove) or, if removed, may lead to severe weakening of the cortex, consideration may be given to the use of resurfacing arthroplasty.2 Removal of intramedullary devices inserted antegrade may leave a significant weakness in the abductors that can increase the likelihood of instability and/or postoperative limp. These issues need to be discussed with the patient.
Knee: The development of post-traumatic arthritis is not unusual following periarticular fractures about the knee or following extra-articular fractures that significantly alter the mechanics of the knee joint. Any subsequent knee arthroplasty must take into account the problems presented by adjacent hardware and/or altered joint mechanics. The removal of hardware can certainly leave a stress riser, which can result in refracture.3,4 Often the biggest challenge presented by previous surgeries about the knee does not involve hardware, but rather involves dealing with the incisions from these previous surgeries.5 Wound healing problems need to be anticipated preoperatively. Patients should be counseled appropriately before undergoing these arthroplasty procedures. For example, a reoperation rate of 21% has been reported when total knee arthroplasty is performed in patients with a prior tibial plateau fracture.6 Similar problems were reported in another study.7 The complication rate is even worse in the case of tibial plateau fractures complicated by infection. When such patients underwent total knee arthroplasty, a 53% complication rate was reported, including a recurrence of infection in 26%.8
The other important challenge with performing knee arthroplasty in patients with prior intra-articular fractures may relate to exposure that can lead to patellar tendon and collateral ligament avulsions.6 In these patients, extreme care should be exercised to debride the lateral and medial gutters and remove adhesions and scar. Consideration should also be given to extended exposures, 251such as a quadriceps snip and, very rarely a tibial tubercle osteotomy. The removal of hardware around the knee may also require the use of a previous incision that may be in proximity to the anterior incision intended for arthroplasty. Wound healing problems are also not uncommon in patients with post-traumatic arthritis of the knee with hardware in place.
The hardware around the knee may be single or multiple screws that can easily be removed without generating stress risers. Most commonly, however, the surgeon encounters plates and screws used for fixation of periarticular fractures. In these cases, the hardware (screws) often traverses the intercondylar area and thereby can interfere with the intercondylar notch cut of a posteriorly stabilized prosthesis. Such hardware must be removed in its entirety or at least cut and removed from the intercondylar area. Stress risers can be addressed by augmenting the area with bone substitutes or grafts or by bypassing the area with a stemmed femoral component. We prefer to remove screws that interfere with insertion of components in such cases and leave the cortical plate and other screws in place. This avoids the generation of stress risers and the use of revision components in most cases. If the entire plate and screws need to be removed, one may consider the use of a conventional knee prosthesis and insertion of a prophylactic retrograde intramedullary nail into the femur at the same time.9
Intramedullary femoral hardware presents an additional challenge because it precludes the use of intramedullary alignment guides for the placement of the femoral component. This problem has been largely overcome by the use of computer navigation in such cases.10,11 Computer navigation has also been used successfully in knee arthroplasty to address the problem of extra-articular deformity about the knee joint.10,11252
Hardware from the treatment of prior tibial fractures, especially tibial plateau fractures, presents similar problems and can be addressed with similar solutions. Often the problem with the tibial component involves the presence of hardware in the metaphyseal space needed to accommodate the keel of the tibial baseplate. This can sometimes be addressed by using a lower profile tibial component, such as a pegged tibial baseplate.12
 
Outcome
Total hip arthroplasty performed in patients with a previous history of an acetabular fracture has historically met with poor results, with 52.9% loosening of the acetabular component noted at a mean follow-up of 7.5 years.13 These results, however, have improved significantly with the use of uncemented components.14 More recent studies of this patient group have reported cemented acetabular component survival, with aseptic loosening as an endpoint, of 97% and 100% at an average follow-up of 4.7 years and 6.3 years, respectively.15,16 However, the risk of complications is still substantial in this group of patients, with a five-year survival of 79% when revision, loosening, dislocation, or infection is used as an endpoint.15 The survivorship of hip arthroplasties done for failed treatment of intertrochanteric fractures has been reported as high as 100% and 87.5% at seven and 10 years, respectively.17
 
References
  1. Angelini M, McKee MD, Waddell JP, Haidukewych G, Schemitsch EH. Salvage of failed hip fracture fixation. J Orthop Trauma. 2009;23:471–8.
  1. Mont MA, McGrath MS, Ulrich SD, Seyler TM, Marker DR, Delanois RE. Metal-on-metal hip resurfacing arthroplasty in the presence of extra-articular deformities or implants. J Bone Joint Surg Am. 2008;90(suppl 3):45–51.253
  1. Bostman OM. Refracture after removal of a condylar plate from the distal third of the femur. J Bone Joint Surg Am. 1990;72:1013–8.
  1. Davison BL. Refracture following plate removal in supracondylar-intercondylar femur fractures. Orthopedics. 2003;26:157–9.
  1. Vince KG, Abdeen A. Wound problems in total knee arthroplasty. Clin Orthop Rel Res. 2006;452:88–90.
  1. Weiss NG, Parvizi J, Trousdale RT, Bryce RD, Lewallen DG. Total knee arthroplasty in patients with a prior fracture of the tibial plateau. J Bone Joint Surg Am. 2003;85:218–21.
  1. Saleh KJ, Sherman P, Katkin P, Windsor R, Haas S, Laskin R, et al. Total knee arthroplasty after open reduction and internal fixation of fractures of the tibial plateau: a minimum five-year follow-up study. J Bone Joint Surg Am. 2001;83:1144–8.
  1. Larson AN, Hanssen AD, Cass JR. Does prior infection alter the outcome of TKA after tibial plateau fracture? Clin Orthop Rel Res. 2009;467:1793–9.
  1. Ries MD. Case report: prophylactic intramedullary femoral rodding during total knee arthroplasty with simultaneous femoral plate removal. J Arthroplasty. 1998;13:718–21.
  1. Klein GR, Austin MS, Smith EB, Hozack WJ. Case report: total knee arthroplasty using computer-assisted navigation in patients with deformities of the femur and tibia. J Arthroplasty. 2006;21:284–8.
  1. Fehring TK, Mason JB, Moskal J, Pollock DC, Mann J, Williams VJ. When computer-assisted knee replacement is the best alternative? Clin Orthop Rel Res. 2006;452:132–6.
  1. Kamath AF, Levack A, Manchester D, Israelite CL. Total knee arthroplasty after tibial intramedullary nailing: use of a pegged, porous tantalum tibial baseplate. Tech Knee Surg. 2011;10:166–70.
  1. Romness DW, Lewallen DG. Total hip arthroplasty after fracture of the acetabulum. J Bone Joint Surg Am. 1990;72:761–4.
  1. Berry DJ, Halasy M. Uncemented acetabular components for arthritis after acetabular fracture. Clin Orthop Rel Res. 2002;405:164–7.254
  1. Ranawat A, Zelken J, Helfet D, Buly R. Total hip arthroplasty for posttraumatic arthritis after acetabular fracture. J Arthroplasty. 2009;24:759–67.
  1. Lai O, Yang J, Shen B, Zhou Z, Kang P, Pei F. Midterm results of uncemented acetabular reconstruction for post-traumatic arthritis secondary to acetabular fracture. J Arthroplasty. 2011;26:1008–13.
  1. Haidukewych GJ, Berry DJ. Hip arthroplasty for salvage of failed treatment of intertrochanteric hip fractures. J Bone Joint Surg Am. 2003;85:899–904.

Management of Wound Drainagechapter 34

James J Purtill
 
Current Evidence
 
Background
Drainage from a surgical incision is common following total hip and total knee arthroplasty. The drainage is usually contained within the surgical dressing that is placed under sterile conditions in the operating room. In general, postoperative drainage consists of blood and serous fluid. In most cases, this drainage stops before the surgical dressing is removed. Serosanguineous drainage that persists beyond 48 hours occurs in 1.3% to 3% of patients undergoing primary total joint arthroplasty.1,2 Prolonged wound drainage is associated with a prolonged hospital stay.3 Lack of wound drainage indicates that the wound has a watertight seal, which may prevent retrograde bacterial contamination of the deeper soft tissues and orthopedic implants.

Rothman Institute Current Practices

  1. Sterile dressing for drainage after surgical dressing is removed.
  2. Negative-pressure dressing for drainage beyond 4 days.
  3. Irrigation and debridement for drainage beyond 10 days.
Infection is the most frequent early complication after total hip and total knee replacement.4 Most infections present within the first year following surgery and may be associated with contamination at the time of surgery or in the early postoperative period.5 Persistent drainage that lasts more than 48 hours has been implicated 256as a risk factor for bacterial infection following joint replacement surgery.1–4,6,7 Each day of persistent wound drainage increases the risk of infection by 42% in total hip arthroplasty and 29% in total knee arthroplasty.3 Retrograde bacterial contamination may lead to superficial surgical site infection. The development of deep infection is much more common in patients treated for superficial infections.7,8
Risk factors for persistent wound drainage include malnutrition,2 the use of low molecular weight heparin3 or warfarin (Coumadin) with an elevated international normalized ratio9 for postoperative thromboembolic disease prophylaxis, obesity,3–5 hematoma,3,4,7 diabetes,8 the use of suction drains,3,9 as well as a higher American Society of Anesthesia Score.5
 
Nonoperative Treatment
Treatment for persistent wound drainage initially consists of local wound care (sterile dressing and wound cleansing to decrease bacterial contamination). Wound drainage has been shown to stop in most patients between two and four days postoperatively.2 Negative-pressure dressings (vacuum) may be used to augment wound healing if wound drainage persists beyond four days. Negative-pressure dressings in general surgical patients have been shown to normalize tissue stresses,10 reduce seroma,11 and aid in healing of surgical wounds in high-risk patients.12 In a study of total hip replacement, negative-pressure dressings reduced seroma and improved healing.13
 
Surgical Management
Surgical intervention should be considered for patients when wound drainage persists beyond 10 days despite nonoperative treatment.1,2,6,8 Surgical treatment consists of irrigation and debridement of the superficial soft tissue, with wound exploration and irrigation and debridement of the deep periarticular tissue if there is communication 257with the periprosthetic hematoma.2 Exchange of modular components (polyethylene liner for total knee arthroplasty; femoral head and acetabular liner for total hip arthroplasty) should be performed if communication with the deep tissue is encountered. Multiple cultures should be obtained at each level. Positive cultures should be expected in 25% of cases.1,2 Treatment with intravenous antibiotics and consultation with an infectious disease specialist are in order if cultures are positive. Antibiotic treatment should be withheld until cultures have been obtained. The presence of purulent fluid at the time of irrigation and debridement portends a poor outcome.2,8
 
References
  1. Weiss AP, Krackow KA. Persistent wound drainage after primary total knee arthroplasty J Arthroplasty. 1993;8(3):285–9.
  1. Jaberi FM, Parvizi J, Haytmanek CT, Joshi A, Purtill J. Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty. Clin Orthop Relat Res. 2008;466(6):1368–71.
  1. Patel VP, Walsh M, Sehgal B, Preston C, DeWal H, Di Cesare PE. Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty. J Bone Joint Surg Am. 2007;89(1):33–8.
  1. Cordero-Ampuero J, de Dios M. What are the risk factors for infection in hemiarthroplasties and total hip arthroplasties? Clin Orthop Relat Res. 2010;468(12):3268–7.
  1. Pulido L, Ghanem E, Joshi A, Purtill JJ, Parvizi J. Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res. 2008;466(7):1710–5.
  1. Vince K, Chivas D, Droll KP. Wound complications after total knee arthroplasty. J Arthroplasty. 2007;22(4 suppl 1):39–44.
  1. Saleh K, Olson M, Resig S, Bershadsky B, Kuskowski M, Gioe T, et al. Predictors of wound infection in hip and knee joint replacement: results from a 20 year surveillance program. J Orthop Res. 2002;20(3):506–15.258
  1. Galat DD, McGovern SC, Larson DR, Harrington JR, Hanssen AD, Clarke HD. Surgical treatment of early wound complications following primary total knee arthroplasty. J Bone Joint Surg Am. 2009;91(1):48–54.
  1. Minnema B, Vearncombe M, Augustin A, Gollish J, Simor AE. Risk factors for surgical-site infection following primary total knee arthroplasty. Infect Control Hosp Epidemiol. 2004;25(6):477–80.
  1. Wilkes RP, Kilpadi DV, Zhao Y, Kazala R, McNulty A. Closed incision management with negative pressure wound therapy (CIM):biomechanics. Surg Innov. 2012;19(1):67–75.
  1. Kilpadi DV, Cunningham MR. Evaluation of closed incision management with negative pressure wound therapy (CIM): hematoma/seroma and involvement of the lymphatic system. Wound Repair Regen. 2011;19(5):588–96.
  1. Stannard JP, Atkins BZ, O'Malley D, Singh H, Bernstein B, Fahey M, et al. Use of negative pressure therapy on closed surgical incisions: a case series. Ostomy Wound Manage. 2009;55(8):58–66.
  1. Pachowsky M, Gusinde J, Klein A, et al. Negative pressure wound therapy to prevent seromas and treat surgical incisions after total hip arthroplasty. Int Orthop. 2012;36(4):719–22.

Management of Fungal Periprosthetic Joint Infectionschapter 35

Khalid Azzam
 
Current Evidence
Periprosthetic fungal infection is a rare complication of total joint replacement. The exact incidence is unknown. One of the important challenges associated with fungal prosthetic joint infection (PJI) is that published case reports present a wide variety of treatment methods, surgical and medical, as well as variable treatment outcomes. It is difficult to draw definitive conclusions on the basis of the very small number of cases in each report. Further, the surgical treatment for these cases varies considerably, making interpretation of the presented data difficult and not directly comparable.1
 
Types of Fungi
Fungal organisms commonly encountered in cases of periprosthetic joint infections include Candida species (C. albicans, C. parapsilosis, C. glabrata, and C. tropicalis) and Aspergillus species (A. fumigatus and A. niger).
The most important virulence factor for fungi, especially C. albicans, in the pathogenesis of periprosthetic infection is biofilm formation (Fig. 35.1). Adherence of the blastospores to the surface of the implant is followed by 260growth and aggregation of the yeast cells.
Figure 35.1: Cells were grown in free-living (planktonic) cultures in Spider medium; filamentation was examined by phase contrast microscopy at 400× magnification (top panels). Biofilms were grown under standard conditions in Spider medium, and stained with concanavalin A conjugate for confocal laser scanning microscopy (CSLM) visualization. [From Nobile CJ, et al. Critical role of Bcr1-dependent adhesions in C. albicans biofilm formation in vitro and in vivo. PLoS Pathog. 2006;2:636-49]
261
This process involves additional gene expression as planktonic forms are transformed into the biofilm forms of yeast cells. The extracellular material is then formed and gradually increases until it completely surrounds fungal colonies. This formation confers resistance to antifungal agents. C. albicans produces larger and more complex biofilms than other Candida species.2,3
Patients with fungal PJI are believed to be a different type of host, with decreased cellular immunity often due to an underlying immunosuppression. Other potential risk factors include multiple revision surgeries and complex bone and soft tissue reconstructions, as well as prolonged hospitalizations.4
 
Antifungal Drugs
Fluconazole and amphotericin B remain the mainstay of systemic antifungal therapy. Resistance of Candida species to -azole drugs has been reported.5 Resistance to fluconazole was noted among C. glabrata infections.1 Thus, selecting appropriate antifungal treatment requires a multiteam approach involving infectious disease specialists, clinical pharmacologists, and the treating orthopedic surgeon.
 
Treatment Outcome of Fungal Periprosthetic Joint Infections (Table 35.1)
 
Controversies
 
Newer Antifungal Agents
Less toxic and potentially more effective broad-spectrum systemic antifungal agents have been introduced to overcome the problems of standard therapy. Among these are the newer -azole drugs voriconazole, posaconazole, and ravuconazole and the echinocandins caspofungin, micafungin, and antidulafungin. In one study, caspofungin displayed potent in vitro activity against sessile C. albicans cells within biofilms, with minimum inhibitory concentrations (MICs) at which 50% of the sessile cells were inhibited well within the drug's therapeutic range.11 Literature coverage of the use of these agents to treat periprosthetic infections is limited to two patients treated with voriconazole12,13 and two with caspofungin.14,15

Pitfalls

  1. Make sure to use antibiotics in addition to antifungal agents in the cement spacer to prevent superinfection and to treat a coexisting bacterial infection.
  2. Consultation with the microbiology team is prudent to differentiate fungal contamination from a true fungal infection, especially in cases of positive fluid cultures.
 
Antifungal Cement Spacer
The appropriate choice of antifungal for addition to cement spacer remains controversial. Previously the only available 269agent for use with cement was amphotericin B. The determination the appropriate dose of this drug depended to a large extent on the type of fungal infection, the sensitivity of the pathogen to this drug, and pre-existing comorbidities of the host. Amphotericin was the preferred agent to be mixed with bone cement as it is heat stable, broad-spectrum, and available in sterile powder form. However, further studies have shown inadequate elution of amphotericin B from bone cement.16,17 Recent data suggest that voriconazole is an effective agent when mixed with bone cement.18–20 In a recent study, 57% to 63% of voriconazole was released from cement in vitro by day 30.20 Another study demonstrated that biologically active concentrations of voriconazole eluded from cement beads over a time period of 2 weeks.18 Thus, it appears that voriconazole may be an effective alternative to amphotericin for local antimicrobial delivery.
 
References
  1. Azzam K. Microbiological, clinical, and surgical features of fungal prosthetic joint infections: a multi-institutional experience. J Bone Joint Surg Am. 2009;91(Suppl 6):142–9.
  1. Chandra J. Biofilm formation by the fungal pathogen Candida albicans: development, architecture, and drug resistance. J Bacteriol. 2001;183:18.
  1. Kuhn DM. Comparison of biofilms formed by Candida albicans and Candida parapsilosis on bioprosthetic surfaces. Infect Immun. 2002;70:2.
  1. Kao AS. The epidemiology of candidemia in two United States cities: results of a population-based active surveillance. Clin Infect Dis. 1999;29:5.
  1. Selmon GP. Successful 1-stage exchange total knee arthroplasty for fungal infection. J Arthroplasty. 1998;13:1.
  1. Brooks DH. Successful salvage of a primary total knee arthroplasty infected with Candida parapsilosis. J Arthroplasty. 1998;13:6.270
  1. Fukasawa N. Candida arthritis after total knee arthroplasty--a case of successful treatment without prosthesis removal. Acta Orthop Scand. 1997;68:3.
  1. Simonian PT. Candida infection after total knee arthroplasty. Management without resection or amphotericin B. J Arthroplasty. 1997;12:7.
  1. Wada M. Prosthetic knee Candida parapsilosis infection. J Arthroplasty. 1998;13:4.
  1. Pappas PG. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009;48:5.
  1. Bachmann SP. In vitro activity of caspofungin against Candida albicans biofilms. Antimicrob Agents Chemother. 2002;46:11.
  1. Fabry K. Infection of a total knee prosthesis by Candida glabrata: a case report. Acta Orthop Belg. 2005;71:1.
  1. Gaston G. Candida glabrata periprosthetic infection: a case report and literature review. J Arthroplasty. 2004;19:7.
  1. Dumaine V. Successful treatment of prosthetic knee Candida glabrata infection with caspofungin combined with flucytosine. Int J Antimicrob Agents. 2008;31:4.
  1. Lejko-Zupanc T. Caspofungin as treatment for Candida glabrata hip infection. Int J Antimicrob Agents. 2005;25:3.
  1. Goss B. Elution and mechanical properties of antifungal bone cement. J Arthroplasty. 2007;22:6.
  1. Marra F. Amphotericin B-loaded bone cement to treat osteomyelitis caused by Candida albicans. Can J Surg. 2001;44:5.
  1. Grimsrud C, Raven R, Fothergill AW, Kim HT. The in vitro elution characteristics of antifungal-loaded PMMA bone cement and calcium sulfate bone substitute. Orthopedics 2011;34:e378–81.
  1. Rouse MS, Heijink A, Steckelberg JM, Patel R. Are anidulafungin or voriconazole released from polymethylmethacrylate in vitro? Clin Orthop Relat Res. 2011;469:1466–9.
  1. Miller RB, McLaren AC, Pauken C, Clarke HD, McLemore R. Voriconazole is Delivered From Antifungal-Loaded Bone Cement. Clin Orthop Relat Res. 2012.

Management of Mycobacterial Infectionchapter 36

Hooman Bakhshi
 
Current Evidence
 
Pathogenic Species
Periprosthetic joint infection (PJI) due to Mycobacteria is an uncommon cause of septic failure, but one that is well documented in the literature. Mycobacterium tuberculosis (MTB) is the causative pathogen in 0.3% of cases.1 The PJI may be either due to local reactivation or, less commonly, secondary to hematogenous seeding.2 The course of disease is usually insidious. PJI secondary to rapidly growing mycobacteria (RGM), including M. fortuitum, M. chelonae, M. abscessus, and M. smegmatis, is even more rare. They are defined by their unusual ability to grow on culture in less than a week, in contrast to MTB. A literature review published in 2007 identified a total of 18 cases.3

Rothman Institute Current Practices

  1. We routinely send AFB cultures in all revision arthroplasty cases.
  2. For documented infections, we start MTB treatment with three drugs for two months and then continue with two drugs for a total course of nine months.
One main source of these 272mycobacteria is tap water. Infection secondary to RGM can occur in both immunocompromised and healthy individuals.3 PJI secondary to Mycobacterium avium complex (MAC) is uncommon in immunocompetent individuals. Case reports have described these infections in patients with AIDS (one case) or recipients of solid organ transplant (two cases).2,4
 
Diagnosis
Considering the rarity and the indolent course of infection, a delay in diagnosis is not uncommon.1 Confirming the diagnosis usually entails combining data from the direct smear, histopathologic studies, and tissue culture, as no single test is 100% reliable. In fact, it has been shown that stained smears of tissue and bone are positive in only 10% to 20% of cases, and cultures are positive in only 30% to 60% of cases.5 Although acid-fast bacillus (AFB) culture is not necessary in all PJI cases, it should be considered in the following circumstances: (1) patients with a previous history of MTB septic arthritis in the native joint and (2) culture-negative PJI without a history of prior antibiotic administration.1 ELISA and PCR on joint tissue are faster than standard Loewenstein cultures and appear promising for an early, more accurate diagnosis. At the Rothman Institute, we routinely send for AFB cultures, as well as fungal cultures, in all revision arthroplasty cases.
 
Antimicrobial Therapy
The medical management of extrapulmonary MTB is the same as that of pulmonary MTB. The first-line drugs for MTB are isoniazid (INH), rifampin (RIF), pyrazinamide (PZA), ethambutol (EMB), and rifapentine. According to the joint statement of the American Thoracic Society, the Centers for Disease Control and Prevention, and the Infectious 273Diseases Society of America, empirical therapy should start with INH, RIF, PZA, and EMB for two months. If the culture shows the organism to be susceptible to both INH and RIF, EMB can be discontinued. After this initial phase, the course of treatment continues with two drugs, based on susceptibility testing (usually INH and RIF).6 For extrapulmonary MTB, a total course of six to nine months has been suggested.6 No general consensus exists on the duration of medical therapy regarding treatment of PJI secondary to MTB, as it is such a rare occurrence, and a range of six to 36 months has been proposed in different studies.2,5 Most nontuberculous mycobacteria are resistant to RIF, INH, and EMB.2 Macrolides have excellent in vitro activity against MAC.7 Some examples of effective antibiotics against RGM are amikacin, cefoxitin, imipenem, sulfonamides, and fluoroquinolones.2 With successful treatment, ESR and CRP will approach normal levels.8

Pitfalls

  1. Failure to suspect a mycobacterial PJI and thus failing to send for AFB cultures during revision surgery; also, if cultures are sent, they must be kept for a minimum of two weeks.
  2. Failure to complete the full course of antimicrobial treatment.
  3. Failure to check liver enzymes during antimicrobial treatment of MTB.
  4. Failure to monitor visual acuity and color discrimination during the course of EMB therapy.
Treatment of multiple drug-resistant MTB is especially difficult, and with the increasing rate of cases being identified, this scenario may prove to be a major clinical challenge in the future. In these particular cases, second-line medications have to be administered. This group includes, but is not limited, to streptomycin, capreomycin, 274cycloserine, ethionamide, and p-aminosalicylic acid. It has been suggested to treat these patients with multiple4–6 drugs for 24 months after culture conversion. A parenteral medication based on the susceptibility of the organism should be included in the treatment regimen.9
 
Surgical Management
Although successful treatment of PJI with prolonged medication has been described, most cases require a combination of medical and surgical treatment.10 Again, no general guideline is available for surgical intervention in PJI cases secondary to MTB, as the majority of publications are small case reports and series. Surgical options ranging from debridement, resection arthroplasty, and arthrodesis to one- or two-stage revision arthroplasty have been reported in different studies, with good results (Table 36.1).
 
Controversies
  • The appropriate composition of antimycobacterial-laden bone cement is unknown. To our knowledge, only one author has reported on the use of vancomycin- and rifampicin-loaded cement in an antibiotic spacer after prosthesis removal. The safety and efficacy of antimycobacterial-loaded cements are not clear and merit further investigation.11
  • Although for extrapulmonary MTB a total course of six to nine months of antimicrobial therapy has been recommended, no general guideline exists for PJI secondary to MTB.5
275
Table 36.1   Outcomes following treatment of PJI secondary to mycobacteria
Author
Journal
No. Patients
Organism
Antimicrobial
Duration (mo)
Surgical Treatment
Success Rate (%)
Marmor10
J Arthroplasty 2004
2
MTB
INH, RIF, and PZA
6
2-stage revision arthroplasty
100
Marmor10
J Arthroplasty 2004
1
MTB
INH, EMB, and PZA
8
Aggressive synovectomy and debridement
100
Shanbhag12
Acta Orthop Belg 2007
1
MTB
RIF, PZA, EMB, and pyridoxine
12
Debridement
100
Khater11
South Med J 2007
1
MTB
INH, RIF, PZA, and EMB
18
Removal of prosthesis and spacer placement
100276
Eid (4)
Clin Infect Dis 2007
8
RGM
Clarithromycin, trimethoprim-sulfamethoxazole,
amikacin, and imipenem-cilastatin
8
Debridement +/−removal of prosthesis + reimplantation
100
Neogi (6)
Acta Orthop Belg 2009
1
MTB
INH, RIF, PZA, and EMB
18
Medication only
100
Gupta (3)
Transpl Infect Dis 2009
1
MAC
ethambutol, rifabutin, and
azithromycin
12
Removal of prosthesis and spacer placement
?277
Klein (7)
J Arthroplasty 2011
1
MTB
INH, RIF, PZA, and EMB
19
Removal of prosthesis and spacer placement and reimplantation
100
Nardo (13)
J Med Case Rep 2012
1
MTB
INH, RIF, PZA, and EMB
15
Debridement
100
EMB, ethambutol; INH, isoniazid; MAC, Mycobacterium avium complex; MTB, Mycobacterium tuberculosis; PZA, pyrazinamide ; RGM, rapidly growing mycobacteria; RIF, rifampin.
278
 
References
  1. Berbari EF, Hanssen AD, Duffy MC, Steckelberg JM, Osmon DR. Prosthetic joint infection due to Mycobacterium tuberculosis: a case series and review of the literature. Am J Orthop. 1998;27(3):219–27.
  1. Marculescu CE, Berbari EF, Cockerill FR III, Osmon DR. Fungi, mycobacteria, zoonotic and other organisms in prosthetic joint infection. Clin Orthop Relat Res. 2006;451:64–72.
  1. Eid AJ, Berbari EF, Sia IG, Wengenack NL, Osmon DR, Razonable RR. Prosthetic joint infection due to rapidly growing mycobacteria: report of 8 cases and review of the literature. Clin Infect Dis. 2007;45(6):687–94.
  1. Gupta A, Clauss H. Prosthetic joint infection with Mycobacterium avium complex in a solid organ transplant recipient. Transpl Infect Dis. 2009;11(6):537–40.
  1. Neogi DS, Kumar A, Yadav CS, Singh S. Delayed periprosthetic tuberculosis after total knee replacement: is conservative treatment possible? Acta Orthop Belg. 2009;75(1):136–40.
  1. American Thoracic Society; Centers for Disease Control and Prevention (CDC); Infectious Diseases Society of America. Treatment of tuberculosis [published correction appears in MMWR Recomm Rep. 2005; 53(51):1203.Dosage error in article text]. MMWR Recomm Rep. 2003;52(RR-11):1–77.
  1. Heifets L. Susceptibility testing of Mycobacterium avium complex isolates. Antimicrob Agents Chemother. 1996;40:1759–1967.
  1. Klein GR, Jacquette GM. Prosthetic knee infection in the young immigrant patient—do not forget tuberculosis! J Arthroplasty. 2012;27(7):1414.e1-4.
  1. Sia IG, Wieland ML. Current concepts in the management of tuberculosis. Mayo Clin Proc. 2011;86(4):348–61.
  1. Marmor M, Parnes N, Dekel S. Tuberculosis infection complicating total knee arthroplasty: report of three cases and review of the literature. J Arthroplasty. 2004;19(3):397–400.
  1. Khater FJ, Samnani IQ, Mehta JB, Moorman JP, Myers JW. Prosthetic joint infection by Mycobacterium tuberculosis: an unusual case report with literature review. South Med J. 2007;100(1):66–9.279
  1. Shanbhag V, Kotwal R, Gaitonde A, Singhal K. Total hip replacement infected with Mycobacterium tuberculosis. A case report with review of literature. Acta Orthop Belg. 2007;73(2):268–74.
  1. De Nardo P, Corpolongo A, Conte A, Gentilotti E, Narciso P. Total hip replacement infected with Mycobacterium tuberculosis complicated by Addison disease and psoas muscle abscess: a case report. J Med Case Rep. 2012;6(1):3.280

Management of Prosthetic Joint Infection Caused by Enterococcuschapter 37

Mohammad R Rasouli
 
Current Evidence
Periprosthetic joint infection (PJI) caused by Enterococcus species, although relatively uncommon, is a potentially devastating complication. According to the available literature, only 2.5% to 3% of PJIs are caused by Enterococcus species;1,2 however, in one series reported by Phillips et al3 the frequency of enterococcal PJIs was reported as high as 9%. With the increasing number of total joint arthroplasties being performed each year, it is expected that the number of cases of enterococcal PJI will increase.
Enterococcus is a Gram-positive, facultatively anaerobic organism, formerly classified as Group D Streptococcus. Enterococcus species cause various types of infections, mainly nosocomial, including endocarditis, and urinary tract infection, as well as intra-abdominal and pelvic infections.4 E. faecalis and E. faecium are the major Enterococcus species that cause PJI (in 95% of cases); however, a small series of nine patients infected by an outbreak of E. gallinarum has been reported after total knee arthroplasty.5 E. gallinarum is intrinsically resistant to vancomycin.5
Pain, loosening of the implant, minimal systemic manifestations (fever occurs in about 10% of cases), and 282longer duration of symptoms have been suggested as clinical characteristics of enterococcal PJI.1

Rothman Institute Current Practices

  1. At the Rothman Institute, vancomycin, ampicillin, and gentamicin are routinely administered for patients with PJI caused by vancomycin-susceptible Enterococcus species.
  2. Patients infected with VRE are treated with either linezolid or daptomycin.
  3. Two-stage exchange arthroplasty is the preferred surgical option.
  4. Some surgeons prefer to do one-stage exchange in acute cases (< 4 weeks between starting symptoms and surgery) after total hip replacement.
  5. I&D may also be tried by some surgeons as the initial management; however, it is highly likely to fail.
  6. Resection arthroplasty is a reasonable option in patients with two or more instances of failed two-stage exchange arthroplasty.
  7. Salvage surgery (fusion or amputation) is performed in cases involving refractory infection with extensive soft tissue loss.
A considerable proportion of patients with enteroccocal PJI have comorbidities. In the study by El Helou et al,1 rheumatoid arthritis was found in 20% of patients, diabetes mellitus in 12%, steroid use in 12%, and malignancy in 6%. In a series from our institute and Rush Medical College that involved 36 joints with enterococcal PJI, rheumatoid arthritis was an accompanying condition in 17% of cases, diabetes mellitus in 14%, malignancy in 8%, organ transplant in 3%, and previous PJI in 14%.6
A considerable proportion of enterococcal PJIs are polymicrobial in nature, which makes infection eradication particularly difficult. In a recent investigation combining data between our institute and Rush Medical College, 14 of 36 joints (39%) with enterococcal PJI had polymicrobial infection.6 283The reason for the high proportion of polymicrobial infections in this series has not been elucidated but may have to do with the factors mentioned in the previous paragraph, including immunosuppression and history of prior PJI. In that study, patients in whom both Enterococcus species and methicillin-resistant Staphylococcus aureus (MRSA) were isolated from cultures were excluded, and the only cases included were monomicrobial PJIs caused by Enterococcus or polymicrobial PJIs with concomitant growth of Enterococcus species and a less virulent microorganism than MRSA. This allowed us to assume the Enterococcus was the main microorganism responsible for PJI. However, the distinction between these infections and polymicrobial PJIs is narrow and, if we consider these cases polymicrobial PJIs, the results support prior research showing that Enterococcus species, including vancomycin-resistant Enterococcus (VRE), can be isolated from up to 32% of polymicrobial PJIs.7
As with other types of PJI, administration of intravenous antibiotics based on the antibiogram is a crucial part of treating enterococcal PJI. Some authors have suggested combination antibiotic therapy for management of patients with enterococcal PJIs.8 However, in a study from the Mayo Clinic, the authors showed that patients who received monotherapy had the same outcome as those treated using a combination therapy regimen.1 In addition, the combination group had more cases of ototoxicity than the monotherapy group. Ampicillin and vancomycin are antimicrobial agents and can be used as monotherapy for treating enterococcal PJI.1 Aminoglycosides act synergistically with this regimen. However, administration of a systematic aminoglycoside is not essential for control of enterococcal PJI and can increase the risk of nephrotoxicity and ototoxicity.1284
Emerging antibiotic resistance, specifically to vancomycin, is a challenging problem for management of this specific type of PJI.6,9 Plasmid-mediated resistance to vancomycin was first described in 1986, and shortly thereafter numerous reports of the VRE species appeared in the literature.10 VRE species are phenotypically and genotypically heterogeneous and, among all of these phenotypes and genotypes, the VanA-resistance phenotype has been most commonly investigated.10 Enterococcus species that are vancomycin resistant are usually managed with either linezolid or daptomycin.11 Although linezolid resistance has been reported,12 daptomycin resistance has not been encountered.13
Surgical options for management of PJIs caused by Enterococcus species are similar to those for other types of PJI: irrigation and debridement (I&D), or one-stage and two-stage exchange arthroplasty. Despite an encouraging early report by El Helou et al,1 the management of enterococcal PJIs seems to be much more challenging.6,9,14 El Helou reported a two-year survival rate, free of infection recurrence, in 94% of patients treated with two-stage exchange, 76% of patients treated with resection arthroplasty, and 80% of patients treated with debridement and retention of the components. A recent collaborative study carried out by the Rothman Institute and the Department of Orthopedic Surgery at Rush Medical College showed that patients with enterococcal PJI often need multiple operations and that definite resection arthroplasty and salvage surgeries (fusion or amputation) are the final outcome in a considerable number of patients. In this series consisting of 36 cases of enterococcal PJI from our institute and Rush Medical College, six patients (17%) ultimately underwent resection arthroplasty and three patients (8.5%) needed salvage surgeries, including one fusion and two above-knee amputations.6285
 
Controversies
  • In contrast to the previous study by El Helou et al,1 it seems that management of enteroccoal PJI is more challenging than previously reported.6,9 The best surgical option for management of enteroccocal PJI is not clear, but two-stage exchange arthroplasty may be the best choice in the majority of cases.
  • Prior use of vancomycin has been suggested as a risk factor for development of VRE.15,16 Therefore, vancomycin should be administered cautiously as the first-line therapy in patients with enterococcal PJI.
  • Previous exposure to linezolid and infection with linezolid-resistant VRE is a matter of controversy.12,17,18

Pitfalls

  1. Management of enteroccocal PJI, particularly VRE, is very challenging, and a considerable number of patients need multiple operations, resection arthroplasty, salvage surgery, or chronic antibiotic suppression therapy.
  2. A considerable proportion of enteroccocal PJI is polymicrobial, which makes control of infection in these cases more difficult.
  3. As with other types of infections caused by Enterococcus species, particularly VRE, patients suffering from enteroccocal PJI may have a higher comorbidity index, which may make management of these cases more difficult.
 
References
  1. El Helou OC, Berbari EF, Marculescu CE, El Atrouni WI, Razonable RR, Steckelberg JM, et al. Outcome of enterococcal prosthetic joint infection: is combination systemic therapy superior to monotherapy? Clin Infect Dis. 2008;47:903–9.
  1. Sia IG, Berbari EF, Karchmer AW. Prosthetic joint infections. Infect Dis Clin North Am. 2005;19:885–914.286
  1. Phillips JE, Crane TP, Noy M, Elliott TS, Grimer RJ. The incidence of deep prosthetic infections in a specialist orthopaedic hospital: a 15-year prospective survey. J Bone Joint Surg Br. 2006;88:943–8.
  1. Murray BE. The life and times of the Enterococcus. Clin Microbiol Rev. 1990;3:46–65.
  1. Cooper MP, Lessa F, Brems B, Shoulson R, York S, Peterson A, et al. Outbreak of Enterococcus gallinarum infections after total knee arthroplasty. Infect Control Hosp Epidemiol. 2008;29:361–3.
  1. Rasouli MR, Tripathi MS, Kenyon R, Wetters N, Della Valle G, Parvizi J. Low rate of infection control in enterococcal periprosthetic joint infections. Clin Orthop Relat Res. In press. 
  1. Marculescu CE, Cantey JR. Polymicrobial prosthetic joint infections: risk factors and outcome. Clin Orthop Relat Res. 2008;466:1397–1404.
  1. Raymond NJ, Henry J, Workowski KA. Enterococcal arthritis: case report and review. Clin Infect Dis. 1995;21:516–22.
  1. Ries MD. Vancomycin-resistant Enterococcus infected total knee arthroplasty. J Arthroplasty. 2001;16:802–5.
  1. Arthur M, Courvalin P. Genetics and mechanisms of glycopeptide resistance in enterococci. Antimicrob Agents Chemother. 1993;37:1563–71.
  1. Twilla JD, Finch CK, Usery JB, Gelfand MS, Hudson JQ, Broyles JE. Vancomycin resistant Enterococcus bacteremia: an evaluation of treatment with linezolid or daptomycin. J Hosp Med. 2012;7:243–8.
  1. McGregor JC, Hartung DM, Allen GP, Taplitz RA, Traver R, Tong T, et al. Risk factors associated with linezolid-nonsusceptible enterococcal infections. Am J Infect Control. 2012 Feb 21. [Epub ahead of print]
  1. Cantón R, Ruiz-Garbajosa P, Chaves RL, Johnson AP. A potential role for daptomycin in enterococcal infections: what is the evidence? J Antimicrob Chemother. 2010;65:1126–36.
  1. Ching CK, Fraser SL, Wortmann GW. A case of Enterococcus faecalis prosthetic joint infection: a rare and difficult infection to treat. Hawaii Med J. 200665264–5. 273.287
  1. Peset V, Tallón P, Sola C, Sánchez E, Sarrión A, Pérez-Bellés C, et al. Epidemiological, microbiological, clinical, and prognostic factors of bacteremia caused by high-level vancomycin-resistant Enterococcus species. Eur J Clin Microbiol Infect Dis. 2000;19:742–9.
  1. Vergis EN, Hayden MK, Chow JW, Snydman DR, Zervos MJ, Linden PK, et al. Determinants of vancomycin resistance and mortality rates in enterococcal bacteremia. A prospective multicenter study. Ann Intern Med. 2001;135:484–92.
  1. Pai MP, Rodvold KA, Schreckenberger PC, Gonzales RD, Petrolatti JM, Quinn JP. Risk factors associated with the development of infection with linezolid- and vancomycin-resistant Enterococcus faecium. Clin Infect Dis. 2002;35:1269–72.
  1. Rahim S, Pillai SK, Gold HS, Venkataraman L, Inglima K, Press RA. Linezolid-resistant, vancomycin-resistant Enterococcus faecium infection in patients without prior exposure to linezolid. Clin Infect Dis. 2003;36:E146–8.288

Irrigation and Debridement with Modular Component Exchange for Periprosthetic Joint Infectionchapter 38

Erik N Hansen
 
Current Evidence
 
Historical Perspective
Irrigation and debridement (I&D) with modular exchange has historically been the recommended treatment for acute postoperative periprosthetic joint infection (PJI) and acute hematogenous PJI.1,2 The theory behind this practice was that because the bacterial glycocalyx had not yet formed at these early time points, by simply debriding the intra-articular bacterial load and exchanging the modular parts, one could potentially eradicate the infection, retain the prior components, and minimize morbidity in the patient. More recently, the literature is suggesting that this may not necessarily be the case.
 
Outcomes in Periprosthetic Hip and Knee Infection
The vast majority of published research on the outcomes following I&D for treatment of PJI has focused on 290either cohorts of total knee arthroplasty (TKA) patients or combined cohorts of total hip arthroplasty (THA) and TKA patients.

Rothman Institute Current Practices

  1. Aggressive debridement of all foreign material and nonviable-appearing tissue. Technique is akin to that of a tumor surgeon removing a soft tissue sarcoma.
  2. Scrub all retained components with Dakin's solution.
  3. Obtain at least three tissue samples; each should be collected with a new, clean instrument.
  4. Irrigate with 9 L warmed fluid, using pulse lavage: first 3 L mixed with polymyxin, second 3 L with dilute povidone-iodine (Betadine), last 3 L as normal saline. Then pour hydrogen peroxide into wound.
  5. Change gowns, gloves, and surgical setup between the I&D and modular component exchange.
  6. Patients are kept on a weight-adjusted dose of vancomycin until culture data are available. The final antibiotic regimen is decided in consultation with infectious disease colleagues.
For this reason, it is difficult to tease out the differential success rate of periprosthetic hip versus knee infections. Sherrell et al3 performed a systematic review of the existing literature and created a table detailing the failure rates for various published articles on I&D for periprosthetic TKA infection (Table 38.1). According to their analysis of the data, the average failure rate was 68% (range, 61–82%).3 The single published series on outcomes following open I&D of THA patients reported an overall failure rate of 79%. Specifically, 21% (4 of 19) of those with an early postoperative infection and 50% (2 of 4) of those with acute hematogenous infections were managed successfully with a debridement and retention of components.4291
Table 38.1   Failure of open irrigation and débridement for periprosthetic knee infection
Study
Failure (number of patients)
Definition of failure
Resistant organism
Hartman et al (1991)
20/33 (61%)
ROI with prosthesis removal
NR
Schoifet and Morrey (1990)
24/31 (77%)
ROI
26%
Burger et al (1991)
32/39 (82%)
Clinical or radiographic signs of infection
18%
Deirmengian et al (2003)
20/31 (65%)
ROI
15%
Teeny et al (1990)
15/21 (71%)
ROI
NR
Rand (review (1993)
267/377 (71%)
ROI
NR
Bradbury et al (2009)
16/19 (84%)
Subsequent infection surgery
100%
Marculescu et al (2006)
53/99 (53%)
ROI
2%
Silva et al (2002)
357/530 (67%)
ROI
NR
Brandt et al (1997)
21/33 (64%)
ROI (same organism strain)
3%
Ivey et al (1990)
7/10 (70%)
Clinical or radiographic signs of infection
NR
Total
852/1253 (68%)
ROI = recurrence of infection; NR = nor reported
Source: Sherrell JC, Fehring TK, Odum S, et al. The Chitranjan Ranawat Award: fate of two-stage reimplantation after failed irrigation and debridement for periprosthetic knee infection. Clin Orthop Relat Res 2011;469:18-25.
292
 
Importance of Microorganisms
Because the glycocalyx has been regarded as the reason for treatment failure in many cases of PJI addressed with I&D, many authors have implicated staphylococcal species as a predictor of a negative outcome, with failure rates ranging from 30% to 35%.5,6 Methicillin-resistant organisms have been shown to be particularly difficult to eradicate with an isolated I&D, with a 72% to 84% failure rate at two-year follow-up.7,8 Interestingly, a recent study by Odum et al9 suggests that neither the infecting microbe nor the antibiotic resistance profile of the organism, as has been classically thought, actually predicts the success of I&D. The authors reported a failure rate of 65% for streptococcal infections compared with 71% for other organisms and a similar failure rate for sensitive Staphylococcus (72%) compared with resistant Staphylococcus (76%).
 
Importance of Timing of Infection and Acuity of Symptoms
Previous reports have indicated that the ability of I&D to control infection is related to the duration of symptoms4,10 and its timing relative to the index surgery.1,11 However, more recent literature is supporting the contrary.5 Koyonos et al reviewed the outcomes of a series of 138 cases of PJI treated with I&D based on acuity of infection: acute postoperative (< 4 weeks), acute delayed (acute onset of symptoms occurring > 4 weeks after surgery), and chronic infections. Overall, the failure rate of controlling infection was 65%. Analyzed by timing of infection, the failure rates were 69%, 56%, and 72% for the acute postoperative, acute delayed, and chronic infections, respectively, leading the authors to conclude that I&D has a limited role in controlling PJI regardless of acuity.5293
 
Importance of Host
Intuitively, the physical health of the host (patient) should influence the success of I&D for the treatment of PJI. Several authors have shown that an immunocompromised state (e.g. rheumatoid arthritis, renal failure, or poorly controlled diabetes mellitus) is a predictor of treatment failure.2,12 Furthermore, Azzam et al7 reported that patients with a higher American Society of Anesthesia (ASA) score, a proxy of severity of medical comorbidities, had a significantly higher failure rate. Although a number of other studies have indicated that comorbidities are not significantly associated with the success of I&D, including Odum et al,9 who showed no difference in outcome based on ASA class, and Brandt et al,13 who showed no difference based on patient age, history of rheumatoid arthritis, or steroid use, these studies were notable for a limited number of patients.10

Pitfalls

  1. Obtain prior op reports to identify modular components in situ and any proprietary insertion/ extraction devices.
  2. Do not withhold preoperative antibiotics because this does not affect intraoperative cultures.13a
  3. Do not get lulled into performing arthroscopic I&D, as it results in incomplete debridement and no ability to perform modular component exchange.
 
Controversies
  • Arthroscopic debridement: Although potentially appealing, owing to relative ease of execution and minimal surgical morbidity, the ability to successfully eradicate infection with an arthroscopic procedure 294may be compromised. Early small case series noted impressive results. Ilahi14 reported 100% success in seven cases of acute-onset PJI involving the knee. Similarly, Hyman et al15 documented a 100% success rate for arthroscopic debridement of eight cases of late, acute periprosthetic hip infections, although it should be noted that patients were maintained on two to six weeks of intravenous antibiotics followed by long-term oral suppression. In a larger series, Waldman et al16 reported a 62% failure rate in patients with acute postoperative (n = 4) or late hematogenous (n = 12) PJI treated with arthroscopic debridement.16 Given the inability to perform a radical surgical debridement, or to exchange modular components, arthroscopic debridement should be used with extreme reservation in any case of PJI, regardless of the host, nature of the infecting organism, or acuity of infection.
  • Irrigation and debridement (I&D) as a conservative, less morbid alternative to two-stage exchange: A growing body of literature suggests that an I&D with modular component exchange may not be a benign, less morbid alternative to the “gold standard” two-stage exchange arthroplasty.3,7 In fact, Sherrell et al have reported that the success of a two-stage antibiotic spacer exchange arthroplasty may be compromised by an initial I&D. They found that patients who were initially treated with an I&D had only a 66% chance of eradicating infection following a two-stage exchange arthroplasty, in contrast to historical reports of 80% to 90% success.3
 
References
  1. Hartman MB, Fehring TK, Jordan L, Norton HJ. Periprosthetic knee sepsis. The role of irrigation and debridement. Clin Orthop Relat Res. 1991;(273):113–8.295
  1. Silva M, Tharani R, Schmalzried TP. Results of direct exchange or debridement of the infected total knee arthroplasty. Clin Orthop Relat Res. 2002;(404):125–31.
  1. Sherrell JC, Fehring TK, Odum S, et al. The Chitranjan Ranawat Award: fate of two-stage reimplantation after failed irrigation and debridement for periprosthetic knee infection. Clin Orthop Relat Res. 2011;469:18–25.
  1. Crockarell JR, Hanssen AD, Osmon DR, Morrey BF. Treatment of infection with debridement and retention of the components following hip arthroplasty. J Bone Joint Surg Am. 1998;80:1306–13.
  1. Koyonos L, Zmistowski B, Della Valle CJ, Parvizi J. Infection control rate of irrigation and debridement for periprosthetic joint infection. Clin Orthop Relat Res. 2011;469:3043–8.
  1. Deirmengian C, Greenbaum J, Lotke PA, Booth RE Jr, Lonner JH. Limited success with open debridement and retention of components in the treatment of acute Staphylococcus aureus infections after total knee arthroplasty. J Arthroplasty. 2003;18:22–6.
  1. Azzam KA, Seeley M, Ghanem E, Austin MS, Purtill JJ, Parvizi J. Irrigation and debridement in the management of prosthetic joint infection: traditional indications revisited. J Arthroplasty. 2010;25:1022–7.
  1. Bradbury T, Fehring TK, Taunton M, et al. The fate of acute methicillin-resistant Staphylococcus aureus periprosthetic knee infections treated by open debridement and retention of components. J Arthroplasty. 2009;24:101–4.
  1. Odum SM, Fehring TK, Lombardi AV, et al. Irrigation and debridement for periprosthetic infections: does the organism matter? J Arthroplasty. 2011;26:114–8.
  1. Marculescu CE, Berbari EF, Hanssen AD, et al. Outcome of prosthetic joint infections treated with debridement and retention of components. Clin Infect Dis. 2006;42:471–8.
  1. Burger RR, Basch T, Hopson CN. Implant salvage in infected total knee arthroplasty. Clin Orthop Relat Res. 1991;(273):105–12.
  1. Segawa H, Tsukayama DT, Kyle RF, Becker DA, Gustilo RB. Infection after total knee arthroplasty. A retrospective study of the treatment of eighty-one infections. J Bone Joint Surg Am. 1999;81:1434–45.296
  1. Brandt CM, Sistrunk WW, Duffy MC, et al. Staphylococcus aureus prosthetic joint infection treated with debridement and prosthesis retention. Clin Infect Dis. 1997;24:914–9.
  1. Ghanem E, Parvizi J, Clohisy J, et al. Perioperative antibiotics should not be withheld in proven cases of periprosthetic infection. Clin Orthop Relat Res. Aug 2007;461:44–7.
  1. Ilahi OA, Al-Habbal GA, Bocell JR, Tullos HS, Huo MH. Arthroscopic debridement of acute periprosthetic septic arthritis of the knee. Arthroscopy. 2005;21:303–6.
  1. Hyman JL, Salvati EA, Laurencin CT, Rogers DE, Maynard M, Brause DB. The arthroscopic drainage, irrigation, and debridement of late, acute total hip arthroplasty infections: average 6-year follow-up. J Arthroplasty. 1999;14:903–10.
  1. Waldman BJ, Hostin E, Mont MA, Hungerford DS. Infected total knee arthroplasty treated by arthroscopic irrigation and debridement. J Arthroplasty. 2000;15:430–6.

One-Stage Exchange Arthroplasty for Periprosthetic Joint Infectionchapter 39

Erik N Hansen
 
Current Evidence
 
Historical Perspective
Although the “gold standard” treatment for periprosthetic joint infection (PJI) in the United States is currently the two-stage antibiotic exchange arthroplasty, renewed interest has recently been shown in re-evaluating the utility of the one-stage exchange arthroplasty. Proponents of the one-stage revision arthroplasty for PJI cite decreased morbidity, improved functional results,1,2 and decreased health care costs, whereas opponents emphasize a higher reinfection rate than is found in the two-stage revision.3 Regardless of the study, what the literature has borne out is that the success of the one-stage procedure is predicated on proper surgical technique, appropriate indications, and patient selection.
The earliest clinical reports of the one-stage exchange arthroplasty were published in Europe, where the technique continues to be practiced more frequently than anywhere else. In one of the earliest clinical series, despite not using systemic antibiotics, Buchholz et al4 reported a 77% success rate in 583 patients, using this 298technique, which improved to a 90% success rate after subsequent exchange procedures. Wrobleski et al,5 using the same surgical technique with the addition of postoperative systemic antibiotics, documented a 91% success rate. Because subsequent studies were not able to reproduce these impressive results,6 the majority of orthopedic surgeons in the United States turned toward two-stage exchange revisions.

Rothman Institute Current Practices

  1. To date, we have used the one-stage exchange arthroplasty for PJI infrequently at our institution. In the past five years, we have had a total of eight cases, comprising 3.2% of our total cases of PJI. These were performed in acute postoperative periprosthetic hip infection cases, in which bone had not ingrown the proximally coated wedge taper stems. They were all revised to another cementless, wedge taper design.
  2. Our indications for one-stage exchange are as follows: a healthy host, acute postoperative infection, susceptible organism, and good soft tissue coverage.
Compared with the Europeans, relatively few publications on one-stage exchange arthroplasty have been published by US surgeons. The difficulty in interpreting the data from these studies is that they had relatively small sample sizes and demonstrated substantial variability in inclusion criteria, surgical technique, and postoperative antibiotic regimens.7 Interestingly, the two domestic series with the longest clinical follow-up reported 92% to 100% infection-free survivorship of the implants at an average of 10 years of follow-up.8,9
 
Indications
Literature written on the one-stage exchange arthroplasty always emphasizes that the success of the procedure hinges on selective use of this technique depending 299on patient-related factors, as well as variables related to the infecting organism, the state of the soft tissue and bone stock, and so on. Oussedik et al1 delineated specific criteria to help decide which patients could be successfully treated with a one-stage procedure (Table 39.1).1
Table 39.1   Specific criteria for treatment of PJI by one-stage exchange arthroplasty
Criteria for single- versus two-stage revision
Single-stage
Two-stage
Healthy soft tissues
Additional compromising factors
Minimal bone loss allowing cemented fermoral reconstruction Organism and sensitivities known
Additional compromising factors considered
Category
Compromising factors
Organism factors
Multiresistant organism MRSA/MRSE
Polymicrobial infection
Unusual commensals
Unusual resistance profiles
Unidentified infective organisms
Host factors
Immunosuppression
Concurrent sepsis
System disease
Reinfection
Local factors
Significant bone loss precluding cemented reconstruction
Significant soft-tissue compromise
Peripheral vascular disease
Abbreviations: MRSA, methicillin-resistant Staphylococcus aureus; MRSE, methicillin-resistant Staphylococcus epidermidis.
Source: Oussedik SI, Dodd MB, Haddad FS. Outcomes of revision total hip replacement for infection after grading according to a standard protocol. J Bone Joint Surg Br. 2010;92(9):1222-6.
Although 300only 22% (11 of 50) of the patients in their cohort met appropriate criteria for a single-stage exchange, all of these patients remained infection free at seven years of follow-up.1 Similarly, Hanssen et al10 tested the feasibility of applying these strict criteria to a consecutive series of patients with infected hip arthroplasty and found that only 11% were deemed potential candidates for a one-stage exchange.10 Citing the increasing emergence of resistant organisms and prevalence of revision arthroplasties, with significant bone loss as the major underlying reason for this, the authors concluded that the feasibility of one stage in the current environment was limited and the two-stage approach was more appropriate.
 
Cost Effectiveness and Quality of Life
With the projected increase in the number of septic revision arthroplasty procedures and the substantial costs of treating an infected joint replacement, measures aimed at decreasing this socioeconomic burden on the US health care system will be particularly important. One of the reported benefits of the one-stage revision arthroplasty for PJI is potential cost savings to the system and improved quality of life for the individual patient. Using a Markov expected-utility decision analysis to compare the one-stage direct exchange arthroplasty with the two-stage revision, investigators in a recent publication favored the one-stage approach regardless of whether patient- or surgeon-derived utilities were applied and regardless of whether a one- or 10-year horizon was considered. In fact, for the two treatment strategies to be equivalent, the reinfection rate for the direct exchange arm had to approach 60%, which is several times higher than rates reported in the literature.11 Oussedik et al1 reported on a consecutive series of single- versus two-stage exchange arthroplasty patients and found that at five years, the Harris Hip Score (HHS) (87.8 vs 75.5, P = 0.0003), the improvement in the HHS (+47.3 vs +39.1, P = 0.027), and the patient 301satisfaction scores (8.6 vs 6.9, P = 0.001) all favored the single-stage cohort. In a study evaluating the results of one-stage revision for septic knee prostheses, Singer et al2 reported total Knee Society Scores (144 points) and range of motion (114° flexion) significantly higher than what has been reported in the literature for septic two-stage revisions.
 
One-Stage Total Hip Arthroplasty Outcomes
Jackson et al performed a literature review to determine when single-stage exchange arthroplasty for infected hip replacements would be most successful. Using data from 12 studies, they identified close to 1300 patients with an average five-year clinical follow-up (Fig. 39.1).7
Figure 39.1: Published series on direct exchange arthroplasty for periprosthetic hip infection. (From Jackson WO, Schmalzried TP. Limited role of direct exchange arthroplasty in the treatment of infected total hip replacements. Clin Orthop Relat Res. 2000;(381):101-5.)
Although 302almost all cases (99%) used antibiotic-laden bone cement, significant variability was seen in the postoperative use of antibiotics. In sum, 83% of patients were infection free at the most recent follow-up.7 They identified the following variables as predictive of a successful outcome: (1) absence of wound complications after index total hip arthroplasty, (2) good health of the patient, (3) methicillin-sensitive organisms, and (4) an organism susceptible to the antibiotic-laden bone cement. Factors that predicted failure were as follows: (1) polymicrobial infection, (2) Gram-negative organisms (especially Pseudomonas), and (3) methicillin-resistant organisms.
 
One-Stage Total Knee Arthroplasty Outcomes
The success of one-stage exchange arthroplasty for periprosthetic knee infection has been reported as somewhere between 73% and 95%.2 The earliest report, by von Foerster et al, with the largest cohort of patients (n = 104) represents the lower end of this spectrum, whereas more recent studies have demonstrated a significant improvement in rates of infection eradication, as detailed in Table 39.2.2 A review of the English literature specifically identified a total of 8 studies, which included 37 knees, of which 33 (89%) were clinically free of infection at the most recent follow-up (Fig. 39.2).2

Pitfalls

The one-stage exchange arthroplasty should be avoided if a microorganism cannot be identified preoperatively, as this precludes microbe-specific local antibiotic treatment.
 
Controversies
  • Use of bone graft during one-stage exchange: The use of allogeneic bone graft in the setting of active infection is controversial because it has been theorized 303that the bone graft will become colonized and serve as a nidus for persistent infection.12
    Table 39.2   Published results on direct exchange for periprosthetic knee infection (Singer Corr 2012)
    Study
    Number of patients
    Follow-up (months)
    Rate of infection control
    Score
    Flexion
    von Foerster et al
    104
    75.5
    73.1%
    -
    -
    Lu et al
    8
    20.1
    87%
    -
    Göksan and Freeman
    18
    60
    89%
    -
    87°
    Buechel et al
    21
    122.4
    91%
    79.5 points (New Jersey Orthopaedic Hostial knee score)
    Sofer et al
    15
    18.4
    93%
    116.4 points (Knee Society score)
    Current study
    63
    35.9
    95%
    144.1 points (Knee Society score)
    114°
    Source: From Singer J, Merz A, Frommelt L, et al. High rate of infection control with one-stage revision of septic knee prostheses excluding MRSA and MRSE. Clin Orthop Relat Res. 2012;470(5):1461-71.
    304
    Figure 39.2: Published series (English language literature) on the results of one-stage exchange for infected knee arthroplastySource: (Mauricio Silva MD, Ravi Tharani BS, Thomas P, Schmalzried, MD. Results of direct exchange or debridement of the infected total knee arthroplasty. Clin Orthop Relat Res. 2002;(404):125-31.)
    However, in many cases of septic revision arthroplasty, significant bone loss is present, resulting in a clinical challenge for the surgeon to adequately reconstruct a stable joint. Winkler et al published a recent series in which they used an antibiotic-impregnated allograft to perform cementless one-stage revisions of infected hip replacements. At a mean follow-up of four years, 92% of hips (34 of 37) were infection free, and of the three failures, two underwent a second round of this procedure with ultimate success.13 Rudelli et al reported on their experience with bone grafting during one-stage revision for PJI at an average follow-up of eight years. Despite a high percentage of both acetabular and femoral bone defects in their series, infection recurred in only two (6.2%) cases.14305
  • Use of intra-articular antibiotic infusion: A theoretical limitation of using antibiotic-impregnated cement is that the elution properties diminish over time and only the antibiotic powder on the surface of the cement is biochemically active.15 Whiteside et al have described the use of direct intra-articular infusion of antibiotics via a Hickman catheter as part of their one-stage exchange arthroplasty protocol. They report that the antibiotic concentrations they are able to achieve in the synovial fluid are hundreds of times higher than can be achieved with either antibiotic spacers or intravenous antibiotics, with no adverse clinical outcomes and 95% success.16 Moreover, this technique allows them to use cementless revision components, which is another topic on which their group has published extensively. Applying this approach to local antibiotic depot in cementless hip revisions for PJI represents an interesting future avenue of academic pursuit.
  • Cement versus cementless reconstruction: One of the classic, fundamental principles of the one-stage exchange arthroplasty is the use of antibiotic cement to provide supratherapeutic local concentrations of antibiotics.4 Currently, a move has been made toward the use of cementless fixation on both the acetabular and the femoral side in revision total hip arthroplasty because of improved long-term survivorship.17 This, then, results in a dilemma; namely, can a one-stage exchange be successfully performed without cement? Yoo et al report on a series of 12 patients with PJI who were treated with a cementless revision and found that only one (8%) failed owing to recurrent infection and one (8%) owing to aseptic loosening at an average follow-up of seven years.18 Oussedik et al performed a hybrid technique, in which a cementless acetabular reconstruction was used in combination 306with a cemented femoral component using PALACOS R impregnated with gentamicin. In 11 patients, the infection-free survivorship was 100% at seven years of follow-up.1 In periprosthetic knee infections, Whiteside et al have published impressive results using a technique of cementless knee reconstruction combined with a direct intra-articular antibiotic infusion. Of 18 patients with methicillin-resistant Staphylococcus aureus infection in their series, only one (5.5%) had recurrence of infection.16
 
References
  1. Oussedik SI, Dodd MB, Haddad FS. Outcomes of revision total hip replacement for infection after grading according to a standard protocol. J Bone Joint Surg Br. 2010;92(9):1222–6.
  1. Singer J, Merz A, Frommelt L, Fink B. High rate of infection control with one-stage revision of septic knee prostheses excluding MRSA and MRSE. Clin Orthop Relat Res. 2012;470(5):1461–71.
  1. Jamsen E, Stogiannidis I, Malmivaara A, Pajamaki J, Puolakka T, Konttinen YT. Outcome of prosthesis exchange for infected knee arthroplasty: the effect of treatment approach. Acta Orthop. 2009;80(1):67–77.
  1. Buchholz HW, Elson RA, Engelbrecht E, Lodenkamper H, Rottger J, Siegel A. Management of deep infection of total hip replacement. J Bone Joint Surg Br. 1981;63-B(3):342-53.
  1. Wroblewski BM. One-stage revision of infected cemented total hip arthroplasty. Clin Orthop Relat Res. 1986(211):103-7.
  1. Hunter GA. The results of reinsertion of a total hip prosthesis after sepsis. J Bone Joint Surg Br. 1979;61-B(4):422-3.
  1. Jackson WO, Schmalzried TP. Limited role of direct exchange arthroplasty in the treatment of infected total hip replacements. Clin Orthop Relat Res. 2000;(381):101–5.
  1. Callaghan JJ, Katz RP, Johnston RC. One-stage revision surgery of the infected hip. A minimum 10-year followup study. Clin Orthop Relat Res. 1999;(369):139–43.307
  1. Ure KJ, Amstutz HC, Nasser S, Schmalzried TP. Direct-exchange arthroplasty for the treatment of infection after total hip replacement. An average ten-year follow-up. J Bone Joint Surg Am. 1998;80(7):961–8.
  1. Hanssen AD, Osmon DR. Assessment of patient selection criteria for treatment of the infected hip arthroplasty. Clin Orthop Relat Res. 2000(381):91-100.
  1. Wolf CF, Gu NY, Doctor JN, Manner PA, Leopold SS. Comparison of one and two-stage revision of total hip arthroplasty complicated by infection: a Markov expected-utility decision analysis. J Bone Joint Surg Am. 2011;93(7):631–9.
  1. Schutzer SF, Harris WH. Deep-wound infection after total hip replacement under contemporary aseptic conditions. J Bone Joint Surg Am. 1988;70(5):724–7.
  1. Winkler H. Rationale for one-stage exchange of infected hip replacement using uncemented implants and antibiotic impregnated bone graft. Int J Med Sci. 2009;6(5):247–52.
  1. Rudelli S, Uip D, Honda E, Lima AL. One-stage revision of infected total hip arthroplasty with bone graft. J Arthroplasty. 2008;23(8):1165–77.
  1. Seeley SK, Seeley JV, Telehowski P, et al. Volume and surface area study of tobramycin-polymethylmethacrylate beads. Clin Orthop Relat Res. 2004;(420):298–303.
  1. Whiteside LA, Peppers M, Nayfeh TA, Roy ME. Methicillin-resistant Staphylococcus aureus in TKA treated with revision and direct intra-articular antibiotic infusion. Clin Orthop Relat Res. 2011;469(1):26–33.
  1. Iorio R, Healy WL, Presutti AH. A prospective outcomes analysis of femoral component fixation in revision total hip arthroplasty. J Arthroplasty. 2008;23(5):662–9.
  1. Yoo JJ, Kwon YS, Koo KH, Yoon KS, Kim YM, Kim HJ. One-stage cementless revision arthroplasty for infected hip replacements. Int Orthop. 2009;33(5):1195–1201.308

Resection Arthroplastychapter 40

Pouya Alijanipour
 
Current Evidence
 
Definition
The Girdlestone procedure was originally defined as resection of the proximal femur and lateral aspect of the acetabulum for the treatment of septic arthritis, particularly that due to tuberculosis, advanced coxarthrosis, and hip ankylosis.1–6 Although many surgeons today claim to perform a “Girdlestone procedure”, the technique for resection arthroplasty currently practiced more closely approximates that described by Murray et al7 in 1964 (Fig. 40.1).

Rothman Institute Current Practices

  1. We recommend using drains for Girdlestone arthroplasty performed in the setting of PJI.
  2. In cases with persistent draining wounds or wounds with a prior history of persistent wound drainage, vacuum-assisted closure (VAC) is recommended.
  3. We do not use postoperative skin or transosseous traction.
  4. We recommend early mobilization to avoid perioperative complications.
  5. Social work intervention is used to improve the patient's quality of life.
With salient advances in total joint arthroplasty, the concept of resection arthroplasty has been modified and the indications for Girdlestone procedure have been narrowed considerably. It currently refers to removal of the implant (including prosthesis and osteosynthesis material 310with or without cement) as the definitive treatment for failed septic and aseptic total joint replacement.
Figures 40.1A and D: Resection arthroplasty. (A) and (B): Original description by Dr Girdlestone. Greater trochanter is resected, turned down and fixed to the distal segment by sutures or bone pegs. (C) and (D): Simplified modification by Dr Murray, avoiding trochanter resection
 
Indications
Resection arthroplasty is a salvage procedure and is indicated in the setting of persistent periprosthetic joint infection (PJI) with any combination of the following conditions8:
  • Failed multiple two-stage procedures due to recurrent PJI with resistant bacteria
  • Failure of suppressive antibiotics
  • Poor general health, severely immunocompromised state, and intravenous drug abuse precluding reimplantation
  • Substantial loss of bone stock
  • Poor soft tissue envelope
  • Limited ambulatory capacity
  • Personal preference of the patient.
311
 
Contraindications
Weakness of the upper extremities that precludes the possibility of using walking aids has been considered a relative contraindication to resection arthroplasty.2 This procedure is not recommended if the patient's general health status is severely compromised, as the Girdlestone procedure has considerable early postoperative morbidity and mortality.5,8

Pitfalls

  1. The surgeon should preoperatively plan to have all necessary instruments available for removal of the prosthesis.
  2. Judiciously achieved balance between tissue resection and preservation is challenging. Meticulous removal of infected tissue is a key element for eradication of infection. However, viable soft tissue and bone should be preserved for better stability and functional outcome.
  3. Optimization of the patient's health status prior to the resection arthroplasty is essential to decrease postoperative morbidity and mortality. This is difficult to achieve in the patient with an infected THA.
  4. A multidisciplinary approach involving several specialties such as infectious disease, plastic surgery, rehabilitation, and social work should be used to provide the best possible care for the patient.
 
Surgical Principles and Intraoperative Strategies
The procedure can be technically challenging, depending on the implants to be removed. The surgical approach should utilize the previous scar and include excision of the existing sinus tract if present. Adequate debridement of infected bony and soft tissue is the most important aspect of the procedure.3 The components and all foreign material, including cement, should be extracted with extreme care to avoid any iatrogenic soft tissue or bone damage. Judicious use of a trochanteric osteotomy or other techniques for 312cement extraction may be required. Multiple samples for microbiologic cultures (including fungal and other atypical organisms) should be sent, given the often recalcitrant nature of these infections. In general, resection at a more proximal level will cause less shortening of the limb and better functional outcome.3 The acetabulum is reamed until bleeding from cancellous bone occurs. Any sharp bone edges around the proximal femoral and acetabular resection should be smoothed to diminish any source of painful impingement between adjacent bony or soft tissue structures.3 Primary wound closure is preferred, although because of dead space at the site of resection, prolonged postoperative wound drainage is usually expected. Nevertheless, proper wound closure is very important and may require plastic surgery intervention. Postoperatively, an infectious disease consultation is helpful in determining the appropriate antibiotic and treatment course.
Historically, patients undergo postoperative traction for three to four weeks with progressive active and passive range of motion and four to six months of minimal weight bearing. Then, the patient can start progressive weight bearing. Patients generally require shoe lifts for correction of limb discrepancy. In these patients, energy consumption during gait has been demonstrated to be 2.5 times more than normal, which is even more than in patients with above-knee amputations.9 Patients may become easily fatigued by a Trendelenburg-like gait and may need assistive canes or crutches.2,10
 
Outcomes
Before proceeding with surgery, the patient should be counseled regarding the expected functional outcome after the Girdlestone procedure. Usually, pain relief of nearly 90% is observed,2 but studies are not consistent in this regard and persistent moderate to severe pain of 313up to 76% has been reported after resection arthroplasty for septic total hip arthroplasty.4 Patients may experience considerable leg shortening (up to 6 cm). Between 85% and 90% of patients are ambulatory with an assistive device,2,5 although in two studies 9% (3 of 33)2 and 40% (4 of 10)8 of patients remained wheelchair bound after a mean follow-up of 6.2 and 3.7 years, respectively. Nevertheless, depending on the individual case, the possibility of conversion to arthroplasty in the future always exists, provided the infection has been eradicated and the host situation has improved sufficiently to permit a reconstructive procedure.
A mortality rate of 58% has been reported 13 years after resection arthroplasty. It is, however, of more concern that half of these patients died within the first postoperative year.8 The postoperative course can potentially be complicated by excessive blood loss, persistent drainage, traction-associated complications (intolerance, common peroneal nerve palsy, contractures, joint stiffness and pin-site infection), prolonged bedrest-related complications (such as decubitus ulcers, urinary tract infection, pneumonia, and disuse atrophy), and depression.8
Table 40.1 summarizes existing evidence regarding outcome of treatment of PJI by resection arthroplasty. In general, recent studies have reported better rates of infection eradication accompanied by higher rates of patient satisfaction, which may be due to improved medical and surgical care over that in the past. However, pain control and functional outcome have not been as satisfying, and inconsistent results have been described, probably because of differences in outcome definition and patient characteristics. Although significant pain relief usually occurs, residual discomfort may require continuing analgesic treatment. It has proposed that the Girdlestone procedure has less favorable outcome in treating septic 314than in treating nonseptic total hip arthroplasty failure,3 but this suggestion has not been confirmed in other studies.4
Table 40.1   Summary of existing evidence regarding outcome of resection arthroplasty in PJI
Principal Author
Publication Year
Study Size*
Mean Follow-up (range) in mo
Infection Control (%)
Pain Control
Functional Outcome
Patient Satisfaction
Sharma8
2005
23
48 (6–156)~
100
50% no pain
40% mild or moderate pain
10% marked pain
10% used 1 stick
10% used 2 sticks
50% used frame
30% chair bound
70% satisfied
10% indifferent
20% dissatisfied
Castellanos5
1998
78
60 (12–240)
85.9
83% satisfactory pain control
40% needed 1 crutch
52% needed 2 crutches
8% could not walk
–315
Ballard4
1995
29
96 (12-756)
96
29.6% no pain
51.9% pain with fatigue
11.1% pain with weight bearing
7.4% pain at rest
100% could walk
14.8% with unlimited activity
The remaining could walk 2.7 blocks on average
96.6%
Böhler12
1991
20
46.6 (12-?)
92
95% no or occasional pain
Harris Score improved from 25 to 53 on average
100%316
Grauer3
1989
33
45.6 (24-126)
90.9
36.4% good
33.3% fair
30.3% poor
27.3% good
73.7% poor
?
Herzog13
1989
51
– (25-190)
88.2
45.3% pain free
45.3% occasional pain
–
?
Kantor9
1986
41
47 (12-120)
–
93% had some pain but it was often not severe
4.8% without assistive device
83% minimal or no ambulation
?317
Bourne2
1984
33
74.4 (36-156)
97
91% satisfactory pain relief
6.1% did not need any aid
15.1% needed cane on long walks
30.3% needed single cane or crutch
33.3% needed double canes or crutches
6.1% needed walker
33.3% very satisfied
45.5% satisfied
21.2% unhappy318
McElwaine14
1984
22
– (15-108)
–
59.1% no pain
40.9% some pain on activity
4.5% could walk better
40.9% maintained their preoperative level of activity
54.6% had restricted indoor activity or were completely bedridden
36.4% satisfied
73.6% disappointed319
Ahlgren15
1980
27
40.8 (12-68)
70.4
66.7% no pain
26.0% slight or occasional pain on weight bearing
7.3% severe pain on weight bearing
81.5% could walk outdoors independently
11.1 % needed help from another person
7.4% wheel chair bound
96.3%
Petty16
1980
21
34.8 (12-98)
76
76% moderate or severe pain
100% could walk with aid
15% satisfied320
Clegg17
1977
30
– (12-72)
80'
40% no pain
46.7 % moderate pain
100% needed walking aid
10% could walk reasonably long distances
–
* Only the results for resection arthroplasty in PJI setting are presented
321
 
Controversies
  • No consensus exists for whether complete cement removal (particularly if it requires extensive bone damage) is mandatory to decrease the risk for recurrence and improve clinical outcome. Some authors advocate complete cement removal for infection control.9 However, others have not found it necessary.2,4 Surgeons should make a decision on the basis of each patient regarding how aggressive they should be with cement removal.
  • The best surgical procedure for recurrent PJI with severe bone and/or soft tissue loss is a matter of debate. Some authors advocate reimplantation because functional outcome after a resection arthroplasty worsens with more severe tissue loss.3 Reconstruction may provide better outcome. However, it is technically more challenging and is associated with several complications.11 Moreover, PJI is more likely to recur.
  • Postoperative use of traction is debated. Although some earlier studies recommended three to four weeks of postoperative skeletal traction,2,3 others have presented similar results with skin traction.5 Some authors have even questioned the role of traction in final outcome.
 
References
  1. Girdlestone GR. Acute pyogenic arthritis of the hip: an operation giving free access and effective drainage. 1943. Clin Orthop Relat Res. 2008;466(2):258–63.322
  1. Bourne RB, Hunter GA, Rorabeck CH, Macnab JJ. A six-year follow-up of infected total hip replacements managed by Girdlestone's arthroplasty. J Bone Joint Surg Br. 1984;66(3):340–3.
  1. Grauer JD, Amstutz HC, O'Carroll PF, Dorey FJ. Resection arthroplasty of the hip. J Bone Joint Surg Am. 1989;71(5):669–78.
  1. Ballard WT, Lowry DA, Brand RA. Resection arthroplasty of the hip. J Arthroplasty. 1995;10(6):772–9.
  1. Castellanos J, Flores X, Llusà M, Chiriboga C, Navarro A. The Girdlestone pseudarthrosis in the treatment of infected hip replacements. Int Orthop. 1998;22(3):178–81.
  1. Haw CS, Gray DH. Excision arthroplasty of the hip. J Bone Joint Surg Br. 1976;58(1):44–7.
  1. Murray WR, Lucas DB, Inman VT. Femoral Head and Neck Resection. J Bone Joint Surg Am. 1964;46:1184–97.
  1. Sharma H, De Leeuw J, Rowley DI. Girdlestone resection arthroplasty following failed surgical procedures. Int Orthop. 2005;29(2):92–5.
  1. Kantor GS, Osterkamp JA, Dorr LD, Perry J, Conaty JP. Resection arthroplasty following infected total hip replacement arthroplasty. J Arthroplasty. 1986;1(2):83–9.
  1. Pagnano MW, Trousdale RT, Hanssen AD. Outcome after reinfection following reimplantation hip arthroplasty. Clin Orthop Relat Res. 1997;(338):192–204.
  1. Charlton WPH, Hozack WJ, Teloken MA, Rao R, Bissett GA. Complications associated with reimplantation after Girdlestone arthroplasty. Clin Orthop Relat Res. 2003;(407):119–26.
  1. Böhler M, Salzer M. Girdlestone's modified resection arthroplasty. Orthopedics. 1991;14(6):661–6.
  1. Herzog T, Link W, Engel S, Beck H. Resection arthroplasty: middle- and long-term results. Arch Orthop Trauma Surg. 1989;108(5):279–81.
  1. McElwaine JP, Colville J. Excision arthroplasty for infected total hip replacements. J Bone Joint Surg Br. 1984;66(2):168–71.
  1. Ahlgren SA, Gudmundsson G, Bartholdsson E. Function after removal of a septic total hip prosthesis. A survey of 27 Girdlestone hips. Acta Orthop Scand. 1980;51(3):541–5.323
  1. Petty W, Goldsmith S. Resection arthroplasty following infected total hip arthroplasty. J Bone Joint Surg Am. 1980;62(6):889–96.
  1. Clegg J. The results of the pseudarthrosis after removal of an infected total hip prosthesis. J Bone Joint Surg Br. 1977;59(3):298–301.324

Removal of Well-Fixed Hip and Knee Arthroplasty Components in the Setting of Periprosthetic Joint Infectionchapter 41

Gregory K Deirmengian
Treatment of periprosthetic hip and knee infections with a two-stage exchange requires a carefully planned, stepwise approach. Successful reimplantation during the second stage of reconstruction depends on both eradication of the infection and minimizing bone loss during removal of components in the first stage. Unfortunately, despite the presence of infection, the prosthetic components are often well fixed and the surrounding bone of poor quality. Therefore, the most difficult aspect of the two-stage exchange is often successful removal of hip and knee components, which requires careful preoperative planning and meticulous technique. This chapter reviews the key aspects of removing hip and knee components in the setting of periprosthetic joint infection (PJI).
 
Preoperative Planning
Because device-specific instrumentation and specialized tools are often required for removing well-fixed hip 326and knee components, thorough preoperative planning is a prerequisite for surgical success and efficiency.1 For both hip and knee arthroplasty, the availability of revision instrumentation (Fig. 41.1) to aid in the removal of components is critical. In the case of hip arthroplasty, the surgeon should strive to obtain operative reports and implant stickers to identify the sizes and device specifications for the implants. This step allows the surgeon to ensure availability of the appropriate screwdriver for the acetabular screws, as well as device-specific insertion handles for the femoral and acetabular components. In addition, for cementless femoral components, the surgeon can anticipate the surface area of femoral component ingrowth and plan for an extended trochanteric osteotomy (ETO) when necessary.

Rothman Institute Current Practices

  1. Careful preoperative planning is critical for successful and efficient removal of components.
  2. Use of extensile surgical approaches, including judicious use of ETOs, for femoral component removal is advised.
  3. Components should be separated from the surrounding bone and cement until they are loose and can be removed with minimal force.
  4. The ETO is repaired with smooth wires prior to spacer implantation.
  5. Removal of the patellar component should proceed with great care to avoid extensor mechanism damage.
 
Surgical Exposure
Successful and efficient removal of well-fixed components in the setting of PJI is one of the most technically challenging aspects of hip and knee arthroplasty. Bone loss during removal of components directly influences 327the surgeon's reconstructive options at the time of the second stage.
Figure 41.1: A typical standard set of hand tools used on a routine basis at our institution for the removal of hip and knee components and cement. From left to right, the tools are grouped as pituitary rongeurs (2), cement osteotomes (5), reverse curettes (4), curved acetabular osteotomes (5), and a small rigid osteotome (1)
An extensile exposure is critical for safe and efficient removal of components.2 From the standpoint of hip arthroplasty, either a posterior or a modified-Hardinge approach is preferred, because both permit an extensile exposure and allow for an ETO if required. Use of prior minimally invasive approaches may compromise the surgeon's ability to perform a thorough synovectomy and debridement and remove components in an efficient manner with minimal bone loss. From the standpoint of knee arthroplasty, an extensile medial parapatellar arthrotomy is advised, with a quadriceps snip, tibial tubercle osteotomy, or other such techniques that improve exposure when needed. Again, use of a mid- or subvastus 328approach should be avoided, as this may compromise the surgeon's ability to obtain complete exposure, perform a thorough synovectomy and debridement, and remove components with minimal bone loss.
 
Removal of Hip Arthroplasty Components
After executing the approach, the exposed pseudocapsule and synovium are excised. Next, the hip is dislocated and the femoral head disimpacted from the trunnion to further facilitate exposure. Attention is then turned to removing the acetabular component. First, we obtain complete exposure of the interface between the component and underlying bone by removing obscuring soft tissues and overhanging bone. Next, the acetabular liner is removed. In cases of metal and ceramic liners, device-specific tools are often available for their removal. Although a polyethylene liner may be removed with an osteotome, a more elegant and efficient means of removing the liner can be achieved simply with an acetabular screw. First, a hole is drilled perpendicular to the periphery of the liner and advanced until the underlying acetabular component is reached. A 40-mm acetabular screw is then advanced through the drill hole. As the tip of the screw reaches the underlying acetabular component, continued advancement of the screw separates the polyethylene from the component, allowing its subsequent removal by hand (Fig. 41.2). Next, transacetabular screws are removed with the appropriate screwdriver.
Removal of a cementless acetabular component requires special instrumentation to minimize bone loss.2 Curved acetabular gouges of varying diameters (Fig. 41.1) are often useful. Care must be taken to keep the instrument flush with the backside of the component as it is advanced in order to avoid damage to the underlying bone (Fig. 41.3). The Zimmer Explant System (Fig. 41.4) is another useful tool for successful removal of the acetabular component.329
Figure 41.2: Screw removal of acetabular liner. A standard acetabular fixation screw is introduced and threaded through the polyethylene. Once the tip of the screw contacts the underlying shell, continued advancement separates the liner from the shell, allowing for its removal
The modular device has two blade lengths and allows for customization for different acetabular shell sizes (outer diameter) and liner sizes (inner diameter). A trial liner, or the one that has just been removed, is replaced into the acetabulum. The Zimmer Explant System is assembled on the basis of the femoral head that articulates with the trial liner and on the outer diameter of the shell. The ball of the Zimmer Explant System is reduced into the trial liner within the shell. First, a short blade is used to separate the component from the underlying bone in a circumferential manner, and then the technique is repeated with the longer blade. No matter which technique is used, it is 330critical for the surgeon to be patient and to proceed in an organized manner until the component becomes visibly loose.
Figure 41.3: A curved osteotome is used to separate the backside of an acetabular component from the surrounding bone. If care is not taken to keep the curved osteotome flush to the backside of the component, bone will be lost
Attempts at removing the component before it is grossly loose may lead to substantial acetabular bone loss or fracture. The component may then be removed with a bone tamp or with its insertion handle (Fig. 41.5). Cemented acetabular polyethylene components are typically removed easily with an osteotome. The underlying cement is then removed carefully in a piecemeal manner with an osteotome. Alternatively, reamers may be used in a serial manner to ream the polyethylene and underlying cement.3 With this technique, care must be taken to avoid eccentric reaming that would threaten the acetabular bone stock.331
Figure 41.4: The Zimmer Explant System is used to remove a well-fixed acetabular component. A 32-mm ball attached to the device fits within the polyethylene liner with a 32-mm inner diameter. A long blade designed to contour the 50-mm outer diameter of the shell is also attached. The device is rotated around the rim, and the blade is slowly advanced toward the apex of the shell until gross loosening is achieved. This design allows for minimization of bone loss
Removal of a cementless femoral component should also proceed in a stepwise manner. Similar to removing the acetabular component, the first step is to completely expose the interface between the component and underlying bone by removing obscuring soft tissues and overhanging bone. Special care is taken to remove all bone that overhangs the lateral aspect of the prosthesis. Failure to achieve this goal often leads to trochanteric fracture during removal of the component. For proximally ingrown components, a high-speed burr is used to debond the proximal aspect of the prosthesis from the surrounding bone (Fig. 41.6).332
Figure 41.5: The device-specific acetabular component insertion handle is applied, and minimal force is used to remove the loose component
We advise against the use of flexible osteotomes, as they may lead to iatrogenic femoral fracture and fragmentation. Next, the device-specific insertion handle or a universal extractor is applied to the component, and force is applied in a retrograde manner. If the stem remains fixed despite moderate force, the burr is used again to further disrupt any bony ingrowth into the prosthesis. If the surgeon is unsuccessful despite these attempts, an ETO is performed to improve exposure of the ingrown areas of the prosthesis. For cemented stems and those with distal fixation and ingrowth, we recommend judicious use of an ETO for exposure.4 Attempts to remove such components without the additional exposure often leads to iatrogenic femoral fracture and canal perforation. A cemented stem is often easily removed from the cement 333mantle prior to performing the ETO.
Figure 41.6: A high-speed pencil-tipped burr is used to separate the femoral component from the surrounding bone in the area of the ingrowth surface
The cement mantle is then removed piecemeal with specialized osteotomes. Care must be taken in removing the cement plug in order to avoid fracture or perforation. We recommend use of an X-shaped osteotome or ultrasound-based tools.5–7 The ETO should be reduced and fixed with smooth wires prior to spacer implantation (Fig. 41.7). Removal of cementless components with distal fixation is the most challenging task. Often, the best strategy is cutting the stem, removing the proximal aspect, and then trephining the distal cylindrical aspect of the prosthesis (Figs 41.8A and B). When dictating the surgical note, it is helpful to describe in detail the degree and location of both femoral and acetabular bone loss, as well as the anticipated components needed for ultimate reconstruction.334
Figure 41.7: A postoperative radiograph shows an ETO repair with smooth wires after removal of components for periprosthetic infection
 
Removal of Knee Arthroplasty Components
After surgical exposure and a thorough synovectomy are completed, the tibial polyethylene component is removed. It is critical for the surgeon to understand the locking mechanism of the tibial polyethylene. If the surgeon is not prepared by having this information, time may be wasted in an effort to independently remove the polyethylene. In some instances, the tibial component is monoblock, precluding independent removal of the polyethylene. In addition, some polyethylene components have a side-loading 335locking mechanism, making its removal from the anteroposterior direction quite difficult.
Figures 41.8A and B: A distally fitting and ingrown stem is removed by cutting the stem with a high-speed carbide burr (A), and the distal aspect of the stem is removed separately with an appropriately sized trephine reamer (B)
336
Finally, some polyethylene liners have a screw or bolt that secures them to the tibial component. Such devices need to be extracted prior to polyethylene removal. On occasion, the post of the polyethylene component needs to be transected with a saw in order to expose the bolt or screw. Although device-specific instruments may be available for the purpose of polyethylene removal, the goal may simply be achieved by impacting an osteotome at the interface of the polyethylene and tibial components.8
Next, the interface of the components and surrounding bone needs to be exposed circumferentially by eliminating obscuring soft tissues and overhanging bone. When exposure allows, we recommend starting with removal of the tibial component so that the intact femoral component protects the underlying bone from forceful retraction. If femoral component removal is necessary to achieve tibial exposure, the posterior tibial retractor should be rested against the femoral bone with great care. A thin oscillating saw is applied to the undersurface of the medial aspect of the tibial component to separate it from the underlying cement and bone, retracting the medial soft tissues for protection (Fig. 41.9). Use of an oscillating saw under the lateral aspect of the tibial component is not advised, as the saw oscillation may cause undue damage to the patellar tendon. Next, a straight, thin, narrow osteotome is used to finish debonding the undersurface of the tibial component, with care taken to avoid damage to soft tissue structures. Often, the most difficult region to reach is the posterolateral corner. In cases of difficult exposure, this region may be better approached from the posteromedial corner (Fig. 41.10). Once debonding of the undersurface is completed, a tamp and mallet are used to apply force 337to the undersurface of the tibial component to allow for its retrograde removal.
Figure 41.9: A thin oscillating saw is used to separate the undersurface of the tibial component from the underlying cement
Figure 41.10: The posterolateral corner of the undersurface of the tibial component is approached with a thin osteotome from the posteromedial side
338
Care must be taken to completely retract the femur and patella away from the path of the tibial component to avoid damage to these structures.1
Similar concepts apply to removal of the femoral component. A thin oscillating saw may be used under the anterior flange of the component, but, otherwise, a small, straight, thin osteotome is recommended. The anterior and distal aspects of the component are easily debonded with the osteotome on the medial and lateral sides (Fig. 41.11). Exposure is often more difficult in the posterior elements of the component. Separating the cement from the implant is made easier in these regions with a small, curved, thin osteotome. In the case of unstemmed components, it is critical for the surgeon to take time to ensure that the component is grossly loose and able to be removed by hand or with little force. Failure to achieve this goal often leads to substantial bone loss or condylar fracture.
Figure 41.11: The femoral component is separated from the underlying cement with a thin osteotome
339
Next, the tibial and femoral canals are found with a small diameter reamer, and residual cement is removed with a burr, osteotomes, and curettes. In cases of cemented stems, ultrasound tools are often helpful for avoiding iatrogenic fractures and canal perforation.5–7
Removal of the patellar component is often viewed as the easiest task, but small errors in this step can lead to catastrophic consequences.8 After complete exposure of the interface of the component and underlying bone, the patella is everted with the knee in extension. Next, a thin oscillating saw is applied to the undersurface of the component. It is critical that the surgeon takes care to maintain the sawblade parallel and flush to the undersurface of the component in order to avoid undue bone loss or extensor mechanism damage (Fig. 41.12). When appropriately performed, the saw should cut the polyethylene peg(s), leaving them embedded in the patella.
Figure 41.12: The patellar component is carefully removed with a thin oscillating saw
340
Finally, a small, round burr is used to remove the embedded pegs as well as residual cement on the undersurface of the patella.

Pitfalls

  1. Lack of preparedness with specialized instrumentation leads to inefficiency and technical error.
  2. The use of flexible osteotomes during component removal should be avoided.
  3. Attempts to remove components prior to complete separation from surrounding bone and cement lead to undue bone loss.
  4. Reconstructive options for reimplantation may be limited if undue bone loss occurs during removal of components at the time of the first stage.
 
Summary
Removal of components is one of the most critical aspects of successfully treating most periprosthetic infections. The surgical results of this step determine the future reconstructive options that will be available to the patient. The crucial elements of component removal include careful preoperative planning, extensile surgical exposure, and meticulous technique.
 
References
  1. Hozack WJ, Wade FA. Removal of components and cement. In: Callaghan JJ, Rosenberg AG, Rubash HE, eds. The Adult Hip. 2nd ed. Philadelphia: Lippincott Williams and Wilkins;  2007:1352-70.
  1. Mitchell PA, Masri BA, Garbuz DS, et al. Removal of well-fixed, cementless, acetabular components in revision hip arthroplasty. J Bone Joint Surg Br. 2003;85:949–52.
  1. De Thomasson E, Mazel C, Cagna G, Guingand O. A simple technique to remove well-fixed, all polyethylene cemented acetabular component in hip arthroplasty. J Arthroplasty. 2001;16:538–40.341
  1. Miner TM, Momberger NG, Chong D, et al. The extended trochanteric osteotomy in revision hip arthroplasty: a critical review of 166 cases at a mean 3-year, 9-month follow-up. J Arthroplasty. 2001;16:188–94.
  1. Brooks AT, Nelson CL, Hofmann OE. Minimal femoral cortical thickness necessary to prevent perforation by ultrasonic tools in joint revision surgery. J Arthroplasty. 1995;10:359–62.
  1. Klapper R, Caillouette JT, Callaghan JJ, et al. Ultrasonic technology in revision joint arthroplasty. Clin Orthop. 1992;285:147–54.
  1. Gardiner R, Hozack WJ, Nelson C, et al. Revision total hip arthroplasty using ultrasonically driven tools: a clinical evaluation. J Arthroplasty. 1993;8:517–21.
  1. Masri BA, Mitchell PA, Duncan CP. Removal of solidly fixed implants during revision hip and knee arthroplasty. J Am Acad Orthop Surg. 2005;13:18–27.342

Two-Stage Exchange Arthroplasty: Antibiotic Spacerschapter 42

Vinay Aggarwal,
Gregory K Deirmengian
 
Introduction
The treatment of periprosthetic joint infection (PJI) with a two-stage exchange was first introduced in the late 1970s with Insall et al publishing initial reports of promising outcomes in 1983.1 Until that point, the most popular treatment methods for infected joint prosthesis were either arthrodesis or resection arthroplasty with concomitant antibiotic suppression. In the United States today, a six-week course of parenteral antibiotics along with the placement of antibiotic-laden cement spacers has become the preferred method for eradication of chronic PJI.2–8 In addition, the use of two-stage exchange procedures is now advocated in cases of acute PJI where initial irrigation and debridement or one-stage exchange procedures have proven unsuccessful.9
Popularization of antibiotic impregnated cement spacers has brought debate regarding optimal use of the procedure as well as an incredible variety of spacer types for the hip and knee joints. Some surgeons dispute that the use of spacers poses a potential threat to treatment of the PJI since there is not complete removal of all foreign objects from within the joint.10 However, once effective infection eradication was proven, the additional benefits of using cement 344spacers far outweighed this qualm: spacers allow for increased joint stability, prevention of soft tissue contraction, effective local delivery of antibiotics, as well as potentially easier reimplantation procedures.1,11,12

Rothman Institute Current Practices

  1. For acute postoperative and acute hematogenous PJI with a strong host and a non-resistant organism, attempt at irrigation and debridement (I&D) with retention of prosthesis and exchange of modular parts is considered.
  2. For chronic infection, failed I&D, and for acute infections with a poor host and/or virulent organism, a two-stage exchange arthroplasty is undertaken.
  3. We use 3 grams of tobramycin and 3 grams of vancomycin per 40 grams packet of Palacos bone cement.
  4. When sufficient bone stock and adequate soft tissue quality allows, we use articulating spacers. Currently, we prefer the Biomet Stage One® molding kit, using hand mixed cement and antibiotic powder.
  5. We use static spacers in the setting of excessive bone loss, poor soft tissue qualiy, and/or high BMI.
This chapter will focus on the methods for antibiotic laden cement spacer production, the different types of spacers available for use in PJI, and the outcomes following spacer placement in hips and knee joints.
 
Current Evidence
The addition of antibiotics to cement spacer blocks allows for high levels of local bactericidal activity directly at the site of PJI, while limiting the potential for host toxicity associated with systemic antibiotics. Although systemic IV antibiotics are able to act locally at a patient's joint to some degree, it is necessary for surgeons to combine local antibiotic delivery through cement to increase the efficacy of infection eradication.2,12–15 While additional details of antibiotics 345combined with cement have been covered in more depth in chapter 18, factors affecting spacer production will be briefly covered here.
There are many considerations when selecting the antibiotics to add to bone cement for spacer production. Due to their favorable properties and broad coverage of the bacteria most commonly causing PJI, the most commonly utilized include tobramycin, vancomycin, and gentamicin.2 Not only are these antibiotics available in powdered form, which is essential for spacer formation, but they have also been shown to maintain excellent thermic stability during the exothermic reaction that occurs during cement polymerization.16,17 A myriad of differing antibiotic concentrations and combinations are currently used amongst joint replacement surgeons around the world (Table 42.1). An in vivo study by Masri et al has shown that using at least 3.6 grams of tobramycin in conjunction with at least 1 gram of vancomycin per 40 grams of bone cement allows for both synergistic elution at the joint and effective local antibiotic concentrations for up to four months.13 There is however a maximum limit of 8 grams total antibiotic powder that should be added to 40 gram packets of cement in order to maintain a moldable cement block for spacer use.18
With regards to the available bone cement powders for use in spacers, the most commonly used in the United States are Simplex (Stryker Orthopaedics, Mahwah, New Jersey) and Palacos (Zimmer, Warsaw, Indiana). Although both products are commercially available with very low levels of antibiotics premixed in the cement, additional doses must be added at time of surgery. In one of the only landmark studies specifically comparing elution profiles of the two bone cements, an in vitro standardized analysis by Stevens et al showed that Palacos cement spacers demonstrated higher antibiotic elution levels for longer 346periods of time than those spacers made with Simplex cement.19
Table 42.1   Review of the available literature of outcomes following antibiotic spacer use
Study
Joint
Dosage of Antibiotics Used (per 40 g bone cement)
Type of Spacer (n)
Infection Eradication Rate (%)
Range of Motion after Reimplantation (°)
Emerson et al49 (2002)
Knee
3.6 g tobramycin + 2.0 g vancomycin
Static (26)
92.4
93.7
Articulating, autoclaved original femoral component (22)
91.0
107.8
Hsieh et al20 (2004)
Hip
2 g piperacillin + 4 g vancomycin
Articulating, steel-molded components (42)
97.6
–
Durbhakula et al42 (2004)
Hip
2.4 g tobramycin + 1 g vancomycin
Articulating, silicone-molded components (20)
90.0
–
Pietsch et al31 (2003)
Knee
1 g gentamicin + 1 g clindamycin or 2 g vancomycin
Articulating, autoclaved original femoral component (24)
95.8
–347
Freeman et al50 (2007)
Knee
1.2-2.4 g tobramycin + 0.5-1.0 g vancomycin
Static (28)
92.1
–
Articulating, plastic molds cement (48)
94.7
---
Kalore et al34 (2012)
Knee
1.0 g tobramycin + 1.5 g vancomycin
Articulating, autoclaved original femoral component (15)
86.7
95.7
Articulating, new femoral component (16)
93.8
98.3
Articulating, silicone-molded components (22)
90.9
93.8
348
Despite the fact that polymethyl methacrylate (PMMA) bone cement has been used safely and effectively for several decades in total joint reconstruction, there are certain rare but potentially dangerous risks surgeons should be aware of when constructing high dose antibiotic spacers. Due to the renal clearance of many of the antibiotics used in spacers, a few isolated cases of acute renal failure have been reported when treating infected joints with two-stage exchange.23,24 Menge et al reported one of the only series examining acute kidney injury (AKI) in 84 patients undergoing spacer placement with variable doses of tobramycin.25 They found AKI, which had an overall incidence of 17%, to be significantly associated with spacer tobramycin dose when analyzed as both a dichotomous variable (> 4.8 grams; Odds Ratio 5.87, p = 0.01) and as a continuous variable (Odds Ratio 1.24 for every 1 gram increase; p = 0.049).25
 
Surgical Technique
When actually constucting a cement spacer in the operating room, it is important to add the polymethyl methacrylate (PMMA) liquid monomer to the cement powder first, followed by addition of the powdered antibiotics to this cement mixture. This method allows for larger crystal formation, increased porosity of the cement, and thus enhanced antibiotic elution from the spacer.2,21 Although commercially mixed antibiotic-cement preparations are the most homogenous and provide optimal elution, vacuum mixing the liquid and powder has been shown to decrease porosity and antibiotic elution of cement spacers compared to hand mixing.22 Finally, the cement should be applied to the bone only after the doughy phase of cement polymerization has occurred, 349as excessive cement-bone interdigitation increases difficulty of spacer resection and increased bone loss during second stage reimplantation. Interestingly, the opposite mechanical properties are desired when cement is being prepared for fixation purposes, as smaller crystals, decreased porosity and greater bone interdigitation, all decrease risk for bone loosening.10 In fact, for knee spacers, it is helpful to release the tourniquet prior to spacer formation to minimize interdigitation.
For static hip spacers, typically a cement dowel is placed within the proximal femoral canal and a string of beads or ball of cement is placed within the acetabulum (Fig. 42.1). Optimization of the surface area of the spacer allows for increased elution.
Figure 42.1: An AP hip radiograph demonstrates a static hip spacer. In this case, a ball of cement has been placed within the acetabular bed and a dowel of cement placed within the femoral canal
350
In the postoperative period, protection of weight bearing is advised in order to avoid damage to the cement and surrounding bone.
For static knee spacers, several technical factors are important to consider in order avoid complications. First, in order to prevent spacer loosening and displacement in the postoperative period, the cement spacer should be constructed as one unit rather than several pieces and should extend into the femoral and tibial canals. In addition, while the spacer is hardening, an assistant should apply traction to the lower leg while holding appropriate sagittal and coronal alignment (Fig. 42.2).
Figure 42.2: An AP hip radiograph demonstrates a dynamic hip spacer. While the spacer involves metallic implant, the entire implant is coated with antibiotic cement. Periarticular heterotopic ossification is associated with this particular example
351
This prevents soft tissue laxity that may lead to spacer loosening and displacement in the postoperative period (Fig. 42.3). When substantial bone loss threatens the stability of the static spacer, an intramedullary rod may be used for stability (Fig. 42.4). Secondly, while the cement is hardening during the exothermic reaction, the joint space should be filled with fluid in order to dissipate the heat, preventing damage to the posterior neurovascular structures. Lastly, the surgeon should avoid spacer prominence that prevents tension-free closure of the arthrotomy. In the postoperative period, the lower extremity is kept in extension with a cast or brace, and protected weight bearing is practiced.
For an articulating hip static spacer (Fig. 42.5), after removal of components and irrigation and debridement, the hip is trialled with hemiarthoplasty trials. When appropriate femoral component sizing and optimal leg length and stability are achieved, the corresponding components are opened.
Figure 42.3: An intraoperative picture depicts a static knee spacer with appropriate traction being placed
352
Figure 42.4: A lateral knee radiograph demonstrates a failed static knee spacer. The tibial aspect of the spacer has escaped and abuts the region of the patellar tendon
Figure 42.5: An AP knee radiograph demonstrates a static knee spacer in conjunction with a stabilizing intramedullary rod
353
The Biomet Stage One® device allows the cement to be injected directly into the mold with a cement gun after hand mixing. After cement hardening and removal of the encasing plastic mold, the mold is press-fit into the femur. Excess cement may be used to loosely fix the component to the proximal femoral metaphysis to prevent component loosening. In the postoperative period, protection of weight bearing is advised in order to avoid damage to the cement and surrounding bone. Also, hip precautions are practiced in order to prevent periprosthetic instability.
Similarly, the appropriate sizes of the articulating knee spacer molds are determined by trialling. Oversizing of components should be avoided as the error may prevent a tension-free deep closure. Once the molds are injected with cement, allowed to harden, and the encasing plastic molds removed the cement components are loosely cemented to the femoral and tibial surfaces. While poor cement technique should be practiced in order to avoid bone loss at the time of spacer removal, failure to achieve secure fixation of components could lead to postoperative failure (Fig. 42.6). In the postoperative period, protected weight bearing is practiced. After wound healing is confirmed, gentle active assisted range of motion is allowed.
 
Controversies
 
Types of Spacers
As mentioned previously, there is an ever-growing number of techniques for hip and knee reconstruction with antibiotic cement spacers. While techniques vary, currently, static and articulating spacers are the two main reconstructive options. Although there is a large volume of literature published comparing the traditional static 354spacers versus the more modern articulating dynamic spacers, confusion as to the optimal choice remains.
Figure 42.6: A lateral knee radiograph depicts a failed dynamic knee spacer. The tibial component has lost fixation, migrated anteriorly, and places pressure on the patellar tendon
Static spacers hold the affected joint in a fixed position, while delivering antibiotics and preserving the joint space for future revision procedures. Some of the drawbacks of static spacer use include limited range of motion and functionality for patients in between the two-staged procedures.26,27 In addition, the joint immobilization afforded by static spacers may lead to ultimate loss of range of motion after the second stage. Furthermore, static spacers fail to form the normal anatomic contours of the joint, and in heavier patients, may lead to spacer displacement and massive bone loss.10,28 In spite of the many disadvantages to static spacers, they have been and continue to be used by many joint reconstruction surgeons due to significant cost reductions compared to articulating spacers. In addition, certain situations such as 355large metaphyseal bony defects or an insufficient extensor mechanism may preclude the use of articulating spacers, thus requiring utilization of the hand molded static variety.28,33
Dynamic spacers are articulating cement structures contoured to the native joint and resemble the original prosthesis itself. While dynamic spacers pose several potential advantages, their use for PJI is still not yet universal.34,35 This is likely due to uncertainty in weighing its potential benefits with its cost and risks. Many studies comparing static and dynamic spacers agree that articulating designs permit more joint motion and improve function prior to second stage reimplantation. In addition, their use may allow for an easier reimplantation procedure and for increased joint motion after the reimplantation.36–38
Articulating spacers can be premade by device companies, made from commercial molding kits, or constructed intraoperatively by hand. Premade varieties include those manufactured by Exactech, which utilizes gentamicin impregnated PMMA bone cement around a stainless steel reinforcing core in hips or with no metal in knees (Exactech, Gainesville, Florida).39 Although they increase intraoperative efficiency, the disadvantage of such premade molds is that they do not allow the surgeon to adjust the dose and type of antibiotic within the cement. In addition, such premade molds are often fabricated with subtherapeutic antibiotic doses. Molding kits include Biomet Stage One products, which allow for custom mixing of powdered antibiotics and subsequent cement prosthesis production. Finally, a variety of handmade versions of articulating spacers have been described using various available operating room tools including Rush rods Steinmann pins, IM nails, trial femoral heads and acetabular cups, and even old autoclaved prostheses.28,39–43
A recent study by Kalore NV et al evaluated three types of articulating cement spacers for infected knees 356(autoclaving an original component, using a new femoral component, or using a silicone mold component) and reported on rates of infection eradication, range of motion in flexion, and cost. Infection control rates were 86.7%, 93.8%, and 90.9%, respectively; flexion was 95.7°, 98.3°, and 93.8°, respectively; and overall costs were $932, $3589, and $3945, respectively, for the three types of articulating methods.44 Therefore, as this study shows, while articulating spacers provide potential advantages compared to static spacers in many, there are significant financial factors that must be considered when deciding how best to fashion one of these cement blocks for a patient with PJI.
 
Outcomes after Spacers
Even with the vast array of spacer models available, the two-stage exchange arthroplasty has become a mainstay for treatment of chronically infected or otherwise difficult to treat PJI. Implantation of antibiotic laden cement spacers, regardless of type, has led to an overall improved infection eradication rate ranging from 85–100%, enhanced joint function, and improved patient satisfaction.10
In general, the literature regarding outcomes after utilizing antibiotic cement spacers for treatment of PJI agrees that infection control rates in both hip and knee joints are not only high, but similar for static and articulating spacers.26,37,45–47 The use of dynamic rather than static spacers in the knee has been more widely published and advocated for than in the hip. With static knee spacers, as mentioned previously, there is a large risk of soft tissue complications such as scarring, ligament and muscle contractions, which cause significant functional derangements even after reimplantation of new prostheses.33,48357
Emerson et al reported a retrospective series of 26 static and 22 articulating knee spacers, showing that those in the articulating group experienced a greater average range of motion in flexion after reimplantation surgery (107.8° vs. 93.7°).49 In addition, Freeman et al showed that although there were no differences in postoperative pain scores, patients with articulating spacers answered with better functional outcome satisfaction than patients with static spacers.50 Finally, Pietsch et al showed that articulating spacers can be made at low costs with autoclaved components, and can achieve high functional outcomes while maintaining high rate of infection eradication.26
 
Conclusion
In conclusion, the use of antibiotic loaded cement spacers has become a mainstay in the treatment of PJI around the world and especially in the United States. Even though several studies implicating the advantages of articulating spacers over the traditional static variety, especially in the knee joint, further randomized control trials with standardized methods for spacer formation must be undertaken.
 
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  1. Hanssen AD, Spangehl MJ. Practical applications of antibiotic-loaded bone cement for treatment of infected joint replacements. Clin Orthop Relat Res. 2004;(427):79–85.
  1. Pitto RP, Spika IA. Antibiotic-loaded bone cement spacers in two-stage management of infected total knee arthroplasty. Int Orthop. 2004;28(3):129–33.
  1. Spangehl MJ, Younger AS, Masri BA, Duncan CP. Diagnosis of infection following total hip arthroplasty. Instr Course Lect. 1998;47:285–95.358
  1. Tsukayama DT, Goldberg VM, Kyle R. Diagnosis and management of infection after total knee arthroplasty. J Bone Joint Surg Am. 2003;85-A Suppl 1:S75-80.
  1. Segawa H, Tsukayama DT, Kyle RF, Becker DA, Gustilo RB. Infection after total knee arthroplasty. A retrospective study of the treatment of eighty-one infections. J Bone Joint Surg Am. 1999;81(10):1434–45.
  1. Tsukayama DT, Estrada R, Gustilo RB. Infection after total hip arthroplasty. A study of the treatment of one hundred and six infections. J Bone Joint Surg Am. 1996;78(4):512–23.
  1. Atkins BL, Athanasou N, Deeks JJ, et al. Prospective evaluation of criteria for microbiological diagnosis of prosthetic-joint infection at revision arthroplasty. The OSIRIS Collaborative Study Group. J Clin Microbiol. 1998;36(10):2932–9.
  1. Parvizi J, Zmistowski B, Adeli B. Periprosthetic joint infection: treatment options. Orthopedics. 2010;33(9):659.
  1. Cui Q, Mihalko WM, Shields JS, Ries M, Saleh KJ. Antibiotic-impregnated cement spacers for the treatment of infection associated with total hip or knee arthroplasty. J Bone Joint Surg Am. 2007;89(4):871–82.
  1. Haddad FS, Masri BA, Campbell D, McGraw RW, Beauchamp CP, Duncan CP. The PROSTALAC functional spacer in two-stage revision for infected knee replacements. Prosthesis of antibiotic-loaded acrylic cement. J Bone Joint Surg Br. 2000;82(6):807–12.
  1. Hofmann AA, Goldberg T, Tanner AM, Kurtin SM. Treatment of infected total knee arthroplasty using an articulating spacer: 2- to 12-year experience. Clin Orthop Relat Res. 2005;(430):125–31.
  1. Masri BA, Duncan CP, Beauchamp CP. Long-term elution of antibiotics from bone-cement: an in vivo study using the prosthesis of antibiotic-loaded acrylic cement (PROSTALAC) system. J Arthroplasty. 1998;13(3):331–8.
  1. Springer BD, Lee GC, Osmon D, Haidukewych GJ, Hanssen AD, Jacofsky DJ. Systemic safety of high-dose antibiotic-loaded cement spacers after resection of an infected total knee arthroplasty. Clin Orthop Relat Res. 2004;(427):47–51.
  1. Nelson CL. The current status of material used for depot delivery of drugs. Clin Orthop Relat Res. 2004;(427):72–8.359
  1. Koo KH, Yang JW, Cho SH, et al. Impregnation of vancomycin, gentamicin, and cefotaxime in a cement spacer for two-stage cementless reconstruction in infected total hip arthroplasty. J Arthroplasty. 2001;16(7):882–92.
  1. Joseph TN, Chen AL, Di Cesare PE. Use of antibiotic-impregnated cement in total joint arthroplasty. J Am Acad Orthop Surg. 2003;11(1):38–47.
  1. Hsieh PH, Chen LH, Chen CH, Lee MS, Yang WE, Shih CH. Two-stage revision hip arthroplasty for infection with a custom-made, antibiotic-loaded, cement prosthesis as an interim spacer. J Trauma. 2004;56(6):1247–52.
  1. Stevens CM, Tetsworth KD, Calhoun JH, Mader JT. An articulated antibiotic spacer used for infected total knee arthroplasty: a comparative in vitro elution study of Simplex and Palacos bone cements. J Orthop Res. 2005;23(1):27–33.
  1. Hendriks JGE, Neut D, van Horn JR, van der Mei HC, Busscher HJ. Bacterial survival in the interfacial gap in gentamicin-loaded acrylic bone cements. J Bone Joint Surg Br. 2005;87(2):272–6.
  1. Seldes RM, Winiarsky R, Jordan LC, et al. Liquid gentamicin in bone cement: a laboratory study of a potentially more cost-effective cement spacer. J Bone Joint Surg Am. 2005;87(2):268–72.
  1. Neut D, van de Belt H, van Horn JR, van der Mei HC, Busscher HJ. The effect of mixing on gentamicin release from polymethylmethacrylate bone cements. Acta Orthop Scand. 2003;74(6):670–6.
  1. Curtis JM, Sternhagen V, Batts D. Acute renal failure after placement of tobramycin-impregnated bone cement in an infected total knee arthroplasty. Pharmacotherapy. 2005;25(6):876–80.
  1. van Raaij TM, Visser LE, Vulto AG, Verhaar JAN. Acute renal failure after local gentamicin treatment in an infected total knee arthroplasty. J Arthroplasty. 2002;17(7):948–50.
  1. Menge TJ, Koethe JR, Jenkins CA, et al. Acute kidney injury after placement of an antibiotic-impregnated cement spacer during revision total knee arthroplasty. The Journal of Arthroplasty. 2012. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22321301. Accessed April 1, 2012.360
  1. Pietsch M, Wenisch C, Traussnig S, Trnoska R, Hofmann S. [Temporary articulating spacer with antibiotic-impregnated cement for an infected knee endoprosthesis]. Orthopade. 2003;32(6):490–7.
  1. Fehring TK, Odum S, Calton TF, Mason JB. Articulating versus static spacers in revision total knee arthroplasty for sepsis. The Ranawat Award. Clin Orthop Relat Res. 2000;(380):9–16.
  1. Shen H, Zhang X, Jiang Y, et al. Intraoperatively-made cement-on-cement antibiotic-loaded articulating spacer for infected total knee arthroplasty. Knee. 2010;17(6):407–11.
  1. Antoci V, Phillips MJ, Antoci V Jr, Krackow KA. Using an antibiotic-impregnated cement rod-spacer in the treatment of infected total knee arthroplasty. Am J Orthop. 2009;38(1):31–3.
  1. Yoo J, Lee S, Han C, Chang J. The modified static spacers using antibiotic-impregnated cement rod in two-stage revision for infected total knee arthroplasty. Clin Orthop Surg. 2011;3(3):245–8.
  1. Kotwal SY, Farid YR, Patil SS, Alden KJ, Finn HA. Intramedullary rod and cement static spacer construct in chronically infected total knee arthroplasty. J Arthroplasty. 2012;27(2):253–9.e4.
  1. Macmull S, Bartlett W, Miles J, et al. Custom-made hinged spacers in revision knee surgery for patients with infection, bone loss and instability. Knee. 2010;17(6):403–6.
  1. Pietsch M, Hofmann S, Wenisch C. Treatment of deep infection of total knee arthroplasty using a two-stage procedure. Oper Orthop Traumatol. 2006;18(1):66–87.
  1. Fink B, Rechtenbach A, Büchner H, Vogt S, Hahn M. Articulating spacers used in two-stage revision of infected hip and knee prostheses abrade with time. Clin Orthop Relat Res. 2011;469(4):1095–1102.
  1. Johnson AJ, Sayeed SA, Naziri Q, Khanuja HS, Mont MA. Minimizing dynamic knee spacer complications in infected revision arthroplasty. Clin Orthop Relat Res. 2012;470(1):220–7.
  1. Durbhakula SM, Czajka J, Fuchs MD, Uhl RL. Antibiotic-loaded articulating cement spacer in the 2-stage exchange of infected total knee arthroplasty. J Arthroplasty. 2004;19(6):768–74.361
  1. Meek RMD, Masri BA, Dunlop D, et al. Patient satisfaction and functional status after treatment of infection at the site of a total knee arthroplasty with use of the PROSTALAC articulating spacer. J Bone Joint Surg Am. 2003;85-A(10):1888-92.
  1. MacAvoy MC, Ries MD. The ball and socket articulating spacer for infected total knee arthroplasty. J Arthroplasty. 2005;20(6):757–62.
  1. Incavo SJ, Russell RD, Mathis KB, Adams H. Initial results of managing severe bone loss in infected total joint arthroplasty using customized articulating spacers. J Arthroplasty. 2009;24(4):607–13.
  1. Romanò CL, Romanò D, Logoluso N, Meani E. Long-stem versus short-stem preformed antibiotic-loaded cement spacers for two-stage revision of infected total hip arthroplasty. Hip Int. 2010;20(1):26–33.
  1. Kent M, Rachha R, Sood M. A technique for the fabrication of a reinforced moulded articulating cement spacer in two-stage revision total hip arthroplasty. Int Orthop. 2010;34(7):949–53.
  1. Goldstein WM, Kopplin M, Wall R, Berland K. Temporary articulating methylmethacrylate antibiotic spacer (TAMMAS). A new method of intraoperative manufacturing of a custom articulating spacer. J Bone Joint Surg Am. 2001;83-A Suppl 2 Pt 2:92-7.
  1. Hsieh PH, Shih CH, Chang YH, Lee MS, Yang WE, Shih HN. Treatment of deep infection of the hip associated with massive bone loss: two-stage revision with an antibiotic-loaded interim cement prosthesis followed by reconstruction with allograft. J Bone Joint Surg Br. 2005;87(6):770–5.
  1. Kalore NV, Maheshwari A, Sharma A, Cheng E, Gioe TJ. Is there a preferred articulating spacer technique for infected knee arthroplasty? A preliminary study. Clin Orthop Relat Res. 2012;470(1):228–35.
  1. Fei J, Liu G, Yu H, Zhou Y, Wang Y. Antibiotic-impregnated cement spacer versus antibiotic irrigating metal spacer for infection management after THA. Orthopedics. 2011;34(3):172.362
  1. Gooding CR, Masri BA, Duncan CP, Greidanus NV, Garbuz DS. Durable infection control and function with the PROSTALAC spacer in two-stage revision for infected knee arthroplasty. Clin Orthop Relat Res. 2011;469(4):985–93.
  1. Hsu YC, Cheng HC, Ng TP, Chiu KY. Antibiotic-loaded cement articulating spacer for 2-stage reimplantation in infected total knee arthroplasty: a simple and economic method. J Arthroplasty. 2007;22(7):1060–6.
  1. Calton TF, Fehring TK, Griffin WL. Bone loss associated with the use of spacer blocks in infected total knee arthroplasty. Clin Orthop Relat Res. 1997;(345):148–54.
  1. Emerson RH Jr, Muncie M, Tarbox TR, Higgins LL. Comparison of a static with a mobile spacer in total knee infection. Clin Orthop Relat Res. 2002;(404):132–8.
  1. Freeman MG, Fehring TK, Odum SM, Fehring K, Griffin WL, Mason JB. Functional advantage of articulating versus static spacers in 2-stage revision for total knee arthroplasty infection. J Arthroplasty. 2007;22(8):1116–21.

Reimplantation Following Two-Stage Exchange Arthroplasty for Periprosthetic Joint Infectionchapter 43

Camilo Restrepo
 
Current Evidence
 
How do You Know periprosthetic joint infection (PJI) is Eradicated?
Prior to proceeding with reimplantation following two-stage exchange arthroplasty, it is critical to determine whether the PJI has been successfully eradicated. Unfortunately, this seemingly simple step is often quite challenging. Routinely, patients are treated with six weeks of culture-specific parenteral antibiotics1 and are then given an “antibiotic holiday” to determine whether the infection has been truly eradicated or only suppressed. The length of the “antibiotic holiday” has been described as anywhere from two weeks to several months, depending on the clinical scenario and the surgeon's pretest suspicion of latent infection, but no evidence supports an ideal time for reimplantation.2,3 Then, multiple variables are assessed to determine whether the PJI has been successfully eradicated. Clinically, the patient 364should be free of systemic symptoms, such as fever, chills, sweating, and malaise.

Rothman Institute Current Practices

  1. Six weeks of parenteral antibiotics are followed by a 4-week “antibiotic holiday.”
  2. Aspiration during spacer period.
  3. Preoperative (reimplantation) prophylactic antibiotic is not withheld.
  4. A minimum of three intraoperative cultures are obtained at time of reimplantation.
In addition, the wound and local soft tissues should be adequately healed, with no evidence of erythema, warmth, drainage, or sinus tract. Serologic analysis can provide additional data to support whether or not the infection has been cleared.4,5 Serial ESR and CRP levels should gradually decline after effective treatment,1 but no definitive evidence supports an ideal cutoff value that predicts the optimal time for reimplantation.6 Joint aspirations can provide further data to help in determining eradication of infection, although the literature is controversial on this topic. Della Valle et al7 reported that synovial leukocyte count (< 3,000 mL) and differential should approximate normal values, although Parvizi et al8 have found the leukocyte count and differential unreliable in determining absence of infection. Finally, cultures obtained by aspiration during the “antibiotic holiday” can be one of the most reliable tools to determine eradication of infection and are often used to predict time of reimplantation. Unfortunately, sometimes cultures could be false negative, as reported by Trampuz et al.9 Although no definite criteria exist regarding eradication of infection, a combination of clinical, serological, and aspiration data can help the clinician make a well-informed decision whether or not to reimplant a prostheses following a two-stage exchange arthroplasty.365
 
Intraoperative Measures
 
Holding Versus giving Antibiotics
Once reimplantation has been determined and the patient is to undergo surgery, a decision about whether or not to give preoperative prophylactic antibiotics must be made. Although there is some theoretical concern that preoperative antibiotics may affect the results of the subsequent intraoperative cultures, the literature definitively supports the benefit of preoperative antibiotics in reducing the risk of deep infection.10 Indeed, a recent study performed at the Rothman Institute concluded that the yield of positive cultures was not significantly affected when preoperative prophylactic antibiotics were used, and recommended not withholding them.10
 
What to do with postoperative positive Cultures?
Although positive cultures can be considered evidence of failure to eradicate infection, it is important to rule out the possibility that such positive cultures are contaminants—“false positives”. Several variables should be taken into consideration when evaluating what constitutes a “true-positive” culture. First, the absolute and relative numbers of positive cultures can be evaluated. Obtaining at least three samples will facilitate interpretation of the summative data.11 A single positive culture of a low-virulence organism (e.g. coryneform bacteria) may or may not indicate a true infection, whereas multiple cultures growing the same virulent organism (e.g. methicillin-resistant Staphylococcus epidermidis [MRSE]) can more reliably be considered a true infection.12 Second, whether or not the samples are tissue or fluid is important, as multiple studies have shown that fluid samples are less reliable than tissue samples and should be avoided.13 In addition, whether the microorganism grows only in enriched broth or in solid media may help differentiate whether a contamination 366or true infection is present.14 In solid media (agar), fewer than 25 colony-forming units is usually considered contamination.15
The results of intraoperative cultures are usually not known before 24 to 48 hours after reimplantation. If an unexpected positive culture—a “true positive”—is obtained at this time point, the surgeon must decide whether to proceed with a repeat surgery or to retain the reimplanted prosthesis and begin suppressive antibiotic therapy.
 
Suppressive Antibiotics
The use of suppressive antibiotics to retain implants and avoid another major operation close in time to the preceding one is attractive for many reasons to both the surgeon and the patient.1 This practice avoids the morbidity and prolonged recovery of a repeat two-stage exchange arthroplasty. It is also a more attractive option than the choice of an arthrodesis or an amputation/disarticulation. This option is particularly important given that the success rates for repeated two-stage exchange arthroplasty for PJI are progressively worse.16 For a more in-depth discussion of suppressive antibiotics, please refer to Chapter 44. In short, of the decision for suppressive antibiotics should usually be made by a multidisciplinary team that includes the surgeon and an infectious disease consultant. Suppressive antibiotic therapy may be indicated for any infecting microorganism but most commonly is used for methicillin-resistant Staphylococcus aureus (MRSA), fungi, and mycobacteria.17
 
Length
Suppressive antibiotic therapy for MRSA is usually established for a period of 6 to 9 months, after which the patient is reevaluated for persistence of infection. The most commonly used antibiotic is vancomycin. 367Using vancomycin for more than 9 months in patients with MRSA has not been shown to promote resistance, but tolerance and diminished effectiveness may occur owing to a decrease in the antibiotic's ability to induce bacterial autolysis.18,19
Suppressive antibiotic therapy for fungi and mycobacteria (due to their insidious and low-virulence nature) is usually established for life.17,20
 
Role for Dual Suppression
Suppressive antibiotic therapy with dual or multiple antibiotics may be recommended by the multidisciplinary team on the basis of the resistance and susceptibility of the infecting organism.11 Another reason for using dual or multiple antibiotics is the fact that certain antibiotics such as rifampin induce resistance very fast if used alone.11 Currently, no evidence shows that such an approach is cost effective (unknown toxicity and efficacy), especially in the event of suppressive therapy for life.11

Pitfalls

  1. Vancomycin for 6 to 9 months may result in diminished antimicrobial effectiveness.
  2. Rifampin alone may induce resistance rapidly and should not be used as monotherapy.
 
References
  1. Glassman AH, Lachiewicz PF, Tanzer M, eds. Orthopaedic Knowledge Update 4: Hip and Knee Reconstruction. 4th ed. Rosewood, IL: American Academy of Orthopaedic Surgeons;  2011.
  1. Mortazavi SJ, Vegari D, Ho A, Zmistowski B, Parvizi J. Two-stage exchange arthroplasty for infected total knee arthroplasty: predictors of failure. Clin Orthop Relat Res. 2011;469(11):3049–54.368
  1. Zmistowski B, Fedorka CJ, Sheehan E, et al. Prosthetic joint infection caused by gram-negative organisms. J Arthroplasty. 2011. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21641762. Accessed July 12, 2011.
  1. Schinsky MF, Della Valle CJ, Sporer SM, Paprosky WG. Perioperative testing for joint infection in patients undergoing revision total hip arthroplasty. J Bone Joint Surg Am. 2008;90(9):1869–75.
  1. Larsson S, Thelander U, Friberg S. C-reactive protein (CRP) levels after elective orthopedic surgery. Clin Orthop Relat Res. 1992;(275):237–42.
  1. Ghanem E, Antoci V, Pulido L, et al. The use of receiver operating characteristics analysis in determining erythrocyte sedimentation rate and C-reactive protein levels in diagnosing periprosthetic infection prior to revision total hip arthroplasty. Int J Infect Dis. 2009;13(6):e444–9.
  1. Della Valle CJ, Sporer SM, Jacobs JJ, et al. Preoperative testing for sepsis before revision total knee arthroplasty. J Arthroplasty. 2007;22(6 suppl 2):90–3.
  1. Parvizi J, Ghanem E, Sharkey P, et al. Diagnosis of infected total knee: findings of a multicenter database. Clin Orthop Relat Res. 2008;466(11):2628–33.
  1. Trampuz A, Widmer AF. Infections associated with orthopedic implants. Curr Opin Infect Dis. 2006;19(4):349–56.
  1. Ghanem E, Parvizi J, Clohisy J, et al. Perioperative antibiotics should not be withheld in proven cases of periprosthetic infection. Clin Orthop Relat Res. 2007;461:44–7.
  1. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic joint infections. N Engl J Med. 2004;351(16):1645–54.
  1. Coyle MB, Lipsky BA. Coryneform bacteria in infectious diseases: Clinical and laboratory aspects. Clin Microbiol Rev. 1990;3(3):227–46.
  1. Roux A–l, Sivadon–Tardy V, Bauer T, et al. Diagnosis of prosthetic joint infection by beadmill processing of a periprosthetic specimen. Clin Microbiol Infect. 2011;17(3): 447–50.
  1. Shetty N, Tang JW, Andrews J. Infectious Disease: Pathogenesis, Prevention and Case Studies. Hoboken, NJ: John Wiley & Sons;  2009.369
  1. Counting Colonies. The Microbiology Network. Available at: http://www.microbiol.org/resources/monographswhite-papers/counting-colonies/. Accessed April 16, 2012.
  1. Kubista B, Hartzler RU, Wood CM, et al. Reinfection after two-stage revision for periprosthetic infection of total knee arthroplasty. Int Orthop. 2011. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21553042. Accessed December 22, 2011.
  1. Eid AJ, Berbari EF, Sia IG, et al. Prosthetic joint infection due to rapidly growing mycobacteria: report of eight cases and review of the literature. Clin Infect Dis. 2007;45(6):687–94.
  1. Sakoulas G, Gold HS, Cohen RA, et al. Effects of prolonged vancomycin administration on methicillin-resistant Staphylococcus aureus (MRSA) in a patient with recurrent bacteraemia. J Antimicrob Chemother. 2006;57(4):699–704.
  1. Hsu C-Y, Lin M-H, Chen C-C, et al. Vancomycin promotes the bacterial autolysis, release of extracellular DNA, and biofilm formation in vancomycin-non-susceptible Staphylococcus aureus. FEMS Immunol Med Microbiol. 2011;63(2):236–47.
  1. Azzam K, Parvizi J, Jungkind D, et al. Microbiological, clinical, and surgical features of fungal prosthetic joint infections: a multi-institutional experience. J Bone Joint Surg Am. 2009;91(suppl 6):142–9.370

Suppression of Prosthetic Joint Infection Using Antimicrobial Therapychapter 44

Jai Hyung Park
 
Current Evidence
Eradication of prosthetic joint infection (PJI) is best achieved by surgical removal of infected tissue, with or without implant removal and antimicrobial therapy with bactericidal activity against biofilm microorganisms.1 The use of suppressive antibiotic treatment is generally reserved for patients with severe coexisting illness, patients who are immobile, patients with a well-fixed and functional prosthesis, or patients who refuse surgical intervention.2 The requirements for long-term suppressive antimicrobial therapy are stable prosthesis, relatively weak pathogen, sensitivity to an oral antibiotic, absence of systemic infection, and good tolerability of oral antibiotic therapy.3,4 The goal of suppressive therapy of PJI is different from that of treatment of PJI: to control clinical manifestations of infection (e.g. pain) rather than to completely eradicate all infecting pathogens.1
Although suppressive antibiotic therapy for PJI is classically described for patients in whom surgical debridement cannot be performed owing to medical frailty, 372it is also used to varying degrees in the following clinical scenarios: open debridement with component retention, one-stage exchange arthroplasty, and two-stage exchange arthroplasty. The rationale behind this practice is that despite aggressive surgical debridement and the absence of clinical or histological signs of infection, latent microorganisms often remain in the periprosthetic tissues. To prevent recrudescence of infection and/or prevent new infection in these often compromised hosts, prolonged suppressive therapy is used. Following initial acute management of PJI, via irrigation and debridement with modular component exchange, intravenous antibiotics should be administered for 2 to 6 weeks.1, 2 The regimen of postoperative antibiotics following one-stage exchange arthroplasty is quite variable in the literature, ranging anywhere from no oral antibiotic course to 8 months.5–8 Prolonged therapy with oral antibiotics even after two-stage exchange arthroplasty is sometimes necessary to prevent reinfection. This is supported by several reports of a high incidence of reinfection with the same organism following two-stage revision.9,10

Rothman Institute Current Practices

  1. Suppressive antibiotic therapy for PJI is reserved for patients who are poor surgical candidates, and the risks of a two-stage exchange arthroplasty outweigh the potential benefits.
  2. Suppressive antibiotic regimens are always decided in conjunction with infectious disease consultants.
The antimicrobial susceptibility of the pathogen should be determined prior to treatment and should be used to design a suitable oral regimen for chronic long-term suppressive antibiotic therapy. Ideally, an agent used long-term should have good oral bioavailability, be well tolerated with few side effects, have few interactions 373with other medications, as well as be efficacious against the pathogen causing the infection. Several antimicrobial agents have excellent oral bioavailability and tolerability, including fluoroquinolones (ciprofloxacin, ofloxacin, moxifloxacin, levofloxacin, gatifloxacin), tetracyclines (minocycline, doxycycline), trimethoprim-sulfamethoxazole, rifampin, fusidic acid, linezolid, and clindamycin.1,11,12 As the aim of suppressive therapy is palliative and not curative, biofilm active agents (such as rifampin) are not generally employed.1 Trimethoprim-sulfamethoxazole or tetracycline antibiotics are commonly prescribed for long-term suppressive therapy in patients with susceptible isolates.1
Complications or adverse effects of antibiotic use include diarrhea (3–8%), pseudomembranous colitis (1%), delayed hypersensitivity reaction (11%), nephrotoxicity (due to vancomycin, 1%), leukopenia (1%), and skin discoloration (due to minocycline, 1%).2,13
The optimal duration of suppressive antimicrobial therapy is unknown.13 Because of this uncertainty, treatment decisions are often made on a case-by-case basis depending on the clinical response to therapy, suppression of inflammatory markers, and tolerability of the antibiotic agent and side effects experienced. Authors report a range of treatment durations from 6 to 128 months, with a median duration between 18 and 60 months.2,13 Retrospective studies show some patients experience a prolonged remission after discontinuation of suppressive antibiotic therapy,14 whereas others report treatment failure following discontinuation of long-term suppressive antibiotic therapy.13
Studies reporting outcomes of long-term suppressive antibiotic therapy are small and report success rates of between 23% and 86.2%.13,14 Tsukayama et al14 report success rates of 23% in their study of 13 chronically infected arthroplasty joints followed up for three years, 374whereas Rao et al2 report success in 86.2% of patients receiving suppressive therapy in their prospective series of 36 PJI patients followed up over five years. Four of the five treatment failures reported by Rao et al had infections caused by Staphylococcus aureus (one methicillin resistant, three methicillin susceptible). However, the authors report overall successful suppression of infection in 69% of PJIs treated for Staphylococcus aureus infection, similar to that reported by Brandt et al (63%).2,15 Advanced age was not predictive of poorer outcome, and joint location, duration of symptoms, and time of onset of infection did not predict success or failure.2 Brandt et al15 found that prosthesis infected with Staphylococcus aureus debrided longer than two days after the onset of infection had a greater chance of failure than did those debrided within two days of onset (relative risk 4.2; 95% confidence interval, 6–10.3).
Prompt recognition of infection, rapid debridement, and antibiotic treatment are recommended for all PJIs.2 The optimal duration and antibiotic regimen for suppressive antibiotic therapy has not been established, and well-designed prospective, multicenter trials are required to clarify issues such as patient selection, antibiotic regimens, and optimal duration of antibiotic therapy to achieve component salvage.
 
Controversies
  • Treatment duration for suppressive therapy is not established, and recrudescence of infection following discontinuation of therapy has been widely reported.
  • Regimens containing rifampin are not recommended for the long-term suppressive treatment of chronic PJI.
 
References
  1. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic joint infections. N Engl J Med. 2004;351:1645–54.375
  1. Rao N, Crossett LS, Sinha RK, Le Frock JL. Long-term suppression of infection in total joint arthroplasty. Clin Orthop Relat Res. 2003;(414):55–60.
  1. Segreti J, Nelson JA, Trenholme GM. Prolonged suppressive antibiotic therapy for infected orthopedic prosthesis. Clin Infect Dis. 1998;27:711–3.
  1. Goulet JA, et al. Prolonged suppression of infection in total hip arthroplasty. J Arthroplasty. 1988;3(2):109–16.
  1. Ure KJ, et al. Direct-exchange arthroplasty for the treatment of infection following total hip replacement. J Bone Joint Surg. 1998;80(7):961–8.
  1. Callaghan JJ, et al. One-stage revision surgery of the infected hip. Clin Orthop Rel Res. 1999;369:25–38.
  1. Yoo JJ, et al. One-stage cementless revision arthroplasty for infected hip replacements. Int Orthop. 2009;33:1195–201.
  1. Jackson WO, et al. Limited role of direct exchange arthroplasty in the treatment of infected total hip replacements. Clin Orthop Rel Res. 2000;381:101–5.
  1. Hanssen AD, et al. Patient outcome with reinfection following reimplantation for the infected total knee arthroplasty. Clin Orthop Rel Res. 1995; 321:55–67.
  1. Hoffmann AA. Treatment of infected total knee arthroplasty. Clin Orthop Rel Res. 2005;440:125–31.
  1. Gomez J, Canovas E, Banos V, et al. Linezolid plus rifampin as a salvage therapy in prosthetic joint infections treated without removing the implant. Antimicrob Agents Chemother. 2011;55:4308–10.
  1. Trampuz A, Zimmerli W. New strategies for the treatment of infections associated with prosthetic joints. Curr Opin Investig Drugs. 2005;6:185–90.
  1. Marculescu CE, Berbari EF, Hanssen AD, et al. Outcome of prosthetic joint infections treated with debridement and retention of components. Clin Infect Dis. 2006;42:471–8.
  1. Tsukayama DT, Wicklund B, Gustilo RB. Suppressive antibiotic therapy in chronic prosthetic joint infections. Orthopedics. 1991;14:841–4.
  1. Brandt CM, Sistrunk WW, Duffy MC, et al. Staphylococcus aureus prosthetic joint infection treated with debridement and prosthesis retention. Clin Infect Dis. 1997; 24:914–9.376

Prognostic Classification for Periprosthetic Joint Infectionchapter 45

Ronald Huang
 
Current Evidence
 
Introduction
An evidence-based approach should be used to determine the appropriate treatment strategy for a patient with periprosthetic joint infection (PJI), as well as to provide sound counseling with regard to expected clinical outcomes. Current literature has identified numerous variables, including those related to host, surgical procedure, and causative microorganism, that are associated with failure of infection control following treatment for PJI. Surgeons can use these prognostic factors to estimate the outcome of treatment for PJI and opt for more aggressive treatment in patients with higher risk of treatment failure.

Risk Factors for Treatment Failure of PJI

  1. Host factors
    1. Physiologic classification
      • A class
      • B class
      • C class
    2. Immunocompromise
    3. Increased number of previous revisions.
  2. Surgical factors
    1. Longer duration of surgery
    2. Local soft tissue compromise
    3. Presence of sinus tract
    4. Prolonged duration of symptoms > 8 days.
  3. Microorganism factors
    1. Staphylococcus aureus
    2. Drug-resistant organisms.
378
 
Host Factors
The physiologic status and immunologic status of patients are major factors that influence their ability to control PJI. Cierny et al developed a physiologic classification to divide patients into three groups based on systemic or local factors that affect their immune system, metabolism, and local vascularity: Class A hosts have normal responses to infection; class B hosts have either systemic deficiencies (malnutrition, renal failure, liver failure, immunodeficiency, alcohol abuse, chronic hypoxia, malignancy, diabetes, advanced age, steroid therapy, and tobacco abuse), local deficiencies (chronic lymphedema, venous stasis, vessel compromise, arteritis, radiation fibrosis, and scarring), or both; and class C patients have a contraindication to surgery because of health status.1 Tsukayama et al2 also identified immunocompromise and increased number of previous revision surgeries as independent risk factors for treatment failure.
 
Surgical Factors
Surgical factors play a significant role in determining the success of PJI treatment. Appropriate choice of surgical treatment has a major impact on infection-free survival rate following PJI. When indications are appropriately followed, one-stage exchange arthroplasty has been found to have as high as 90% infection-free survival rates in multiple series. However, these studies were limited by their small sample sizes. Irrigation and debridement (I&D) with modular component exchange has been regarded as a viable alternative to two-stage exchange arthroplasty in acute infections. However, a recent systematic review has found failure rates to be as high as 61% to 82% following I&D for periprosthetic infection after total knee 379arthroplasty.3 Conversely, infection control appears to be most successful following two-stage exchange, with multiple studies reporting infection-free survival rates of 80% to 90% at 2 to 5 years of follow-up.4–7
Other surgical factors that influence success of treatment for PJI include timing of surgery, use of antibiotics, and duration of surgery, among others. In a study by Marculescu et al,8 preoperative presence of a sinus tract and prolonged duration of symptoms longer than eight days before surgery have been identified as independent predictors for failure to control infection with I&D and retention of components. Preoperative antibiotics have been shown to be important in preventing infection in multiple studies and should not be withheld before revision surgery.9–11 Mortazavi et al12 studied risk factors for failure of two-stage exchange arthroplasty for infection and identified longer duration of surgery (2.90 hours in the failed arthroplasty group versus 2.75 hours in the infection-free survival group) as an independent predictor of failure. Furthermore, existing literature supports more aggressive two-stage exchange as opposed to I&D or one-stage exchange when local soft tissue compromise is present.13
 
Microorganism Factors
Numerous studies have suggested that the type of microorganism heavily influences infection control rate. Specifically, the literature indicates that infections with Staphylococcus aureus species are more likely to fail initial treatment than are infections with less virulent species.14–16 Marculescu et al14 found a 22% two-year infection-free survival rate of Staphylococcus aureus infections, compared with a success rate of 82%, 92%, and 70% for coagulase-negative staphylococci, enterococci, and other organisms, respectively, treated with I&D and retention of components. Brandt et al15 similarly found a 69% probability of reinfection following treatment 380of Staphylococcus aureus infections. In addition, Gram-negative organisms, suggested as being more virulent, are associated with lower infection-free survival rates following treatment.17,18 Zmistowski et al18 found a 52% two-year infection-free survival rate of Gram-negative infections, compared with 51% and 69% success rates, respectively, in methicillin-resistant Gram-positive and methicillin-sensitive Gram-positive infections treated with two-stage exchange. Finally, culture-negative infections have historically been reported to have worse treatment outcomes when compared with culture-positive PJIs.4,19 However, recent data from our institution have found that culture-negative PJIs have two-year infection control rates similar to those of culture-positive PJIs when treated aggressively with two-stage exchange.
Besides type of microorganism, the antibiotic resistance profile of the infecting bacteria has also been found to be significantly associated with the success of infection eradication. Methicillin resistance is a well-established risk factor for treatment failure of infection.20–23 Kurd et al21 found that in a cohort of 102 patients who underwent two-stage exchange arthroplasty for PJI, methicillin resistance was an independent predictor of subsequent reinfection, with a success rate of only 55% in patients infected with methicillin-resistant organisms, compared with 80% success in patients infected by non-methicillin-resistant organisms (odds ratio 3.37). Nevertheless, other studies indicate that similar infection control rates may be achieved in methicillin-resistant and nonresistant infections if patients are aggressively treated.24,25
 
Prognostic Classification
A simple prognostic calculator using the aforementioned risk factors is being developed at our institution to guide patient counseling and appropriate treatment decisions for PJI. About 589 patients treated for infected total knee 381and hip arthroplasties at the Rothman Institute were followed up for a minimum of two years. Treatment failure is defined as the need for subsequent resection of components because of infection. Host factors, including Cierny classification, previous revisions, and comorbidities, were collected. Surgical factors, such as treatment type, presence of sinus tract, duration of symptoms before treatment, preoperative antibiotics, and duration of surgery, were also collected. Furthermore, microorganism factors such as organism type and antibiotic sensitivity were recorded. All variables are being evaluated as risk factors for PJI treatment failure, and a prognostic classification model is being developed using the identified risk factors.
 
References
  1. Cierny G III, Mader JT, Penninck JJ. A clinical staging system for adult osteomyelitis. Clin Orthop Relat Res. 2003;(414):7–24.
  1. Tsukayama DT, Estrada R, Gustilo RB. Infection after total hip arthroplasty. A study of the treatment of one hundred and six infections. J Bone Joint Surg Am. 1996;78:512–23.
  1. Sherrell JC, Fehring TK, Odum S, et al. The Chitranjan Ranawat Award: fate of two-stage reimplantation after failed irrigation and debridement for periprosthetic knee infection. Clin Orthop Relat Res. 2011;469:18–25.
  1. Bejon P, Berendt A, Atkins BL, et al. Two-stage revision for prosthetic joint infection: predictors of outcome and the role of reimplantation microbiology. J Antimicrob Chemother. 2010;65(3):569–75.
  1. Biring GS, Kostamo T, Garbuz DS, Masri BA, Duncan CP. Two-stage revision arthroplasty of the hip for infection using an interim articulated Prostalac hip spacer: a 10- to 15-year follow-up study. J Bone Joint Surg Br. 2009;91:1431–7.
  1. Haleem AA, Berry DJ, Hanssen AD. Mid-term to long-term follow-up of two-stage reimplantation for infected total knee arthroplasty. Clin Orthop Relat Res. 2004;428:35–9.382
  1. Hirakawa K, Stulberg BN, Wilde AH, Bauer TW, Secic M. Results of two-stage reimplantation for infected total knee arthroplasty. J Arthroplasty. 1998;13(1):22–8.
  1. Marculescu CE, Berbari EF, Hanssen AD, et al. Outcome of prosthetic joint infections treated with debridement and retention of components. Clin Infect Dis. 2006;42:471–8.
  1. Hanssen AD, Osmon DR. The use of prophylactic antimicrobial agents during and after hip arthroplasty. Clin Orthop Relat Res. 1999;(369):124–38.
  1. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control. 1999;27(2):97-132; quiz 133-4; discussion 96.
  1. Burnett RS, Aggarwal A, Givens SA, McClure JT, Morgan PM, Barrack RL. Prophylactic antibiotics do not affect cultures in the treatment of an infected TKA: a prospective trial. Clin Orthop Relat Res. 2010;468(1):127–34.
  1. Mortazavi SM, Vegari D, Ho A, Zmistowski B, Parvizi J. Two-stage exchange arthroplasty for infected total knee arthroplasty: predictors of failure. Clin Orthop Relat Res. 2011;469(11):3049–54.
  1. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic joint infections. N Engl J Med. 2004;351(16):1645–54.
  1. Marculescu CE, Berbari EF, Hanssen AD, Steckelberg JM, Harmsen SW, Mandrekar JN, et al. Outcome of prosthetic joint infections treated with debridement and retention of components. Clin Infect Dis. 2006;42(4):471–8.
  1. Brandt CM, Sistrunk WW, Duffy MC, Hanssen AD, Steckelberg JM, Ilstrup DM, et al. Staphylococcus aureus prosthetic joint infection treated with debridement and prosthesis retention. Clin Infect Dis. 1997;24(5):914–9.
  1. Azzam KA, Seeley M, Ghanem E, Austin MS, Purtill JJ, Parvizi J. Irrigation and debridement in the management of prosthetic joint infection: traditional indications revisited. J Arthroplasty. 2010;25(7):1022–7.
  1. Buchholz HW, Elson RA, Engelbrecht E, Lodenkämper H, Röttger J, Siegel A. Management of deep infection of total hip replacement. J Bone Joint Surg Br. 1981;63-B(3):342-3.383
  1. Zmistowski B, Fedorka CJ, Sheehan E, Deirmengian G, Austin MS, Parvizi J. Prosthetic joint infection caused by gram-negative organisms. J Arthroplasty. 2011;26(suppl 6):104–8.
  1. Malekzadeh D, Osmon DR, Lahr BD, Hanssen AD, Berbari EF. Prior use of antimicrobial therapy is a risk factor for culture-negative prosthetic joint infection. Clin Orthop Relat Res. 2010;468:2039–45.
  1. Kilgus DJ, Howe DJ, Strang A. Results of periprosthetic hip and knee infections caused by resistant bacteria. Clin Orthop Relat Res. 2002;(404):116–24.
  1. Kurd MF, Ghanem E, Steinbrecher J, Parvizi J. Two-stage exchange knee arthroplasty: does resistance of the infecting organism influence the outcome? Clin Orthop Relat Res. 2010;468(8):2060–6.
  1. Maheshwari AV, Gioe TJ, Kalore NV, Cheng EY. Reinfection after prior staged reimplantation for septic total knee arthroplasty: is salvage still possible? J Arthroplasty. 2010;25(suppl 6):92–7.
  1. Salgado CD, Dash S, Cantey JR, Marculescu CE. Higher risk of failure of methicillin-resistant Staphylococcus aureus prosthetic joint infections. Clin Orthop Relat Res. 2007;461:48–53.
  1. Laudermilch DJ, Fedorka CJ, Heyl A, Rao N, McGough RL. Outcomes of revision total knee arthroplasty after methicillin-resistant Staphylococcus aureus infection. Clin Orthop Relat Res. 2010;468(8):2067–73.
  1. Mittal Y, Fehring TK, Hanssen A, Marculescu C, Odum SM, Osmon D. Two-stage reimplantation for periprosthetic knee infection involving resistant organisms. J Bone Joint Surg Am. 2007;89(6):1227–31.384

Outcome in Periprosthetic Joint Infection Treatmentchapter 46

Joel B Durinka,
Claudio Diaz-Ledezma
 
Current Evidence
 
Success and Failure in Periprosthetic Joint Infection Treatment

Rothman Institute Current Practices

  1. Infection eradication has been used as a synonym for “success” in outcomes data regarding treatment for PJI. However, we believe it is a multidimensional concept, and the relative value of the various elements composing it may be valued differently by different individuals (e.g. patient, surgeon, hospital administrator, researcher).
  2. Research regarding this topic is currently under way at our institution to more accurately define “success” or “failure” of PJI treatment.
In the periprosthetic joint infection (PJI) literature, there is no uniform definition of success or failure of treatment. Various definitions have been proposed, and most authors include the concept of “infection eradication” (Table 46.1). This goal can be potentially achieved using different treatment strategies, and, depending on the situation, the perception of success may vary based on the individual's (e.g. patient's vs. surgeon's) perspective.386
Table 46.1   Definitions of success and failure in PJI treatment
Author
Setting
Definition of Success
Definition of Failure
Volin27
Two-Stage revisions
Treatment was considered successful if the patient was disease free at the most recent follow-up
Jamsen1
Meta-analysis
Success in infection management was analyzed in three ways. First, the total number of infections appearing after treatment was recorded, supplemented by the number of recurrent infections and of new infections (i.e. postoperative infections caused by an organism other than the one detected upon treatment)
387
Bradbury29
Open debridement and component retention
Clinical resolution of infection and the lack of further surgery. Patients who demonstrated clinical resolution of infection but were maintained on suppressive oral antibiotics were also considered successes
Need for subsequent infection-related surgery
Waagsbo30
Open debridement and component retention
Treatment response was defined as postdebridement period free from PJI relapse during the time of follow-up
Need for further orthopedic surgery
Azzam31
Open debridement and component retention
Absence of symptoms and signs of infection till the date of the last follow-up
Need for resection arthroplasty or recurrent microbiologically proven infection388
Estes32
2-Stage revisions
Success was considered as infection control. Serum inflammatory makers (ESR and CRP) had normalized and there were no clinical signs or symptoms of infection
Recurrence of infection requiring additional surgery or clinically apparent infection diagnosed with a positive aspiration or persistently elevated inflammatory markers and treated with long-term antibiotic suppression
Parvizi25
MRSA PJI
Infection eradication
389
Senneville21
Staphylococcus aureus PJI
Remission was defined by the absence of local or systemic signs of infection assessed during the most recent contact with the patient and absence of the need to reoperate or to administer antibiotic therapy directed to the initial infected site from the end of treatment to the most recent contact
Any other outcome, including death related to the PJI390
El Helou33
2-Stage revisions
Treatment failure was defined by 1 of the following criteria: (1) recurrence of prosthetic joint infection caused by the same strain of microorganism or a different microorganism at any time after reimplantation surgery; (2) death caused by prosthesis-related infection at any time after reimplantation surgery; (3) clinical failure defined as clinical, laboratory, or radiographic findings suggestive of prosthetic joint infection at any time after reimplantation surgery
391
For instance, an amputation or a resection arthroplasty can eradicate the infection after a failed revision, but from the perspective of the patient, this may not constitute a successful outcome. So, for these reasons the concept of a “successful outcome” remains ambiguous and is worthy of further investigation. In addition, one main deficiency of previously used definitions is a failure to include general health status or functional scores to categorize the results. In reality, the definition of success and failure is a multidimensional concept, and the relative value of the various elements composing it may be valued differently by different individuals (e.g. patient, surgeon, hospital administrator, researcher) (Fig. 46.1).
 
Results in Terms of Infection Control
Infection control can be defined and analyzed in three distinct but related ways1: (1) the total number of infections appearing after treatment; (2) rate of recurrent infections (caused by the same organism); and (3) rate of new infections (infections caused by a different organism).
Figure 46.1: Multidimensional definition of success after PJI treatment
392
The literature on treatment of periprosthetic knee infection is notable for a considerable range in rates of infection eradication due to variability in study methodology. According to a meta-analysis by Jamsen et al,1 the failure to eradicate infection after treatment for a periprosthetic knee infection ranged from 0% to 31%. Recurrent infections occurred in 0% to 18%, and new infections varied from 0% to 31%. In some series, only recurrent infections were studied,2 whereas in other ones, only new infections were analyzed.3 From the available evidence, two-stage revisions with antibiotic-loaded bone cement (ALBC) has the highest and most consistent rate of infection eradication compared with other treatment modalities.4
Similar variability is noted in the published literature regarding the success of infection eradication following treatment for a periprosthetic hip infection. In a meta-analysis conducted by Parvizi et al,5 the rates of reinfection ranged from 0% to 24% after one-stage revisions and from 0% to 17% after two-stage revisions. Fink6 reviewed the available literature and compared different surgical modalities for eradicating periprosthetic hip infections. Fink reported rates of 88% to 93.7% for one-stage cemented (with antibiotics) revision, 92% for one-stage cementless revision (antibiotic loaded in bone graft), between 84% and 100% for two-stage cemented revision, and between 82% and 100% for two-staged cementless revisions. Given the similar rates of success between the different modalities, conclusive evidence for the best alternative is not available.
Success of infection eradication for irrigation and debridement with modular component exchange (Chapter 38) and one-stage exchange arthroplasty (Chapter 39) is discussed in further detail in other sections of this book. In short, the reported success of these two procedures has historically been lower than that of a two-stage exchange 393arthroplasty, but as prognostic variables are better defined, they may be appropriate treatment strategies in certain clinical scenarios.
Finally, the isolated use of antibiotics as primary treatment in PJI has also been studied, with a reported 6% rate of success, which makes it the least desirable treatment option of the group.7
 
Results in Terms of Functional Outcomes
In the PJI literature, the so-called “organ-specific functional scores” are frequently used to evaluate functional outcome. For total hip arthroplasty (THA), the most commonly used scores are the Harris hip score and Oxford hip score, whereas for total knee arthroplasty (TKA), the Knee Society Score, the Oxford Knee score, and the Hospital for Special Surgery score are used. However, the minimal clinical important difference (MCID)8 for those scores is not available in the literature. In the majority of published studies, the symptomatic improvement after surgery has been quantified and reported only in terms of statistical differences, rather than clinically important differences, making interpretation of the data difficult to translate into practical application. Despite this drawback, the results in the available existing literature show fairly consistently that PJI produces lower functional outcomes compared with well-functioning arthroplasty procedures.9
For treatment of periprosthetic hip infection, Masri et al10 demonstrated an improvement in Harris hip score from 38 (15.5–77.5) preoperatively to 70 (42–100) postoperatively (no P value provided), using cementless revision components in the second stage of a planned two-stage exchange arthroplasty. Erhart et al10 reported that the Harris hip score was inversely correlated with the interval of time between explant and reimplantation for two-stage THA revisions. Comparing one- and two-staged 394revisions, Oussedik et al11 described an improved Harris hip score for one-stage revisions compared with two-stage revisions (one-stage 87.8 versus two-stage 75.5; P = 0.0003).
Barrack et al,12 in a multicenter study of surgical outcomes following revision knee arthroplasty, demonstrated lower Knee Society scores (KSSs) in their cohort of septic revisions compared with revisions for aseptic failure. Interestingly, a prospective study by Patil et al13 found opposite results; namely, TKA patients undergoing revision surgery due to PJI had better KSSs than did patients with aseptic revision (e.g. knee stiffness). Regarding radical treatment for failed treatment of TKA infections, Chen et al14 demonstrated that patients with knee fusions had better functional scores than did patients with knee amputations.
Although evidence is not conclusive regarding which treatment strategy is best in terms of functional outcome for infected THA or TKA, some literature does support benefit of the one-stage exchange over the two-stage exchange arthroplasty. Further study is needed on this topic to better characterize this important determinant of “success” after treatment of PJI.
 
Results in Terms of Patients’ Satisfaction
Evidence focused on patients’ satisfaction after PJI treatment is scarce, and evaluation of satisfaction is not standardized. The “patient acceptable symptom state”15 is probably the more reliable method to evaluate patient satisfaction in knee and hip arthroplasty; however, its value in PJI treatment has not been studied. Some studies have reported only postoperative satisfaction, without a point of comparison.16
The literature describing patient satisfaction following PJI not only is scarce, but the data are mixed, which leaves this topic open for further investigation. In a study by 395Oussedik11 et al comparing 11 patients with one-stage versus 39 patients with two-stage revisions for THA, the authors found that patients who had undergone the one-stage procedure had better satisfaction than patients with two-stage revision, as measured by patient-reported visual analog scale (VAS) (8.6 versus 6.9; P = 0.001). Cahill et al9 reported a similar finding in a case control study of 34 arthroplasty patients who developed a deep infection versus a cohort of 62 patients who had an uncomplicated recovery. The infected group had a mean VAS satisfaction score of 56 versus 88 in the control cohort (P < .0001). Conversely, in TKA revisions, Barrack et al12 demonstrated that revisions due to infection, compared with aseptic revision cases, produced no differences in patients’ satisfaction. This observation was further supported in two subsequent studies.13,17
 
Results in Terms of Complications
Although complications following TJA are relatively low, their existence continues to be a cause for concern. Mahomed et al18 studied the rates of complications and their effect on patient outcomes. The rates of complications occurring within 90 days after primary total hip replacement were 1.0% for mortality, 0.9% for pulmonary embolus, 0.2% for wound infection, 4.6% for hospital readmission, and 3.1% for hip dislocation. The rates after revision total hip replacement were 2.6%, 0.8%, 0.95%, 10.0%, and 8.4%, respectively. Factors associated with an increased risk of an adverse outcome included increased age, gender (men were at higher risk than women), race (blacks were at higher risk than whites), a medical comorbidity, and a low income. The overall rates of adverse outcomes were relatively low, but they were significantly higher after revision.
The most dreaded complication following PJI is death. Recently, several studies have evaluated mortality 396after PJI. Mahomed et al18 showed, that revision procedures, compared with primary THA, carry a two-fold increased risk in mortality.18 Similarly, McGarry et al3,19 reported a five-fold increase in mortality at 90 days for patients with surgical site infection in an elderly population undergoing various surgical procedures. The most drastic effect of PJI on mortality is between 90 days and 1 year. Many risk factors for PJI (male gender, advanced age, increased body mass index, greater number of comorbidities) are also associated with an increased risk of mortality, implying that the association between mortality and PJI is secondary to the poor health status of the patient. Undergoing treatment for PJI significantly increases the risk of mortality; thus, in addition to the many efforts invested to control infection in patients with PJI, it is paramount to also ensure tight control of their chronic diseases.
 
Economic Impact of PJI and the Impact on Global Health Status
With limited health care resources and a projected increase in the rate and number of PJI cases, future research on PJI will have to look not only at the most effective treatment strategy but also at what constitutes the most cost-effective strategy. By virtue of the number of procedures performed on these patients, the overall annual cost for management of PJI has been estimated at $200 million in the United States alone.20 With the projected increase in number of septic revision arthroplasty procedures, measures aimed at decreasing this socioeconomic burden on the health care system are becoming particularly important. Kurtz et al21 reported that between 1990 and 2004 the number of revision arthroplasties performed for infection increased two-fold, and by 2030, the number of revision hip procedures is estimated to double. Several studies on the true financial burden of PJI have been published. In 1996, Hebert et al22 estimated that a case 397of PJI cost between $50,000 and $60,000. Bozic et al23 reported in 2005 that this cost had risen to about $96,000, and the cost of revision arthroplasty for infection was three times that of aseptic revision and five times that of primary arthroplasty. More recently, Parvizi et al24 found the cost of in-hospital treatment alone to be $107,264, placing an increasingly larger burden on society and the health care system.
Although the field of cost-effectiveness research is still in its infancy, several articles focused on the topic of PJI treatment have been published. Cummins et al25 evaluated the cost-effectiveness of antibiotic-impregnated bone cement use in primary THA and found that when revision due to either infection or aseptic loosening is considered the primary outcome, the use of antibiotic-impregnated cement resulted in an overall cost decrease. Wolf et al recently published an article comparing different treatment strategies for managing PJI using a Markov expected-utility decision analysis. They reported that the one-stage exchange was more favorable, regardless of whether patient- or surgeon-derived utilities were applied and regardless of whether a 1- or 10-year time horizon was considered.26 Because the treatment of PJI is often complex and requires a tremendous amount of work and coordinated effort by the health care system, more studies of this nature to determine the optimal use of limited resources are desperately needed.
 
References
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401Index
Page numbers followed by f for figure and t for table, respectively
A A. fumigatus A. niger AAOS clinical practice Abnormal CRP levels Absorbable sutures versus nonabsorbable sutures Accountable care organizations Acid-fast bacillus Active intravascular clotting Acute kidney injury renal failure After joint replacement AIBC for PJI treatment in primary cemented TJA Air changes per hour Alcohol , Alcohol-based hand rub American Academy of Oral Medicine Orthopaedic Surgeons American Dental Association Aminoglycoside Anaerobes Anaerobic bacteria Antibiotic cement holiday impregnated sutures loaded bone cement preparation loaded cement prophylaxis used to treat PJI, classes of Antifungal cement spacer drugs Antimicrobial film resistance susceptibility testing therapy Antiplatelet drugs Arthroplasty for periprosthetic joint infection , in PJI Arthroscopic debridement Aseptic loosening Aspergillus , fumigatus niger Aspiration Autologous blood derivative derived product application to wound Azole drugs B Bacitracin Bacterial attachment to surfaces shedding Bacteroides bile esculin agar Barbed sutures 402 Betadine , Biofilm maturation Blood conservation culture vials for culturing synovial fluid loss transfusion Body mass index , Bone cement and antibiotics loss threatens scan Brucella laked blood agar Bulb syringe C C. albicans , , , , cells C. glabrata , , , infections C. parapsilosis , , , C. tropicalis , , , Candida species , Capreomycin Castile soap Cefazolin , Cefuroxime , Cell count saver Cells grown in free-living (planktonic) Cement ALBC preparation spacers versus cementless reconstruction Cemex genta bone cement system Cephalosporin antibiotic Charlson comorbidity index , Chest pain CHG/alcohol Chlorhexidine , gluconate Chronic lymphedema Ciprofloxacin , Cleocin Clindamycin Clostridium difficile Cobalt G-MV MV with gentamicin bone cement Collection of fluid or tissue Colony-forming units Conditions mimicking periprosthetic joint infection Confocal laser scanning microscopy Controversial preventive strategies Coronary artery disease Coumadin C-reactive protein , , , level Crystalline deposition disease , Culture-negative periprosthetic joint infection Culture principles Cycloserine D Dakin's solution , Deep venous thrombosis Dental abscess 403 infection prophylaxis Development of PJI Diabetes mellitus , , Dialysis Disadvantages of routine use of AIBC Disease control, centers for , Disease-modifying antirheumatic drugs Dose of cefazolin Doxycycline Drains E E. faecalis E. gallinarum Economic impact of PJI Economics of periprosthetic joint infection Enterococcus , species Equipment and surfaces Erythrocyte sedimentation rate , , , , Ethambutol , Ethicon Ethionamide Ethylenediamine-tetraacetic acid Extended trochanteric osteotomy F F- fluorodeoxyglucose- positron emission tomography Faecium False-negative results False-positive aspiration Fasting glucose Femoral head Flourine-18-fluorodeoxyglucose positron emission tomography Fluoroquinolones Food and Drug Administration , Forced air warming Functional disability Fungal periprosthetic joint infections, management of Fungi types of Fusidic acid G Gastrointestinal infection Gatifloxacin Gentamicin bone cement GI endoscopic procedures Girdlestone procedure Global health status Glycemic control Gram stain and frozen sections Gram-negative bacteria organisms , Granulocyte colony stimulating factor H Harbor bacteria Healthcare professional Hematoma formation Herbal supplements High false-negative rate High-efficiency particulate air Hip , , and knee joints arthroplasty surgery 404 Holding versus antibiotics Humoral and cell-mediated immune functions Hydrogen peroxide Hyperglycemia , Hypersensitivity reactions Hypoalbuminemia Hypotension Hypothermia I Imaging Implant and bone graft coating Impregnated bone cement Inappropriate collection of tissue samples Incidence and burden of periprosthetic joint infections Incise drapes Indications for vancomycin Infection control Infectious Disease Society of America , Inflammatory arthritis arthropathy International normalized ratio Intra-articular antibiotic infusion fluid Inversion and eversion of foot Iodine povacrylex Iodophors Irrigation solutions in total joint arthroplasty Isoniazid , J Joint arthroplasty , aspiration culture K Kidney injury, acute Knee , , , arthroplasties arthroplasty , components aspirations of , , infections joint spacer Knife blade change L Laked blood with kanamycin Laminar airflow systems Length of hospital stay Leukocyte differential esterase Levofloxacin Linezolid Local antibiotic prophylaxis , Low allergenic potential Lowenstein-Jensen growth Lower knee society scores limb arthroplasty Lymphedema Lymphocyte M M. abscessus M. chelonae M. fortuitum M. smegmatis Malnutrition Management of fungal periprosthetic joint infections 405 mycobacterial infection prosthetic joint infection caused by Enterococcus wound drainage Metal artifact reduction sequence Methicillin-resistant organisms , S. aureus Staphylococcus aureus epidermidis Methicillin-sensitive organisms S. aureus Meticulous removal of infected tissue Microbial cultures Microcolony formation Middlebrook agar Minimally invasive TKA Minimum inhibitory concentrations Minocycline Molecular markers Monofilament sutures versus polyfilament sutures Most common operating room skin antiseptics Moxifloxacin Musculoskeletal Infection Society , , , Mycobacteria , and fungal cultures growth indicator tube Mycobacterial Infection, management of Mycobacterium avium complex tuberculosis , N National inpatient sample rates of PJI temporal trend Negative-pressure dressings Neomycin New health care mantra Newer antifungal agents Nonabsorbable sutures Noninflammatory arthritis Nonsteroidal anti-inflammatory drugs Normothermia O Obesity Occupational Safety and Health Administration Ofloxacin One-stage total hip arthroplasty outcomes knee arthroplasty Operating room environment Oral hypoglycemic drugs Organism identification profile Osteoarthritis P Painful metal-on-metal hip arthroplasty P-aminosalicylic acid Parachlorometaxylenol Pathogen growth Patient medical optimization Pelvic infections Penicillin Periprosthetic joint infection , , , , , , , , , , , , , , , , 406, , , , , , , arena arthroplasty for , diagnosis of , future trends and challenges hematoma hip and knee infection in hip and knee, diagnosis of knee infection irrigation and débridement for multidisciplinary approach treatment , , success and failure in Phenylethyl alcohol blood agar Plain X-ray and computed tomography scan Platelet-derived growth factor PMMA, suitable antibiotics for Polydioxanone Polyethylene Polyfilament sutures Polymerase chain reaction , Polymethyl methacrylate , , Polymicrobial infection Polymixin Polymorphonuclear cells leukocyte Polymyxin Polysaccharide intercellular adhesin Positron emission tomography Postarthroplasty antibiotic prophylaxis joint infections Povacrylex Povidine-iodine Predisposing factors for periprosthetic joint infection Preoperative anemia autologous blood donation planning skin preparation, decolonization and antisepsis Projection of inpatient costs for PJI treatment Propionibacterium acnes species Prosthetic joint infections , , , caused by Enterococcus, management of in inflammatory conditions, diagnosis of Pseudomonas aeruginosa Pulmonary embolus Pyrazinamide , Q Quorum sensing R Random glucose Rapidly growing mycobacteria , Rationale for antibiotic- impregnated bone cement use 407 Reaction of cement Red man syndrome neck syndrome Refobacin Reimplantation Removal of hip arthroplasty components knee arthroplasty components well-fixed hip Renal dialysis failure, acute Reports of fungal prosthetic joint infections Resection arthroplasty , Results in terms of patients’ satisfaction Reverse transcriptase PCR Rheumatoid arthritis Rheumatologic agents Rhodotorula minuta Rifampin , , Rifapentine Role for dual suppression of biofilm in periprosthetic joint infection S S. aureus , infections S. epidermidis , Sample acquistition Scintigraphy Sensory innervation Septic knee prostheses Serum C-reactive protein erythrocyte sedimentation rate white blood cell Setting of periprosthetic joint infection Sheep's blood agar Sickle cell anemia Simplex p speedset with tobramycin bone cement Single dose of antibiotic Slipped capital femoral epiphysis Smartmix pre-filled mixing system Smartset GHV gentamicin bone cement , HV bone cement Soaps Sodium hypochlorite Soft tissue infection Spacers, types of β-lactam ring-based penicillins β-lactams Staphylococcus aureus , , , , , , , , , PJI epidermidis , , Stem with distal fixation Strategies to isolate organism Streptococcus Streptomycin Stryker orthopaedics Superb tissue penetration Suppression of prosthetic joint infection Suppressive antibiotics 408 Surgical attire drains site infection , Synovial fluid WBC count Systemic lupus erythematosus T Techniques and expeditious surgery Tertiary and teaching hospitals Tetracyclines Thin oscillating saw , Threshold for acute PJI for chronic PJI Thromboembolic disorders TJA lack standardization Tobramycin Total hip arthroplasty , , , , , , joint arthroplasty , , , , , , , , in patients with prior septic arthritis irrigation in knee arthroplasty , , , , , , , white blood cell count Tourniquet use Tranexamic acid Transfusion of allogenic blood Treatment of periprosthetic hip and knee infections joint infection (PJI) , , by one-stage exchange arthroplasty secondary to mycobacteria Treatment outcome of fungal periprosthetic joint infections Trimethoprim-sulfamethoxazole , Triple gloving , Trunion corrosion Tuberculous arthritis Tumor necrosis factor Two-stage exchange arthroplasty: antibiotic spacers Types of fungi spacers U Urinary incontinence tract infection , V Vacuum-assisted closure Vancomycin powder resistant Enterococcus Vascular endothelial growth factor Venous stasis Versabond AB bone cement Vicryl plus Visual analog scale 409 W White blood cell , count Workup of patients with suspected urinary tract infection Wound closure drainage, management of edge healing problems infection rate Z Zimmer explant system