Periprosthetic Joint Infection: Treatment Options

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.

Low Rate of Infection Control in Enterococcal Periprosthetic Joint Infections

“…These include a combination of medical (antibiotic therapy) and surgical treatments [12]. Regarding the antibiotic therapy, intravenous ampicillin, gentamicin, or vancomycin is sufficient for non-VRE species [8].…”

“…Irrigation and débri-dement, one-stage exchange arthroplasty, two-stage exchange arthroplasty, and salvage surgeries (fusion and amputation) are available surgical options for management of PJI. Among these options, two-stage exchange arthroplasty is the preferred method of treatment of patients with chronic PJI in North America [12]. The exact success rate of these interventions is not well known and varies widely depending on what is considered a success.…”

High Infection Control Rate and Function After Routine One-stage Exchange for Chronically Infected TKA

“…Some authors believe débride-ment should be performed only in the early stage of infection [22]. When the infection is chronic, Parvizi et al [18] considered prosthesis removal mandatory. Reimplantation of a new TKA is generally performed in a subsequent stage after a variable period of time (two-stage protocol) and initial control of the infection [24].…”

“…However, there might be a higher risk of persistence or recurrence of the index infection due to a deficient débridement or insufficient antibiotic treatment. Some authors consider two-stage protocols for control of infections in total joint arthroplasty the gold standard [10,18]. Kalore et al [11] suggested one-stage protocols were contraindicated or should be reserved for selected patients (no fistula, no severe bone damage, known pathogen with high sensitivity to antibiotics, etc).…”

The report of tumor resection prosthesis infection due to Sphingomonas paucimobilis: A case report

“…In the presented case, Sphingomonas paucimobilis was grown in the culture of the tissue biopsy sample obtained from the sinus tract. In the literature review, it was determined that S. paucimobilis infection had always been defined as accompanying different comorbidities, such as malignancy, diabetes mellitus, alcoholism, hepatic cirrhosis, late stage renal failure, chronic obstructive pulmonary disease, burn wounds, and acquired immune deficiency syndrome (10). In the presented case, the comorbidity was tibial proximal osteosarcoma, in addition to secondary immune suppression due to the previous chemotherapy.…”