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

Chapter 16: Surgical Treatment of Hip and Knee Prosthetic Joint Infections

of 12 L of solution that includes continued mechanical débridement with brushes and pulse lavage. Antiseptic solutions such as 1% povidone-iodine solution and 3% hydrogen peroxide are then applied, followed by a sec ond normal saline wash. Povidone-iodine or polymeric biguanide-hydrochloride (polyhexanide)–soaked swabs are placed in the wound and the incision is closed and dressed. The entire surgical team rescrubs, the patient is reprepped and draped, and all new surgical instruments are used. The wound is reincised, irrigated with normal saline, and the final revision implant is placed. 60,61 Indications The ICM on PJI considers single-stage revision arthro plasty to be a reasonable treatment for PJI when the patient is a good host and not septic, there is no sinus tract or severe soft-tissue involvement, and the organ ism is identified and not drug resistant. 62 In 2022, a systematic review reported on updated indications for single-stage revision, which include the absence of severe immunocompromise, significant soft-tissue or bony compromise, and concurrent acute sepsis. 63 It was concluded that a two-stage approach should be used for multidrug-resistant or atypical organisms such as fungus. Overall success rates reported in this systematic review of the single-stage approach were 82% to 100% at 2 years. There are efforts to make single-stage treatment more common at centers in the United States. However, one tertiary referral center reported in 2020 that of 91 patients who underwent two-stage treatment, only 19% would qualify for single-stage treatment based on the ICM criteria. 64 Outcomes A 2019 retrospective review of 111 patients who under went single-stage revision with noncemented recon struction for total hip arthroplasty PJI found that 99 of 111 patients (89.2%) were free of infection at a mean of 6 years. 65 A 2019 retrospective case review demonstrated favorable long-term results of single-stage revision for total hip arthroplasty PJI with a 10-year infection-free survival rate of 94% and a surgery-free survival rate of 75.9%, with the most common indication for revision being instability in 10 of 20 patients. 66 This study of 230 one-stage exchanges did have significant loss to follow-up during the study time frame (only 85 [37%] were avail able for final follow-up), but follow-up was relatively long term at 10 years. A 2019 study created a Monte Carlo simulation for the hypothetic situation of knee PJI with all pathogens and one for difficult-to-treat pathogens. 67 This expected value decision tree was constructed to estimate the change in quality of life and costs associ ated with single-stage versus two-stage revision. Single stage revision was the dominant strategy for patients in

approximately 85% and 69% of the trials, respectively. Single-stage revision is more cost effective for hospital centers, with a savings of approximately $20,000 per patient. 68 However, as of 2019, the physician reimburse ment for a single-stage revision is approximately one third the hourly rate of a primary procedure. 69 Despite the challenges, the use of single-stage revision is likely to increase in the United States. SALVAGE PROCEDURES Unfortunately, some patients are unable to remain infection free. In patients whose procedures result in repeated failure, severe soft-tissue damage, significant host compromise, and those unable to tolerate multiple surgeries, salvage procedures such as knee arthrodesis, resection arthroplasty, or amputation/disarticulation should be considered. Although rare, knee resection arthroplasty was described in 2020 as an alternative to amputation with an infection control rate of 84%. 70 One study of patients who underwent knee resection arthro plasty found that 45% were community ambulators, 35% were household ambulators, and 20% were only able to transfer. All patients require a knee-ankle-foot orthosis and walking aid, and 15% of patients were on chronic narcotic medications. Regarding knee arthrod esis, it can be performed with multiple fixation options including an Ilizarov frame, intramedullary fusion nail, intermedullary arthrodesis system that obtains biologic fixation, or plate fixation ( Figures 7 and 8 ). There is a paucity of literature on the specific implants available and outcomes. A 2021 retrospective review of 20 patients who underwent transfemoral amputation and 23 patients who underwent knee arthrodesis demonstrated a similar

Section 4: Prosthetic Joint Infections

A FIGURE 7 A , AP and B , lateral radiographs showing knee arthrodesis with a reamed, statically locked, intramedullary nail from the proximal femur to the distal tibia. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2023 B

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Orthopaedic Knowledge Update ® : Musculoskeletal Infection 2