PERIPROSTHETIC JOINT INFECTION and treatment options

this powerpoint discuss periporsthetic joint infections. the pathogenesis, clinical features, investigations and treatment options including single stage and two stage procedures

1. PERIPROSTHETIC JOINT INFECTION: DIAGNOSIS AND MANAGMENT Kwasi Twumasi-Baah Jnr

2. OUTLINE INTRODUCTION PATHOPHYSIOLOGY CLASSIFICATION RISK FACTORS DIAGNOSIS TREATMENT COMPLICATION

3. INTRODUCTION It one of the most devastating and costly complications following total joint arthroplasty (TJA). Periprosthetic joint infection (PJI) occurs in 1% in primary hip arthroplasties and between 1% and 2% for primary knee arthroplasties. PJI occurs in 4% of revision arthroplasties Significant morbidity and mortality associated with periprosthetic joint infection (PJI) Dale H, Hallan G, Hallan G, Espehaug B, Havelin LI, Engesaeter LB. Increasing risk of revision due to deep infection after hip arthroplasty. Acta Orthop 2009; 80: 639–45. Kurtz SM, Ong KL, Lau E, Bozic KJ, Berry D, Parvizi J. Prosthetic joint infection risk after TKA in the Medicare population. Clin Orthop Relat Res 2010; 468: 52–56

4. INTRODUCTION Infections accounted for 14.8% of revisions after hip arthroplasty and were the most common revision cause after knee arthroplasty (25.2%) Due to higher life expentancy , lifestyle changes in increasing elderly populations and more expectations for mobility in older age, the number of implanted prosthetic joints continue to rise. Longer prosthesis indwelling time is associated with a higher cumulative risk for haematogenous infections during the entire implant lifetime

5. DIAGNOSIS XRAY – Periosteal reaction Scattered patches of osteolysis Generalized bone resorption without implant wear Transcortical sinus tracts Implant loosening

6. CRITERIA FOR PJI

7. Diagnosis- Intra-operative frozen section valuable tool in diagnosing PJI during revision surgery. Offers a rapid assessment of tissue samples to guide surgical decisions. Sensitivity of 85% and specificity of 90% to 95% 5PMN/ hpf - 10PMN/ hpf probably indicates an infection. Limitations Prior antibiotic use Patients with inflammatory arthropathies Subjective Intra and inter-observer variability among pathologists.

8. TREATMENT Articulating antibiotic spacers may benefit patients in the treatment of infected TKA with two-stage revision. Compared to static spacers, articulating spacers showed superior range of motion, SF-12 PCS, WOMAC function, and KSS scores at 5 years postoperatively. Vasarhelyi E, Static vs Articulating Spacers for Two-Stage Revision Total Knee Arthroplasty: Minimum Five-Year Review. Arthroplast Today. 2022 Jan 20;13:171-175 Early reimplantation within 2 weeks has 35% success rate Delayed reimplantation >6 weeks has a 70-90% success rate Cementless reimplantation in the hip has better outcomes than cemented

9. TREATMENT – RESECTION ARTHROPLASTY indications Poor bone and soft tissue quality Recurrent infections with multi-drug resistant organisms Medically unfit for multiple surgeries Failure of multiple previous reimplantations Elderly nonambulatory patients Total knee success rate is 50% to 89% Total hip success rate is 60% to 100%

10. TREATMENT - ARTHRODESIS indications reimplantation is not feasible due to poor bone stock 71% to 95% success rate with bony fusion and infection eradication

11. TREATMENT - AMPUTATION Indications Total knee infections recalcitrant to other options Severe pain, soft tissue compromise, severe bone loss, or vascular damaged

12. FUTURE Pathogen-specific markers in synovial fluid such as D-Lactate (product of bacterial fermentation), are being currently tested for early and quick detection of PJI Biofilm detection techniques like FISH and DNA microarray are being developed to identify pathogens within biofilms. Molecular techniques is also being used to identify specific bacterial DNA in culture-negative PJI

13. CONCLUSION Currently, two-stage exchange arthroplasty serves as the gold-standard method for clearance of chronic infection, whereas the more conservative procedure of one-stage exchange is garnering renewed interest in certain subsets of patients.