Management of Periprosthetic Joint Infection: The Current Knowledge

Abstract

Periprosthetic joint infection continues to frustrate the medical community. Although the demand for total joint arthroplasty is increasing, the burden of such infections is increasing even more rapidly, and they pose a unique challenge because their accurate diagnosis and eradication can prove elusive. This review describes the current knowledge regarding diagnosis and treatment of periprosthetic joint infection. A number of tools are available to aid in establishing a diagnosis of periprosthetic joint infection. These include the erythrocyte sedimentation rate, serum C-reactive protein concentration, synovial white blood-cell count and differential, imaging studies, tissue specimen culturing, and histological analysis. Multiple definitions of periprosthetic joint infection have been proposed but there is no consensus. Tools under investigation to diagnose such infections include the C-reactive protein concentration in the joint fluid, point-of-care strip tests for the leukocyte esterase concentration in the joint fluid, and other molecular markers of periprosthetic joint infection. Treatment options include irrigation and debridement with prosthesis retention, one-stage prosthesis exchange, two-stage prosthesis exchange with intervening placement of an antibiotic-loaded spacer, and salvage treatments such as joint arthrodesis and amputation. Treatment selection is dependent on multiple factors including the timing of the symptom onset, patient health, the infecting organism, and a history of infection in the joint. Although prosthesis retention has the theoretical advantages of decreased morbidity and improved return to function, two-stage exchange provides a lower rate of recurrent infection. As the burden of periprosthetic joint infection increases, the orthopaedic and medical community should become more familiar with the disease. It is hoped that the tools currently under investigation will aid clinicians in diagnosing periprosthetic joint infection in an accurate and timely fashion to allow appropriate treatment. Given the current knowledge and planned future research, the medical community should be prepared to effectively manage this increasingly prevalent disease.

Synovial Cytokines and the MSIS Criteria Are Not Useful for Determining Infection Resolution After Periprosthetic Joint Infection Explantation

“…Current guidelines to diagnose periprosthetic joint infection (PJI) have been proposed by the Musculoskeletal Infection Society (MSIS) criteria and require a combination of serum, synovial fluid, and histologic parameters [14]. Results can often be difficult to interpret, requiring a complex clinical algorithm to determine a diagnosis [22], which may be incorrect in up to 10% of cases of presumed aseptic joints [19].…”

Prevention of Periprosthetic Joint Infection

“…Infection is the leading cause of revision after TKA and the third most common reason for revision THA in the Medicare population. PJI can occur any time after the surgery, and there is no "gold standard" for diagnosis (2)(3)(4)(5)(6)(7)(8). PJI has a huge financial impact on the healthcare system.…”

Combined <em>In vivo</em> Optical and &#181;CT Imaging to Monitor Infection, Inflammation, and Bone Anatomy in an Orthopaedic Implant Infection in Mice

“…First, this mouse model is an oversimplification of the actual procedures and materials used in orthopaedic surgery in humans 24 . Nonetheless, this model does recapitulate the chronic infection and ensuing inflammation in the bone and joint tissue that is seen in human orthopaedic implant infections 8,9 . In addition, to obtain the μCT images, relatively low doses of X-ray irradiation were used to minimize any adverse effects on the health of the animals during the course of infection.…”

“…Since μCT imaging permits the exquisite visualization of bone anatomy, using μCT imaging in conjunction of with optical imaging represents a unique combination that might be especially useful for investigating processes that involve bone biology [5][6][7] . An example would be to use these techniques to study orthopaedic implant infections, which represent a disastrous complication following orthopaedic surgical procedures 8,9 . Bacteria biofilms form on the implanted foreign objects that promote survival of the bacteria by serving as a physical barrier that prevents immune cells from sensing the infection and blocks antibiotics from accessing the bacteria 10,11 .…”

“…Bacteria biofilms form on the implanted foreign objects that promote survival of the bacteria by serving as a physical barrier that prevents immune cells from sensing the infection and blocks antibiotics from accessing the bacteria 10,11 . The chronic and persistent infection of the joint tissue (septic arthritis) and bone (osteomyelitis) induces bone resorption that leads to loosening of the prosthesis and eventual failure 8,9 . This resulting periprosthetic osteolysis is associated with increased morbidity and mortality 12,13 .…”