Tertiary care centre adherence to unified guidelines for management of periprosthetic joint infections: a gap analysis

Abstract

Background:The success rate of surgical treatment for periprosthetic joint infection (PJI) remains inconsistent in the literature. Variability in PJI clinical guidelines and surgeon adherence to guidelines could affect treatment success. The objectives of this study were to appraise current recommendations for PJI management and develop a unified clinical standard of care, to perform a gap analysis of PJI cases in a tertiary institution to determine the rate of guideline adherence, and to determine if adherence to unified PJI guidelines affected 2-year treatment outcomes. Methods: We appraised the PJI guidelines from 3 academic medical societies, and consistent statements were aggregated. We retrospectively reviewed all PJI cases in a tertiary care institution. We defined PJI based on Musculoskeletal Infection Society PJI criteria. Surgeon adherence to preoperative, intraoperative, surgical and medical management guidelines was calculated, and we evaluated the association between guideline adherence and 2-year treatment outcomes. Results: The institutional rate of PJI was 1.13% (38 of 3368). Treatment success was 57.8% at 2 years. Unified guideline adherence percentages varied substantially: 92% of patients had preoperative erythrocyte sedimentation rate and C-reactive protein, 97% had intraoperative tissue cultures, 42% had appropriate preoperative arthrocentesis, and 74% underwent guideline-appropriate surgery. Performing appropriate preoperative arthrocentesis significantly correlated with positive treatment outcomes at 2 years (p = 0.028). Conclusion: Adherence to PJI guidelines varies considerably, indicating that clinicians are either unaware of them or do not recognize their value for PJI treatment. This study shows the need for institution-based PJI treatment pathways that are consistent with published guidelines and the need to monitor adherence. Contexte :Les études ne concordent pas quant au taux de réussite du traitement chirurgical des infections de prothèses articulaires (IPA). Une certaine variabilité dans les lignes directrices sur ces infections et dans l'adhésion des chirurgiens à celles-ci pourrait nuire à la réussite du traitement. La présente étude visait à évaluer les recommandations actuelles sur la prise en charge des IPA afin d'élaborer une norme de soins uniforme, à effectuer une analyse des lacunes entourant les cas d'IPA dans un établissement de soins tertiaires pour déterminer le taux d'adhésion aux lignes directrices, et à déterminer si l'adhésion à des lignes directrices uniformes influençait les issues de traitement après 2 ans. Méthodes : Nous avons évalué les lignes directrices sur les IPA de 3 sociétés médi-cales universitaires, et agrégé des énoncés cohérents. Nous avons également examiné de façon rétrospective tous les cas d'IPA dans un établissement de soins tertiaires. Aux fins de notre étude, l'IPA était définie selon les critères de la Musculoskeletal Infection Society. Nous avons calculé l'adhésion des chirurgiens aux lignes directrices de prise en charge préopératoire, ...

New Innovations in the Treatment of PJI and Biofilms—Clinical and Preclinical Topics

“…The combination of invasive surgery, side effects from antibiotics, and complications from spacer implants culminate in high perioperative morbidity rates with two-stage revision treatments, with rates being reported as high as 15% in a recent series of patients treated in a high volume center [4]. Treatment of early PJI with irrigation and debridement, while less morbid, has been associated with poor cure rates of just over 50% [10,30]. Such low cure rates are believed to occur in part due to surgeon variability in how surgical debridement is performed, but also due to current topical agents being ineffective in removing biofilm from metal and plastic implant surfaces [30].…”

“…Treatment of early PJI with irrigation and debridement, while less morbid, has been associated with poor cure rates of just over 50% [10,30]. Such low cure rates are believed to occur in part due to surgeon variability in how surgical debridement is performed, but also due to current topical agents being ineffective in removing biofilm from metal and plastic implant surfaces [30]. Currently, administration of dilute betadine [31], chlorhexidine [32], and vancomycin powder [33] has all been separately advocated to improve irrigation and debridement treatment outcomes, but these effects have only been observed in retrospective case series.…”

Integrated IT Platform for Coordination of Diagnosis, Treatment, and Aftercare of Prosthetic Joint Infections

“…Inconsistencies and deviations from standardized diagnostic and clinical pathways for PJIs even in specialized high-volume centers have been described (25,26). While there is no evidence for worse treatment outcomes associated with such deviations, an effect on overall treatment success is very likely.…”

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“…While the number of required revisions to define "highvolume" is currently unknown, ICM has set the recommendation for case volume to be a minimum of 25 based off this knowledge [17]. In addition to surgical technique, surgeons must be familiar with diagnostic and treatment algorithms that have been empirically proven on an international level to improve outcomes after PJI [3,4].…”

“…Tetreault et al evaluated the consistency of current methods for evaluating PJI according to American Academy of Orthopaedic Surgeons (AAOS) guidelines and noted an alarming gap between expectation and reality, even amongst orthopedic-trained surgeons. The study concluded that there is still significant underdiagnosis of PJI, leading to unnecessary order of advanced diagnostic imaging, adding to medical costs and a delay in treatment [3,4].…”