Orthopaedic Knowledge Update®: Musculoskeletal Infection 2 Print + Ebook (AAOS - American Academy of Orthopaedic Surgeons)

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CHAPTER

Surgical Treatment of Hip and Knee Prosthetic Joint Infections

MARK A. HAIMES, MD, MS • MICHAEL J. O’MALLEY, MD, FAAOS

ABSTRACT Prosthetic joint infection (PJI) is a devastating condition with high morbidity and mortality. With the increased number of hip and knee replacements being performed, the expected number of PJIs is likely to increase as well. Treatment is usually surgical; however, the choice of surgical procedure is not universally agreed on. The spec trum of surgical treatment includes débridement with exchange of modular components (débridement, antibiot ics, and implant retention), revision of all components in either a single-stage or two-stage manner, or a salvage procedure. A two-stage revision of components is the standard treatment for chronic PJI in the United States; however, single-stage revision is becoming more common internationally and in some centers in the United States. Débridement, antibiotics, and implant retention is commonly used for the treatment of acute infections with less virulent organisms and when patients cannot tolerate a full revision of components. The 1.5-stage procedure has resulted, as some patients and surgeons have both decided to defer second-stage reimplantation because of their satisfaction with their temporary spacer. The surgical options should be weighed to consider the patient’s symptoms, microbiology, medical comorbidities, prior surgeries/implants, and goals for quality of life. When all other options are most likely to fail, salvage procedures should be discussed with the patient.

Section 4: Prosthetic Joint Infections

Keywords: 1.5-stage revision; antibiotics, débride ment, and implant retention; prosthetic joint infection; single-stage revision; two-stage revision

arthroplasty with reimplantation at one or two stages, arthrodesis, resection arthroplasty alone, or amputation. There is no universal standard treatment and there are differences in practice based on the region of the world. However, there are general guidelines and strong evi dence in certain cases that can help surgeons plan the appropriate surgical treatment of PJI of the hip or knee.

INTRODUCTION Generally, the treatment of prosthetic joint infection (PJI) consists of both surgical débridement and antimicrobial therapy. The proper surgical and antimicrobial approach depends on the timing of symptoms, microbiology, sta bility of prosthesis, quality of soft-tissue envelope, and individual patient function. Surgical options include débridement with retention of prosthesis, resection

DÉBRIDEMENT, ANTIBIOTICS, AND IMPLANT RETENTION Indications A 2019 literature review discussed the traditional indi cations for a débridement, antibiotics, and implant retention (DAIR) procedure: patients with a PJI who have well-fixed components, absence of a sinus tract, less than 3 weeks of symptoms, less than 4 weeks since index surgery, or those for whom alternative surgi cal strategies are unacceptable. 1 DAIR has obvious appeal if successful in that the retention of well-fixed Dr. O’Malley or an immediate family member serves as a paid consultant to or is an employee of Smith & Nephew and Stryker. Neither Dr. Haimes nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2023

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Orthopaedic Knowledge Update ® : Musculoskeletal Infection 2