Orthopedics

Periprosthetic Joint Infection: Treatment Options

Javad Parvizi, MD; Benjamin Zmistowski, BS; Bahar Adeli, BS

  • Orthopedics. 2010;33(9)
  • Posted September 1, 2010

Abstract

Periprosthetic joint infection has become the most common cause of failure following total knee arthroplasty. Over the past 4 decades, treatment of this disease has evolved with technological innovations and pathogen profiling. The appropriate treatment selection is dependent on patient immune system quality, timing of symptom onset, and pathogen type. Antibiotic suppression alone is reserved for those cases without drainage, low-virulent antimicrobial-susceptible pathogens, and patients whose level of health increases the risk of surgery past any risk associated with chronic infection. In patients with an acute onset of symptoms and antimicrobial-susceptible pathogens, irrigation and debridement with exchange of modular components is moderately successful and offers the advantage of component retention and maximum knee function. In failed irrigation or chronic periprosthetic joint infection, resection of all components is necessitated. Resection and reimplantation can either be performed in one or two stages. A single-stage exchange has the potential to decrease the number of surgeries and therefore cost. However, the success rate of direct exchange is lower than that of two-stage revision. This has led to two-stage revision, with the placement of an intra-stage antibiotic-loaded spacer, to become the “gold” standard for periprosthetic joint infection eradication. In an immunocompromised patient with an uncontrollable periprosthetic joint infection, salvage procedures are necessitated. Complete eradication of periprosthetic joint infection is achieved by resection of all components without reimplantation through arthrodesis or above-the-knee-amputation. While amputation may be unpopular with patients it provides a greater ability to reconstruct, with an external prosthesis, a functioning joint.

Periprosthetic joint infection has emerged as the most common cause for failure following total knee arthroplasty (TKA).1 Management of periprosthetic joint infection is complex and current success of surgical treatment is less than ideal. Patient, surgical, and organism-related factors all must be considered as they directly affect the course and outcome of the chosen treatment.

The major problem with eradication of periprosthetic joint infection relates to formation of biofilm. Requiring only a few microorganisms to adhere to and seed the implant, a protective biofilm with an extremely complex structure is generated. This biofilm not only provides the molecular mechanism by which the organism communicates with itself,2 but it also thwarts attempts made by both the host immune response and antimicrobial agents to eradicate it.3 The timing of biofilm formation is debated, ranging from 36 hours to 3 weeks. What is known, however, is that formation of a complete and mature biofilm adversely affects the treatment outcome of periprosthetic joint infection.4

Multiple treatment options for periprosthetic joint infection exist and despite their common goal of eradicating the infection and providing a painless and functioning joint, the selection of appropriate treatment must be carefully based on established criteria to ensure complete eradication while maximizing function. Two-stage exchange arthroplasty is the “gold” standard for treatment of periprosthetic joint infection, at least in North America. Other treatment options include: antibiotic suppression alone, debridement with antibiotics, single-stage prosthetic exchange, arthrodesis, and amputation.

Foremost, antibiotic suppression alone is appropriate in cases where there is a susceptible organism and a well-matched oral antibiotic. Further, the prosthesis should not only be well-fixed but also well-positioned. The sole use of antibiotics is contraindicated in scenarios where there is a persistent drainage, loose prosthesis, and an organism that is unresponsive to oral antibiotics. Moreover, this form of treatment is discouraged in young or active patients. Antibiotic suppression is ideal in those patients with controllable infections whose level of health increases the risk of surgery past any risk associated with chronic infection.

Debridement in addition to antibiotic use has generally been implemented in patients with acute symptoms. Additionally, the infection should be caused by…

Abstract

Periprosthetic joint infection has become the most common cause of failure following total knee arthroplasty. Over the past 4 decades, treatment of this disease has evolved with technological innovations and pathogen profiling. The appropriate treatment selection is dependent on patient immune system quality, timing of symptom onset, and pathogen type. Antibiotic suppression alone is reserved for those cases without drainage, low-virulent antimicrobial-susceptible pathogens, and patients whose level of health increases the risk of surgery past any risk associated with chronic infection. In patients with an acute onset of symptoms and antimicrobial-susceptible pathogens, irrigation and debridement with exchange of modular components is moderately successful and offers the advantage of component retention and maximum knee function. In failed irrigation or chronic periprosthetic joint infection, resection of all components is necessitated. Resection and reimplantation can either be performed in one or two stages. A single-stage exchange has the potential to decrease the number of surgeries and therefore cost. However, the success rate of direct exchange is lower than that of two-stage revision. This has led to two-stage revision, with the placement of an intra-stage antibiotic-loaded spacer, to become the “gold” standard for periprosthetic joint infection eradication. In an immunocompromised patient with an uncontrollable periprosthetic joint infection, salvage procedures are necessitated. Complete eradication of periprosthetic joint infection is achieved by resection of all components without reimplantation through arthrodesis or above-the-knee-amputation. While amputation may be unpopular with patients it provides a greater ability to reconstruct, with an external prosthesis, a functioning joint.

Periprosthetic joint infection has emerged as the most common cause for failure following total knee arthroplasty (TKA).1 Management of periprosthetic joint infection is complex and current success of surgical treatment is less than ideal. Patient, surgical, and organism-related factors all must be considered as they directly affect the course and outcome of the chosen treatment.

The major problem with eradication of periprosthetic joint infection relates to formation of biofilm. Requiring only a few microorganisms to adhere to and seed the implant, a protective biofilm with an extremely complex structure is generated. This biofilm not only provides the molecular mechanism by which the organism communicates with itself,2 but it also thwarts attempts made by both the host immune response and antimicrobial agents to eradicate it.3 The timing of biofilm formation is debated, ranging from 36 hours to 3 weeks. What is known, however, is that formation of a complete and mature biofilm adversely affects the treatment outcome of periprosthetic joint infection.4

Multiple treatment options for periprosthetic joint infection exist and despite their common goal of eradicating the infection and providing a painless and functioning joint, the selection of appropriate treatment must be carefully based on established criteria to ensure complete eradication while maximizing function. Two-stage exchange arthroplasty is the “gold” standard for treatment of periprosthetic joint infection, at least in North America. Other treatment options include: antibiotic suppression alone, debridement with antibiotics, single-stage prosthetic exchange, arthrodesis, and amputation.

Antibiotic Suppression

Foremost, antibiotic suppression alone is appropriate in cases where there is a susceptible organism and a well-matched oral antibiotic. Further, the prosthesis should not only be well-fixed but also well-positioned. The sole use of antibiotics is contraindicated in scenarios where there is a persistent drainage, loose prosthesis, and an organism that is unresponsive to oral antibiotics. Moreover, this form of treatment is discouraged in young or active patients. Antibiotic suppression is ideal in those patients with controllable infections whose level of health increases the risk of surgery past any risk associated with chronic infection.

Irrigation and Debridement With Prosthesis Retention

Debridement in addition to antibiotic use has generally been implemented in patients with acute symptoms. Additionally, the infection should be caused by a susceptible organism and there must be good soft tissue coverage surrounding a well-fixed prosthesis. The reported success of irrigation and debridement varies widely from 16% to 80%.5-7 A recent analysis has found that in the face of periprosthetic joint infection caused by methicillin-resistant Staphylococcus aureus, irrigation and debridement has a failure rate of 84%.5 Based on the latter multi-institutional study, retention of prosthesis in infections caused by resistant organism is discouraged. In theory, on complete formation of a biofilm on the nonmodular prosthesis, irrigation and debridement will prove ineffective. However, adequate intraoperative detection of biofilm has not yet been optimized. Prosthesis retention is also contraindicated in those with multiple joint arthroplasty, a loose prosthesis, or when the duration of symptoms is >30 days.

Single-stage Exchange

Revision arthroplasty to treat periprosthetic joint infection in a single procedure, with resection and reimplantation of all components, is the next most vigorous treatment. A single-stage exchange provides removal of infected prosthesis while limiting the number of surgeries, recovery time, and expense. Limited success has been found with direct exchange arthroplasty. Local application of continuous antibiotics provides greater opportunity for overcoming recolonization. This local therapy is achieved by loading cement for fixation with antibiotics.

The reported success of direct exchange varies widely from 73% to 100%.8-10 It has been contended that the use of single-stage exchange is as effective and is more cost-efficient than two-stage exchange. This conclusion is based on the repeat effectiveness of single-stage exchange (repeating a direct exchange for only those patients who fail the first stage; in essence performing a two-stage). However, this does not account for increased morbidity and bone loss due to complete resection of a well-fixed component during the repeat resection. An extensive cost-effectiveness analysis has yet to be performed, limiting the full understanding of these treatments. At this institution direct exchange is limited to those patients who cannot tolerate multiple procedures and periprosthetic joint infection with a single infecting pathogen that is non-virulent and not resistant.

Two-stage Exchange

In the presence of nonacute, resistant, or recurrent periprosthetic joint infection two-stage revision provides the most successful rate of eradication while maintaining the possibility of complete function following reimplantation.11,12 Successful two-stage revision requires complete eradication of infection in the knee prior to reimplantation; this requires diligence during resection and close intra-stage monitoring.

The first-stage consists of complete resection of all foreign material—prosthesis and cement—with an aggressive debridement of surrounding soft tissue. Local doses of antibiotics are then supplied through the placement of an antibiotic-loaded cement spacer. This spacer maintains joint structure while eluting appropriate antibiotics directly to the joint. The combination of 3.6 g of tobramycin with 3 g of vancomycin per 40 g of polymethylmethacrylate provides the greatest elution quantities of vancomycin and is current antibiotic regimen at the Rothman Institute.13

Reimplantation should be delayed until completion of antibiotic regimen and wound healing. Although normal serology—erythrocyte sedimentation rate and C-reactive protein—are desired, but elevated values are common and do not preclude successful reimplantation.14 The use of aspiration prior to reimplantation is not well-studied, but it will prove useful in confirming an aseptic joint. Aspirate fluid should be sent for culture, as well as cell count (white blood cell count <1760 per microliter) and differentiation (<73% neutrophils).15 Similar to direct exchange, fixation should be achieved with antibiotic-loaded cement, which is available commercially or can be prepared at the time of reimplantation.

Salvage: Fusion vs Amputation

In an immunocompromised patient with an uncontrollable periprosthetic joint infection or the impossibility of successful reconstruction salvage procedures become the ideal treatment. Successful reconstruction is severely limited in those patients with insufficient bone stock, inadequate muscle function, and poor soft tissue coverage. When faced with these difficult cases, it is important to make the distinction that such patients will not be successfully reimplanted and therefore initiation of a two-stage revision is imprudent.

Above-the-knee amputation, while possibly appearing most disastrous to patients, provides an opportunity for return to function with a fitted prosthesis, especially in sick patients who cannot tolerate multiple procedures, or those with bone quality precluding possible fusion.

Alternative to amputation is fusion, which allows the patient to retain the extremity. However, ambulation is usually difficult for patients with a fused knee. Fusion can be achieved through placement of intramedullary nail or external fixation. The advantage of external fixation is that fusion may be achieved without having any hardware implanted in the infected knee, hence reducing the possibility of persistent infection. There is also a higher likelihood for development of malunion when an external frame is used. The intramedullary nail, however–in addition to the convenience of patient not having an external frame–allows an earlier return to weight bearing. The intramedullary nail, however, can act as a nidus for infection and colonization, which may compromise the outcome of fusion. The decision to use one versus the other lies in the hand of the surgeon and familiarity with one device versus the other.

Conclusion

Infection following TKA is a debilitating complication with significant morbidity. Appropriate treatment attempts to maximize functionality while eradicating periprosthetic joint infection. However, infection eradication is necessary for the patient’s global health. Adequate reconstruction of the joint is second in importance. Navigation of the treatment algorithm is dependent on host-quality and organism virulence and resistance.

References

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Authors

Dr Parvizi, Mr Zmistowski, and Ms Adeli are from the Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.

Dr Parvizi is a consultant for Stryker and has intellectual properties on SmarTech. Mr Zmistowski and Ms Adeli have no relevant financial relationships to disclose.

Presented at Current Concepts in Joint Replacement 2009 Winter Meeting; December 9-12, 2009; Orlando, Florida.

Correspondence should be addressed to: Javad Parvizi, MD, Rothman Institute of Orthopedics at Thomas Jefferson University Hospital, 925 Chestnut St, Philadelphia, PA 19107 (parvj@aol.com).

doi: 10.3928/01477447-20100722-42

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