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Prosthetic
joints are at risk of acute and chronic infection, which can cause
sepsis, morbidity, or mortality.
Etiology
Infections are more common in prosthetic joints. They are frequently caused by perioperative inoculations of bacteria into the joint or by postoperative bacteremia resulting from skin infection, pneumonia, dental procedures, invasive instrumentation, UTI, or possibly falls. They develop within 1 yr of surgery in 2⁄3 of cases. During the first few months after surgery, the causes are Staphylococcus aureus in 50% of cases, mixed flora in 35%, gram-negative organisms in 10%, and anaerobes in 5%.
Symptoms and Signs
There is a history of a fall within 2 wk of symptom onset in about 25% of patients and of prior surgical revisions in about 20%. Some have had a postoperative wound infection that appeared to resolve, satisfactory postoperative recovery for many months, and then development of persistent joint pain at rest and on weight bearing. Symptoms and signs may include pain, swelling, and limited motion; temperature may be normal.
Diagnosis
The diagnosis often uses a combination of clinical, microbiologic, pathologic, and radiographic criteria. Communication between a sinus tract and the prosthesis may also be considered diagnostic of infection. Synovial fluid should be sampled for cell count and culture. X-rays may show loosening of the prosthesis or periosteal reaction but are not diagnostic. Technetium-99m bone scanning and indium-labeled WBC scanning are more sensitive than plain x-rays but may lack specificity in the immediate postoperative period. Ultimately, periprosthetic tissue collected at the time of surgery may be sent for culture and histologic analysis.
Treatment
Treatment must be prolonged and usually involves arthrotomy for prosthesis removal with meticulous debridement of all cement, abscesses, and devitalized tissues. Debridement is followed by immediate prosthesis revision or placement of an antibiotic-impregnated spacer and then delayed (2 to 4 mo) implantation of a new prosthesis using antibiotic-impregnated cement. Long-term systemic antibiotic therapy is used in either case; empiric therapy is initiated after intraoperative culture is done and usually combines coverage for methicillin-resistant gram-positive organisms (eg, vancomycin 1 g IV q 12 h) and aerobic gram-negative organisms (eg, piperacillin/tazobactam 3.375 g IV q 6 h or ceftazidime 2 g IV q 8 h) and is revised based on culture and sensitivity testing. Infection develops in 38% of new implants, whether replaced immediately or after delay.
If patients cannot tolerate surgery, long-term antibiotic therapy alone can be tried. Excision arthroplasty with or without fusion usually is reserved for patients with uncontrolled infection and insufficient bone stock.
Prevention
In the absence of other indications (eg, valvular heart disease), patients with prosthetic joints do not need prophylactic antibiotics before procedures such as dental work and urologic instrumentation. Detailed recommendations are available at www.aaos.org.
Last full review/revision February 2008 by Steven Schmitt, MD
Content last modified February 2008
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