Prevention of Periprosthetic Joint Infection (PJI): A Clinical Practice Protocol in High-Risk Patients

Abstract

Background: Periprosthetic joint infection (PJI) represents 25% of failed total knee arthroplasties (TKA). The European Knee Associates (EKA) formed a transatlantic panel of experts to perform a literature review examining patient-related risk factors with the objective of producing perioperative recommendations in PJI high-risk patients. Methods: Multiple databases (Pubmed/MEDLINE, EMBASE, Scopus, Cochrane Library) and recommendations on TKA PJI prevention measures from the International Consensus Meetings on PJI from the AAOS and AAHKS were reviewed. This represents a Level IV study. Results: Strong evidence was found on poor glycemic control, obesity, malnutrition, and smoking being all associated with increased rates of PJI. In the preoperative period, patient optimization is key: BMI < 35, diet optimization, Hemoglobin A1c < 7.5, Fructosamine < 292 mmol/L, smoking cessation, and MRSA nasal screening all showed strong evidence on reducing PJI risk. Intraoperatively, a weight-based antibiotic prophylaxis, accurate fluid resuscitation, betadine and chlorhexidine dual skin preparation, diluted povidone iodine solution irrigation, tranexamic acid administration, and monofilament barbed triclosan-coated sutures for soft tissues closure all represented effective prevention measures. In the postoperative period, failure to reach normalization of ESR, CRP, D-dimer, and IL-6 six weeks postoperatively suggested early PJI. Conclusion: The current recommendations from this group of experts, based on published evidence, support risk stratification to identify high-risk patients requiring implementation of perioperative measures to reduce postoperative PJI.

The mildly decreased preoperative bilirubin level is a risk factor for periprosthetic joint infection after total hip and knee arthroplasty

“…The reported incidence of PJI is 1-3% following primary arthroplasty and 3-5% after revision arthroplasty [4,5]. With prolonged life expectancy and a growing indication for primary joint arthroplasty, there Fu et al Arthroplasty (2021) 3:40 will be a fold increase in the number of PJI patients [6]. Early and accurate identification of individuals at high risk of PJI is conductive to clinical decision-making and development of effectively preventive strategies.…”

Predicting the Exception—CRP and Primary Hip Arthroplasty

“…The development of a PJI prolongs the inpatient stay considerably [31,32]. The maximum CRP and the presence of a second peak can be helpful for early infection detection [33][34][35]. This study was able to demonstrate the clinical applicability of two formulas forecasting a PJI.…”

Clinical Application of Antibacterial Hydrogel and Coating in Orthopaedic and Traumatology Surgery

“…Although a routine use for all patients has not yet been put forth, a cost-benefit study proposed by Trentinaglia et al simulated how the routine use of antibiotic gel on all non-cemented prosthetic surgery implants, similar to the use of antibiotic-loaded cement in cemented prostheses, would reduce the management costs of infected patients, with greater savings compared to other types of surface coatings, such as the silver-coating [ 20 ]. Recently, with regard to high-risk patients, there have also been proposals of risk reduction strategies using calcium sulphate antibiotic-loaded beads (Stimulan; Biocomposites Ltd., Keele, UK) with the same antibiotics [ 21 ]. However, the application of this type of local antibiotic carrier is burdened by a variable risk of complications such as hypercalcemia, heterotopic ossifications and prolonged secretion from the surgical wound, which appear to be closely related to the application site and the quantity of the beads used [ 22 ].…”