Wound Management in Total Knee Prosthetic Joint Infections - Nicholas R. Johnson, MD and Ryan Garcia, MD
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Total knee arthroplasty complicated by periprosthetic joint infection can be devastating. Patients undergoing treatment for prosthetic joint infection have often undergone multiple surgeries and may have associated soft tissue defects that complicate treatment. These defects often require soft tissue reconstruction in order to cover the prosthesis. Coverage options range from simple tissue rearrangement to free flap reconstruction. A team approach between orthopaedic and plastic surgery is imperative to help retain the prosthesis and improve functional outcomes. (Journal of Surgical Orthopaedic Advances 30(4):196–201, 2021)
Key words: prosthetic joint infection (PJI), soft tissue defects, flap reconstruction
Prevention of Periprosthetic Joint Infection of the Hip and Knee: Modern Techniques and Strategies - Nicholas R. Johnson, MD and Jesse E. Otero, MD, PhD
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Prosthetic joint infection is a feared complication following elective total joint arthroplasty of the hip and knee. Infection following arthroplasty leads to high morbidity and even mortality and is a major burden to the health care system. Although many advances are being made in the treatment of prosthetic joint infection, with the increasing volume of total joint arthroplasty anticipated over the next decade, a significant emphasis should be placed on prevention. Several preoperative, intraoperative, and postoperative strategies may be employed to help reduce the risk. (Journal of Surgical Orthopaedic Advances 30(4):202–206, 2021)
Key words: prosthetic joint infection, prevention, perioperative management
Patient Optimization Strategies Prior to Elective Total Hip and Knee Arthroplasty - Nicholas R. Johnson, MD and Bryan Springer, MD
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Periprosthetic joint infection (PJI) following elective total hip and knee arthroplasty remains a devastating complication. PJI is associated with high morbidity and mortality to the patient as well as high expenses to the health care system. Although patient optimization prior to elective arthroplasty has gained notoriety and shown to help prevent complications, surgeons continue to operate on patients who are not optimized for surgery. Lack of optimization has been shown to lead to increased risk of complications and poor outcomes. The surgeon should be vigilant to correct modifiable risk factors prior to elective arthroplasty to help minimize the risk of PJI. (Journal of Surgical Orthopaedic Advances 30(4):207–211, 2021)
Key words: periprosthetic joint infection (PJI), optimization, body mass index (BMI), elective arthroplasty
Diagnosis of Prosthetic Joint Infection - William Jiranek, MD, FACS, and Peter Surace, MD
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An 81-year-old male with an infected aortic valve presents to the orthopaedic service with a painful total knee of unclear chronicity and several weeks of intravenous antibiotics. While some prosthetic joint infections (PJI) present very clearly, many come as consultations after previous partial work-up, administration of antibiotics, and an unclear history or timeline. Even in these more “real-world” clinical scenarios, the development of evidence-based practices will allow the orthopaedic surgeon the ability to accurately detect PJI and prudently determine when to take a patient to the operating room. The most widely- accepted algorithm is that developed by the Musculoskeletal Infection Society (MSIS), which utilizes major and minor criteria and a scoring system that diagnoses PJI. Beyond this scoring system, recent studies have also shown the utility of laboratory tests, including serum and synovial fluid tests, as well as next generation sequencing techniques. These, with the addition of both simple radioimaging and more advanced nuclear imaging tests, provide surgeons the tools required to make the determination of PJI even in the most complex or difficult clinical scenarios. (Journal of Surgical Orthopaedic Advances 30(4):212–215, 2021)
Key words: total joint replacement, prosthetic joint infection, hip, knee, antibiotic spacer
One-stage Treatment of Prosthetic Joint Infection - Cody C. Wyles, MD and Brian M. Curtin, MD
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Management of prosthetic joint infection in hip and knee arthroplasty patients is traditionally undertaken with a two-stage treatment protocol. However, this strategy carries high morbidity and cost, yet a substantial portion of patients sustain reinfection. One-stage treatment protocols have been popularized in Europe and other parts of the world but remain infrequently performed in the United States, despite equivocal efficacy with two-stage treatment based on currently available data. Herein, we describe a current one-stage treatment protocol used as part of a multicenter randomized clinical trial in the United States. Furthermore, a case example is presented of a patient with prosthetic joint infection of the hip, successfully treated with a one- stage protocol including details on revising the hip through a direct anterior approach with use of an anterior cortical window osteotomy for removal of a well-fixed femoral component. (Journal of Surgical Orthopaedic Advances 30(4):216–219, 2021)
Key words: one-stage treatment, prosthetic joint infection, double setup, direct anterior hip revision, anterior cortical window osteotomy
Two-stage Treatment for Hip and Knee Periprosthetic Infections - Murillo Adrados, MD; Benjamin R. Coobs, MD; and Joseph T. Moskal, MD
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Two-stage exchange remains the standard of care for treatment of chronic periprosthetic infections in the United States. The strategy involves three steps; a resection arthroplasty with a thorough debridement and placement of a temporary spacer, an extended period of targeted antibiotics, and finally, a second definitive reconstruction procedure. The lengthy period of time between surgeries, where patients have diminished mobility, a long period of IV antibiotics and its considerable side effects, and the need for two large operations and hospitalizations places physiologic and emotional demands on patients and their families. A two-stage exchange has considerable morbidity and mortality, with significant attrition between stages. Nonetheless, it remains the gold standard for treatment of chronic periprosthetic infections, with good historic success rates. In this review, we outline its historical origins, surgical technique, outcomes and current research shaping two-stage exchanges. (Journal of Surgical Orthopaedic Advances 30(4):220–225, 2021)
Key words: two-stage exchange, periprosthetic joint infection (PJI), revision arthroplasty
The Role of Antiseptic Irrigation Solutions and Topical Antibiotics in Total Joint Arthroplasty - Joshua T. Anderson, MD; A. Jack Barnes, MD; and Jeffrey B. Stambough, MD
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Prosthetic joint infections (PJI) are devastating complications. Antiseptic irrigation fluids have shown promising in vitro results in eradicating planktonic bacteria and decreasing biofilm burden. Topical antibiotics, specifically vancomycin, represents another potentially cost-effective way to prevent acute postoperative PJI. We provide a review of the current literature and recommendations on these measures. Overall, a current lack of high-powered, prospective studies exists to definitively support the use of any specific antiseptic solution or topical antibiotic in primary or revision total joint arthroplasty. Some studies support the use of dilute povidone-iodine lavage when combined with vancomycin powder. Data also exists to support the cost effectiveness of povidone-iodine, with the necessary risk reduction to justify its cost. Contradictory evidence exists demonstrating no differences in PJI rates with these measures and possibly higher rates of aseptic wound complications associated with vancomycin power. Further study is warranted. (Journal of Surgical Orthopaedic Advances 30(4):226–230, 2021)
Key words: prosthetic joint infection, irrigation solutions, topical antibiotics, Betadine povidone-iodine, vancomycin, chlorhexidine gluconate
Review of Salvage Therapies for Periprosthetic Joint Infection After Total Knee Arthroplasty - Joshua W. Mueller, BS; Simon C. Mears, MD, PhD; Benjamin M. Stronach, MS, MD; C. Lowry Barnes MD; and Jeffrey B. Stambough, MD
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Periprosthetic joint infection after knee arthroplasty is exceptionally challenging to manage and can result in significant morbidity and mortality for the patient. When irrigation and debridement, polyethylene exchange, and one- or two-stage exchange fail to clear the infection, the surgeon is left with two primary salvage therapies: knee arthrodesis and amputation. The decision between these two treatments is difficult and requires an open conversation with the patient about their desire and expectations. The purpose of this review article is to give an overview of knee arthrodesis and amputation after periprosthetic joint infection about the knee as well as provide two case examples to highlight these two management strategies. (Journal of Surgical Orthopaedic Advances 30(4):231–234, 2021)
Key words: knee arthrodesis, above-the-knee amputation, periprosthetic joint infection
Extraction Techniques for Well-fixed, Infected Hip Arthroplasty Implants - Thomas L. Bradbury, MD, FAOA
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Periprosthetic joint infection after knee arthroplasty is exceptionally challenging to manage and can result in significant morbidity and mortality for the patient. When irrigation and debridement, polyethylene exchange, and one- or two-stage exchange fail to clear the infection, the surgeon is left with two primary salvage therapies: knee arthrodesis and amputation. The decision between these two treatments is difficult and requires an open conversation with the patient about their desire and expectations. The purpose of this review article is to give an overview of knee arthrodesis and amputation after periprosthetic joint infection about the knee as well as provide two case examples to highlight these two management strategies. (Journal of Surgical Orthopaedic Advances 30(4):231–234, 2021)
Key words: knee arthrodesis, above-the-knee amputation, periprosthetic joint infection
Considerations for Intravenous Antibiotic Treatment of Prosthetic Joint Infections - Courtney Russ-Friedman, FNP-BC; Erika Ross, PA-C; Benjamin Whitt, MD; Chukwunyelu Enwezor, MD; Jose R.Trigueros, MD; and Erin Barnes, MD, MS
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Intravenous antibiotic therapy remains necessary for many patients with prosthetic joint infections. Intravenous therapies may be used for short durations before switching to oral regimens or may be used for the entirety of therapy. Factors to consider intravenous antibiotic selection include pathogen factors such as resistance profiles, host factors such as allergies, and drug factors including how difficult the selected agent would be to administer in the outpatient setting. Monitoring of prolonged intravenous therapy in the outpatient setting requires weekly monitoring of labs with specific labs required to monitor certain antibiotics. This narrative review assesses the appropriate duration, antimicrobial selection by pathogen, and monitoring parameters for intravenous antibiotic treatment of prosthetic joint infections. (Journal of Surgical Orthopaedic Advances 30(4):243–248, 2021)
Key words: outpatient parenteral antibiotic therapy (OPAT), intravenous antibiotic, prosthetic joint infection treatment, antibiotics
Debridement and Implant Retention for Acute Periprosthetic Knee Infection - Carl L. Herndon, MD and Keith A. Fehring, MD
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Periprosthetic joint infection (PJI) is a devastating complication of total joint arthroplasty. We reviewed the current data on DAIR procedures and two-stage exchange for periprosthetic knee infection. This case study illustrates successful treatment of an acute PJI using a debridement and implant retention (DAIR) technique with adjuvant intraosseous (IO) vancomycin. (Journal of Surgical Orthopaedic Advances 30(4):249–252, 2021)
Key words: periprosthetic joint infection, irrigation and debridement, intraosseous antibiotics
The Importance of Appropriate Incision Choice in Conversion Total Knee Arthroplasty - Omar A. Behery, MD MPH and Thomas K. Fehring, MD
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When faced with the necessity of surgery in a previously operated knee, pre-operative planning and understanding of the vascular anatomy to the front of the knee is essential. Blood flow to the anterior aspect of the knee comes from medial to lateral. Therefore, in the case of multiple previous knee incisions the most lateral incision should always be chosen to avoid skin necrosis. The concept of a safe distance between incisions is inappropriate, risks extensive skin necrosis, and should be abandoned. (Journal of Surgical Orthopaedic Advances 30(4):253–255, 2021)
Key words: knee skin incision, vascular supply, necrosis
The Use and Monitoring of Oral Antibiotics for Treatment of Prosthetic Joint Infections - Erin Barnes MD, MS; Courtney Russ-Friedman FNP-BC; Erika Ross PA-C; Ernesto Aranda MD; and Benjamin Whitt, MD
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Intravenous antibiotic therapy remains necessary for many patients with prosthetic joint infections. Intravenous therapies may be used for short durations before switching to oral regimens or may be used for the entirety of therapy. Factors to consider in intravenous antibiotic selection include pathogen factors such as resistance profiles, host factors such as allergies, and drug factors including how difficult the selected agent would be to administer in the outpatient setting. Monitoring of prolonged intravenous therapy in the outpatient setting requires weekly monitoring of labs with specific labs required to monitor certain antibiotics. This narrative review assesses the appropriate duration, antimicrobial selection by pathogen, and monitoring parameters for intravenous antibiotic treatment of prosthetic joint infections. (Journal of Surgical Orthopaedic Advances 30(4):256–262, 2021)
Key words: outpatient parenteral antibiotic therapy (OPAT), intravenous antibiotic, prosthetic joint infection treatment, antibiotics
The Perils of Open Wound Management in Prosthetic Joint Infection Treatment - Thomas K. Fehring, MD
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Wound breakdown following a total joint arthroplasty is a difficult problem to manage. Early aggressive debridement and closure is essential to prevent a subsequent prosthetic joint infection. Open management of a wound that communicates directly with the joint in the form of wet to dry dressings, iodoform packings, or a non-incisional wound vac should be avoided. Such treatment is inappropriate and leads to difficult to treat multi-organism infections and less than optimal results. (Journal of Surgical Orthopaedic Advances 30(4):263–264, 2021)
Key words: open wound management, prosthetic joint infection