orthopaedics

1. Approach for periproshetic
infection
By:
Dr.abdulrahman aldowesh
Tutor:
Dr. ahmad bin nasser

2. I. Epidemiology and Overview
• Prevalence
• The risk of periprosthetic infection following
primary knee arthroplasty (1% to 2%) is
slightly higher than that following hip
arthroplasty (0.3% to 1.3%).
• The risk of infection is higher after revision
procedures: 3% for hips and 6% for knees.

3. 1.Risk factors
1.Postoperative surgical site infection or hematoma
formation
2.Wound healing complications
3.Malignant disease
4.Prior joint arthroplasty
5.Prior surgery or infection of the joint or adjacent bone
6.Perioperative nonarticular infection
7.Rheumatoid arthritis
8.Psoriasis
9.Diabetes

4. • Prophylaxis
• —Administration of antibiotics within 60
minutes before surgery is the most effective
method for prevention of periprosthetic
infection.

5. II. Presentation and Etiology
Type of Infection Etiology Time of Onset Signs and Symptoms
Acute
postoperative
infection
Frequently caused by
Staphylococcus aureus, B-
hemolytic Stretptococcus, and
sometimes by gram-negative
bacteria
Symptoms appear
within days to weeks
Acute onset of joint pain and
swelling together with
erythema, warmth, tenderness,
and possible wound discharge
Sinus tract extending to the joint
is a definitive sign of infection
Late chronic
infection
Frequently caused by less-
virulent organisms: coagulase-
negative Staphylococcus and
Propionibacterium acnes
Occurs several months
to 2 years after
prosthesis implantation
Subtle signs and symptoms, if
any
Chronic pain and implant
loosening are common
Difficult to differentiate from
mechanical aseptic loosening,
but pain associated with chronic
infection worsens with time and
is accompanied by deterioration
in function.
Hematogenous
seeding
Inciting events: skin infection,
dental extraction, respiratory
tract infection, urinary tract
infection
Within days after
inciting event
Sudden onset of pain

6. III. Diagnosis
A-History and physical examination
– A detailed history and physical examination can
diagnose periprosthetic infection with reasonable
certainty; laboratory tests simply confirm the
diagnosis.
– Many times, signs and symptoms of periprosthetic
infection overlap those of hematoma formation,
aseptic loosening, and instability; thus, additional
diagnostic tests are often required

7. B- imaging studies:
1- x-ray signs:
1.- Periosteal reaction.
2.Scattered foci of osteolysis .
3.Generalized bone resorption in absence of implant
wear.

10. C-blood tests
• Erythrocyte sedimentation rate (ESR) and C-
reactive protein (CRP) are nonspecific markers.
• Combined, ESR and CRP have a sensitivity of 99%
and a specificity of 89%.
• Continued elevation of levels of CRP and ESR is
concerning for infection.
• Interleukin-6 may be useful for diagnosis and for
monitoring the progress of infection

11. D-Joint aspiration
• Joint aspiration is performed when there is a
strong suspicion of infection.
• Aspiration has a sensitivity of 57% to 93% and
a specificity of 88% to 100%. Sensitivity can be
improved by repeat aspiration.

12. Type Presentation Definition Treatment
I
Acute postoperative
infection
Acute infection within
first month
Attempt at débridement
and prosthetic retention
II
Late chronic
infection
Chronic indolent
infection presenting >1
month after surgery
Prosthetic removal
III
Acute
hematogenous
infection
Acute onset of
symptoms in a
previously well-
functioning joint
Attempt at débridement
and prosthetic retention,
or prosthetic removal
IV
Positive
intraoperative
cultures
Two or more positive
intraoperative cultures
Appropriate antibiotics
Classification of Periprosthetic Joint Infections

13. -Treatment options
1.Surgical
1.Débridement with retention of prosthesis
2.Resection arthroplasty with reimplantation
3.Definitive resection arthroplasty with or without
arthrodesis
4.Amputation
2.Nonsurgical—Suppressive antimicrobial therapy

14. 1.Two-stage replacement arthroplasty—Two-
stage resection and replacement arthroplasty
is the gold standard for treatment of infection
beyond 4 weeks.
1.Procedure
1.Removal of prosthesis
2.Surgical débridement of the joint
3.Administration of antimicrobials with subsequent
delayed reimplantation

15. • The time interval between the two surgical procedures is
highly variable.
• No specific protocol is in place, but early reimplantation has
less success.
• In infected total knee arthroplasty, reimplantation within 2
weeks has a success rate of approximately 35% compared
to success rates of 70% to 90% with delayed reimplantation
(>6 weeks) and more extensive antimicrobial therapy.
• The proper timing of reimplantation after parenteral
antibiotic therapy should be based on the clinical
appearance of the wound and improvement in serologic
markers of infection, such as the CRP level and the ESR.

16. 2.One-stage replacement arthroplasty
1.Procedure
1.All prosthetic components, infected bone, and soft
tissue are excised.
2.The new prosthesis is implanted during the same
surgery.
3.Intravenous antibiotics are administered for a variable
period of time after the revision
2.Indications
1.Mainly for managing infected hip prostheses
2.Used more commonly in Europe

17. – Advantages
• Single procedure
• Lower cost
• Earlier mobility
• Patient convenience
– Disadvantage
– Risk of reinfection from residual microorganisms

18. 3.Débridement with retention of prosthesis
1. Procedure
1. Débridement of infected tissue and exchange of polyethylene insert
with large-volume irrigation
2. Prolonged postoperative antibiotic therapy
2. Indications—Considered when infection developed within 4
weeks of surgery or after an inciting event such as dental
extraction.
3. Advantages
Limited surgery with preservation of prosthesis and bone stock.
4.Disadvantages
1. Risk of leaving infected foreign body in place
2. Failure rate is generally approximately 20%, with occasional reports of
success up to 85%, depending on the outcome factors listed above.

19. 4.Resection arthroplasty
1. Procedure
1.Definitive removal of all infected components and tissue
2.No subsequent implantation
2. Indications—Currently are limited, but include the
following:
1.Poor quality of bone and soft tissue
2.Recurrent infections
3.Infection with multi-drug-resistant organism
4.Medical conditions that preclude major surgery (reimplantation)
5.Failure of multiple previous exchange arthroplasties
6.Also an acceptable alternative in elderly nonambulatory patients

20. 5. arhtodesis.
6. amputation.

21. VI. Nonsurgical Treatment
1.Treatment—Suppressive antimicrobial therapy.
2.Indications—Considered for frail, elderly, and ill
patients in whom surgery is not possible or is
refused by the patient.
3.Goals
1.Provide symptomatic relief
2.Maintain joint function
3.Prevent systemic spread of infection rather than
eradication of infection
4.Outcomes
1.Success rates of only 10% to 25%
2.Complications occur in 8% to 22% of patients.

22. •Thank you