Despite the gains in preventative measures and treatment options,
deep periprosthetic infections still occur, and surgeons are
far from a 100% success rate in treating these infections with current
techniques. However, continuing research and the promise of new technologies
offer hope to surgeons facing these difficult to treat complications.
“Infection in total joints continues, and it has not been
eliminated by all we have done,” said Leo Whiteside, MD, executive
director of the Missouri Bone and Joint Research Foundation in St. Louis.
“Infections have almost been eliminated for a few people, but … there
is a significant percentage that persists.”
“We have a challenge on our hands, because [treatment] options
today are far from perfect,” said Javad Parvizi, MD, FRCSC, professor of
orthopedic surgery and director of clinical research at the Rothman Institute
at Thomas Jefferson University in Philadelphia.
Current data show an average periprosthetic infection rate of 0.25% to
2% at 1 year after total hip arthroplasty (THA) or total knee arthroplasty
(TKA), according to a scientific exhibit presented by Parvizi and his
colleagues at the 2010 Annual Meeting of the American Academy of Orthopaedic
Javad Parvizi, MD, FRCSC, professor
of orthopedic surgery and director of clinical research at the Rothman
Institute at Thomas Jefferson University in Philadelphia, said that treatment
options for periprosthetic infection are far from perfect.
Image: Daniel Burke
Parvizi said recent studies have shown a rise in the incidence of deep
periprosthetic infection. Last year, he and his colleagues reported a 1.55%
incidence of infection after 2 years in Medicare patients who underwent TKA.
This year they reported a 1.63% incidence within the first 2 years among
Medicare patients who underwent THA.
They cited potential reasons for the increase. “One is that we are
operating on more ill and infirm patients who may not have been deemed ideal
candidates for elective arthroplasty in the early era of joint
replacement,” Parvizi, who is also an Orthopedics Today
Editorial Board member, said. Other potential reasons include the rising
incidence of resistant organisms including methicillin-resistant
Staphylococcus aureus (MRSA) and improved diagnosis of these infections.
Preventing infection preoperatively
Surgeons employ a number of measures to prevent infection before, during
and after knee and hip arthroplasty. “The key things … are aggressive
management of the patient prior to coming into the hospital, and then
administering IV antibiotics within 1 hour of surgery and for 24 hours
postoperatively,” Thomas P. Sculco, MD, surgeon-in-chief at the Hospital
for Special Surgery in New York, said.
The first step is resolving any potential sources of contamination in
high-risk patients before surgery, including treating periodontal disease or
urinary tract infections and ensuring glucose control in patients with
diabetes, Sculco said. Patients receiving immunosuppressive medications for
inflammatory arthritis or patients who may be receiving immunosuppressive
chemotherapeutic agents or corticosteroids should stop medication 1 to 3 weeks
Other high-risk factors include obesity, skin lesions, previous
infection or MRSA colonization. “[For patients who have] anything that
predisposes them to potentially higher infection rates, we should treat them
aggressively with periprosthetic antibiotics in the cement material,”
However, he stressed that surgeons should be selective in choosing which
patients should receive antibiotics in the cement due to the risk of developing
resistant bacteria and the higher cost involved.
According to Parvizi and his colleagues, other preoperative preventions
include smoking cessation, skin decontamination and hair removal at the
The most important prevention measure overall, he said, is
administration of perioperative antibiotics, either second-generation
cephalosporins or vancomycin in selected patients.
Sculco stressed the importance of using a
laminar flow filtration system with body exhaust units to
reduce contamination between the surgical team and the operative site.
“We have to be
careful about how we treat patients in terms of anticoagulation. We have to
monitor them carefully because if we get bleeding, it can really increase
— Thomas P. Sculco, MD
According to Merrill Ritter, MD, of Mooresville, Ind., infection is most
likely for those wounds left open for longer periods of time and those with
large amounts of dead tissue. He stressed rapid surgery, reduced traffic in the
operating room and use of
“I used to think laminar flow was [the best option] … but
ultraviolet light kills instantly,” Ritter said. “This is a
controversial subject because ultraviolet light is very inconvenient; the whole
operating room staff [needs to be covered].”
Another group of high-risk patients includes those with clotting
disorders because they are likely to develop hematomas, which are a culture
medium for bacteria, Sculco noted.
Parvizi said surgeons must address hematoma formation immediately and
try to prevent it by not administering aggressive anticoagulation. Sculco
echoed that statement: “We have to be careful about how we treat patients
in terms of anticoagulation,” he said. “We have to monitor them
carefully because if we get bleeding, it can really increase infection
Postoperatively, patients should receive prophylactic antibiotics, have
persistent wound drainage controlled in a timely manner, and antibiotics should
be used before any dental, genitourinary or gastrointestinal procedures,
Current treatment options
Options for treating deep periprosthetic infections include irrigation
and debridement or a one- or two-stage exchange.
Irrigation and debridement, according to Parvizi, has historically been
performed in patients with acute or early infection and does not require
prosthesis removal, but recent reports show the success of this procedure is
waning. In 2009, Parvizi and his colleagues reported an 18% success rate at 2
years with open irrigation and debridement and component retention for TKA
infections caused by resistant organisms.
“It appears that irrigation and debridement will become less and
less of a surgical option available in the future. Two-stage exchange is
becoming more common even for those patients with so-called early
periprosthetic infections,” Parvizi said.
The two-stage exchange remains the gold standard in North America. It
involves removing all components, radical extensive debridement of all
potential infected tissue and use of a spacer impregnated with high
concentrations of antibiotics in the first procedure, according to Sculco. He
gives patients antibiotics for 6 weeks, stops the antibiotics for another 3 to
4 weeks and then re-evaluates the patient to ensure the infection is
eradicated. He then reimplants with an antibiotic-loaded cemented implant.
Whiteside said that with resistant organisms such as MRSA, the
reinfection rate with the two-stage exchange is “unacceptably” high.
Therefore, he adds indwelling catheters that deliver antibiotics directly to
the knee, which has improved his recurrence rate from 15% to 1%.
“I have had more success with that, but I would say it’s still
not enough,” he said. “Other people [have reported] failure with that
technique, which has to do with adequate debridement and other surgical
management of the condition.”
The typical success seen with two-stage exchange varies, Parvizi said.
“If you define success as retention of the prosthesis, the numbers may be
in the range of 80% to low 90%,” he said. “But if you define success
as retention of prosthesis, being off all antibiotics and having excellent
functional outcome [and] being pain free, it is likely that the numbers may be
in the range of mid to low 70%.”
Disadvantages to the two-stage procedure include the additional surgery
and, particularly in the knee, the potential for motion to be restricted by the
To address motion, Sculco uses a technique by Aaron Hofmann, MD, which
involves autoclaving the femoral component and using it with a new polyethylene
component on the tibia as an articulated spacer. He puts high concentrations of
antibiotics into the bone cement and places the femoral and tibial components
loosely, so he can more easily remove them during the second-stage procedure 6
to 8 weeks later. He and his colleagues reported last year that one of 25
patients treated with this technique developed a reinfection; they also
reported excellent knee motion in between stages and at long-term follow-up.
The one-stage exchange, typically performed in Europe, involves removing
all components and replacing them during the same surgery. In 2008, Winkler and
colleagues described their one-stage technique for THA infection that involves
component removal, thorough debridement and insertion of antibiotic-impregnated
allograft bone. At 4.4 years, they reported a 92% success rate.
The issue of performing a one- or two-stage exchange for periprosthetic
infections is somewhat controversial. However, Sculco said that for acute
infections that develop within 2 to 3 weeks postoperatively, he will perform a
one-stage reimplantation, “[In] select patients with a very sensitive
bacteria and a relatively acute onset of the infection,” he said.
Whiteside said he typically performs a one-stage revision using
cementless implants for infected TKAs. “After doing that for several
years, I have found the cementless TKA seldom has to be removed because the
infection is eradicated with the combination of thorough debridement, careful
soft-tissue management and direct infusion of antibiotics into the infected
area,” he said.
Future options for preventing infection are “smarter” implants
with covalent bonding of antibiotics on their surface, and molecular
diagnostics, which will help to identify infection earlier and treat patients
sooner, Parvizi said.
In the end, preventing infection depends on persistence in improving
management, Whiteside said.
Sculco added, “If you don’t have an infection rate in the
order of 1%, then you should be looking at the environment … Deal with the
problem that is increasing your infection rate rather than try to deal with the
secondary phenomenon and using periprosthetic antibiotics in all cases, which
can lead to resistant organisms.” — by Tina DiMarcantonio
- Anderson JA, Sculco PK, Heitkemper S, et al. An articulating spacer
to treat and mobilize patients with infected total knee arthroplasty. J
- Bradbury T, Fehring TK, Taunton M, et al. The fate of acute
methicillin-resistant Staphylococcus auerus periprosthetic knee infections
treated by open debridement and retention of components. J
Arthroplasty. 2009;24(6 Suppl):101-104.
- Kurtz SM, Ong KL, Lau E, et al. Prosthetic joint infection risk
after TKA in the Medicare population. Clin Orthop Relat Res.
- Ong KL, Kurtz SM, Lau E, et al. Prosthetic joint infection risk
after total hip arthroplasty in the Medicare population. J
- Winkler H, Stoiber A, Kaudela K, et al. One-stage cemented revision
of infected total hip replacement using cancellous allograft bone impregnated
with antibiotics. J Bone Joint Surg [Br]. 2008;90-B:1580-1584.
- Javad Parvizi, MD, FRCSC, can be reached at 925 Chestnut St., 2nd
Floor, Philadelphia, PA 19107; 267-399-3617; e-mail:
- Merrill Ritter, MD, can be reached at 1199 Hadley Road,
Mooresville, IN 46158; 317-831-2273; e-mail:
- Thomas P. Sculco, MD, can be reached at 525 East 71st St., New
York, NY 10021; 212-606-1475; e-mail: email@example.com.
- Leo Whiteside, MD, can be reached at 1000 Des Peres Road, Suite
150, St. Louis, MO 63131; 314-775-0521; e-mail:
What surgical technique do you use to treat deep periprosthetic
The one-stage exchange of infected endoprosthesis was introduced in the
1970s by Buchholz, using bone cement (polymethylmethacrylate – PMMA) as an
antibiotics carrier. There is no scientifically based argument for fear of
re-infection; a literature review by Jackson and Schmalzried in Clinical
Orthopaedics and Related Research in 2000 found comparable results
between one- and two-stage procedures. Yet, the method did not gain widespread
One reason for this may be the difficulty of removing a well-fixed
cemented prosthesis. Failures in all protocols seem to be caused by small
fragments of bacterial biofilms remaining after debridement, which cannot be
eliminated by systemic antibiotics or antibiotic-loaded PMMA. Reachable
antibiotic concentrations are too low for eliminating biofilm remnants, which
makes the use of PMMA spacers doubtful.
The antibiotic storage capability of highly purified bone grafts exceeds
that of PMMA. The eluted amounts of antibiotics are likely to eliminate even
biofilm remnants, dead space management is more complete, and defects may be
reconstructed efficiently. These features make them more attractive for local
therapy and allow using uncemented implants in one-stage procedures, providing
the chance for re-removal in the case of failure and improved long-term results
in the case of success.
We routinely use our one-stage method as described in our article in the
Journal of Bone and Joint Surgery (Br) in 2008. The procedure,
which follows a standardized protocol, was introduced in 1998 and further
developed since then. In brief, after thorough debridement and lavage, osseous
defects are filled with antibiotic-impregnated bone graft, and uncemented
implants are fixed in original bone. We use the technique both in hips and
knees with similar success rates.
Other advantages of the technique are: only one planned surgical
intervention; hospital stay is reduced to less than 2 weeks as a rule; patients
are fully mobilized immediately after a nonseptic revision; there is no
interval without prosthesis; and the use of systemic antibiotics is reduced to
The only disadvantages are the limited availability and high costs for
processing of the impregnated grafts, although costs are negligible with
respect to those of a two-stage procedure, and training is needed to follow the
Heinz Winkler, MD, is a consultant orthopedic surgeon and director of
the Osteitis Center at PrivatklinikDöbling in Vienna. He is also a board
member of the European Bone and Joint Infection Society.
I perform a two-stage exchange for the vast majority of my patients with
a deep periprosthetic knee infection. At the time of the first stage, we remove
any infected or devitalized tissue along with the implanted components and any
associated cement. We then place a high-dose, articulating, antibiotic-loaded
spacer into the joint; a static spacer is used if there is severe soft-tissue
or bone loss that precludes the use of an articulating spacer.
Craig J. Della
Patients are then treated with 6 weeks of organism-specific antibiotics
as guided by an infectious disease specialist. We then discontinue the
antibiotics for a minimum of 2 weeks and repeat the erythrocyte sedimentation
rate (ESR) and C-reactive protein (CRP). Based on work from our center as well
as from Thomas Jefferson University, we now understand that the ESR and CRP may
not necessarily normalize, but they should show a decrease over preoperative
levels, and they should not dramatically increase once the antibiotics have
been discontinued. At this time, we also aspirate the knee joint and send the
synovial fluid for not only cultures but a synovial fluid white blood cell
count with differential as well.
The biggest advantage of this technique is that the published results
with a two-stage exchange, in general, are better than a one-stage exchange.
Most patients are on the conservative side, and they are more accepting of a
longer treatment course associated with a higher rate of eventual cure.
Further, I believe there is substantial morbidity associated with a failed
one-stage exchange as the extraction of well-fixed revision components can be
associated with additional bony and soft-tissue damage that can lead to a worse
eventual result or the need for fusion or amputation.
When looking at our own results, as part of a multicenter study, we
found recurrent infection developed in 11% of patients when treated with a
two-stage exchange. This series did contain a number of complex patients who
had previously failed a two-stage exchange, and interestingly, a number of the
recurrent infections were with a different organism than had previously been
identified. Based on our results and the literature, I think it is reasonable
to expect a 90% rate of cure using a two-stage exchange protocol.
Craig J. Della Valle, MD, is associate professor, Department of
Orthopedic Surgery, and director of the Adult Reconstructive Fellowship at Rush
University Medical Center/Central DuPage Hospital in Chicago.