S To Take Before Surgery
In the weeks before surgery, see your dentist to check for cavities or other problems that need attention. This is because an infection from your mouth, or anywhere else in your body, can go to your knee.
Before your knee surgery, the following steps can help prevent infections:
- Antibiotics. Your healthcare team will usually give you antibiotics in the hour before surgery, and then at 24 hour intervals afterwards.
- Testing for and reducing nasal bacteria. There is some evidence that testing for Staphylococcus bacteria in the nasal passages, and using intranasal antibacterial ointment before surgery, could reduce infections.
- Washing with chlorohexidine. Some evidence says that washing with cloths soaked in chlorhexidine in the days leading up to surgery could help prevent infection. Brands include Betasept and Hibiclens.
- Avoid shaving. Opt not to shave your legs before surgery as this can increase the bacterial load.
The surgeon may recommend rescheduling your surgery if there are any changes in your medical condition, cuts or scratches on the skin, signs of a urinary tract infection, or symptoms of a cold.
Inadequate Number Of Periprosthetic Tissue Samples For Bacterial Culture
The most commonly used intra-operative diagnostic method is tissue sampling for culture. The IDSA recommends submitting at least three and optimally five or six periprosthetic intra-operative tissue samples for aerobic and anaerobic culture . Peel et al. found that five or more tissue samples did not improve diagnostic accuracy, and recommended using three samples of periprosthetic tissue in blood culture bottles or four samples in conventional culture .
Fig. 2
Sensitivity, specificity, and accuracy of diagnosis of PJI with two or more samples using conventional culture methods
Errors In The Selection Of Antibiotic Treatment
Antibiotic treatment should be based on the type of microorganism, drug susceptibility, and the type of surgery performed . Not all antibiotics are equally active against sessile bacteria embedded in biofilm and ciprofloxacin for gram-negative rods), and these should be reserved for the period after implantation of the definitive implant . In two-stage exchanges, we do not recommend using the antibiotics in the prosthesis-free interval but rather initiate them once the prosthesis has been re-implanted. In one-stage exchanges and infections treated with DAIR, biofilm-active therapy should be initiated post-operatively as soon as the wounds are dry and drains removed . Another error is prescribing oral antibiotics with bad bone penetration and poor oral bioavailability, resulting in insufficient local concentrations at the site of infection . Furthermore, single-drug regimens such as rifampin monotherapy should be avoided in order to minimize the risk of selecting drug-resistant micro-organisms .
Table 3 Targeted antibiotic therapy regimens
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Joint Infection After Hip Replacement Is Linked To Some Risk Factors That Could Be Modified
This is a plain English summary of an original research article
Ten years of National Joint Registry data show that many factors may increase the risk of joint infection following hip replacement. Less than 1 in 1,000 people on average needed revision surgery for infection per year.
Several modifiable patient factors increased risk, such as obesity and diabetes. Using ceramic components, and approaching surgery from the back rather than the side of the hip, may slightly reduce infection risk.
This NIHR-funded study analysed registry data for 623,253 hip replacement procedures carried out in England and Wales from 2003 to 2013. The study provides useful quantification of the risk of revision surgery due to infection.
The study highlights some modifiable risk factors that might be addressed preoperatively, such as weight loss, and could support decision-making between clinicians and patients.
Loosening Of The Joint
This happens in up to 5 in 100 hip replacements. It can cause pain and a feeling that the joint is unstable.
Joint loosening can be caused by the shaft of the implant becoming loose in the hollow of the thigh bone , or due to thinning of the bone around the implant.
It can happen at any time, but it usually happens 10 to 15 years after the original surgery was done.
Another operation may be necessary, although this cannot be done in all patients.
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The Initial Stage Staged Surgery
- Total removal of the implant
- Washout of the soft tissues and the area surrounding joint
- Placement of an antibiotic spacer
- IV antibiotics
An antibiotic spacer is a type of medical device that is put in place to aid with the proper alignment of the joint and to maintain normal joint space. Treatment of infection also provides comfort and mobility to the patient.
Also, spacers are loaded with antibiotics and made with bone cement. The antibiotics will be able to flow into the surrounding tissues and joint helping the body to eliminate the entire infection. Patients who choose to undergo a staged surgery will generally need a minimum of six full weeks, possibly longer, of oral or IV intravenous antibiotics and the duration of therapy. Infectious disease professionals will team up with the orthopedic surgeons and will work closely to determine which treatment route is best as well as which antibiotics each individual patient will be on. Antibiotics will be either oral or IV .
Revision total knee replacement components
The image shows modular total knee replacement components used in revision surgery in the case of an infected primary knee replacement. The modular components allow the surgeon to make intra-operative changes to achieve maximum stability and function.
Revision total hip modular femoral component
The modular femoral stem shown in the image above may be used in revision hip replacement for an infected primary hip replacement.
Complications Of Total Hip Replacement
As with all major surgical procedures, complications can occur. The most common complications following hip replacement are:
- Thrombophlebitis
- Dislocation of the joint
- Loosening of the joint
This is not intended to be a complete list of the possible complications, but these are the most common. Pneumonia can also result from anesthesia if you dont do breathing exercises after surgery. Here are more tips on recovery after surgery.
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S To Take After Surgery
After surgery, the following steps can help reduce the chances of infection:
- Follow your surgeons guidance on how to take care of your incision.
- Treat any cuts, wounds, burns, or scrapes as soon as they happen. Clean with an antiseptic product and then cover it with a clean bandage.
- Keep up with preventive dental health and dont delay in seeing your dentist. Your dentist or orthopedic surgeon may want you to take antibiotics about an hour before any dental procedures to reduce your chance of infection.
See your doctor if you think you might be developing any kind of infection after total knee replacement, including urinary tract infections, ingrown toenails, and skin infections.
How Long Will A Replacement Hip Last
Wear and tear through everyday use means your replacement hip might not last forever. Some people will need further surgery.
According to the National Joint Registry , only 7 in 100 hip replacements may need further surgery after 13 years. However, this depends on the type of implant and how it was fixed in place.
Most hip replacements last much longer than 13 years.
Find more information on how long hip implants last from the NJR website.
Page last reviewed: 23 December 2019 Next review due: 23 December 2022
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What Is The Best Way To Treat Infected Hip Replacements
- Date:
- University of Bristol
- Summary:
- New research has found treating an infected hip replacement in a single stage procedure may be as effective or better than the widely used two-stage procedure. Hip replacement is a very common operation that is effective at providing pain relief and improving mobility, however, infection can sometimes occur following joint replacement.
New research has found treating an infected hip replacement in a single stage procedure may be as effective or better than the widely used two-stage procedure. To date no well-designed study has compared these procedures head-to-head to decide if one is better or if they achieve the same results. Hip replacement is a very common operation that is effective at providing pain relief and improving mobility, however, infection can sometimes occur following joint replacement. The findings have wide implications for orthopaedic surgery, the NHS, and health systems worldwide.
The research team, led by the University of Bristol, conducted a study that reviewed patient data from 44 studies to compare the effectiveness of the two types of surgery currently used to treat infections — one-stage and two-stage revisions.
The study found that the one-stage revision strategy is as good, if not better, as the two-stage strategy. The one-stage strategy may also be better suited for patients with certain types of infection or problems that were previously thought not to be appropriate for this type of surgery.
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Errors During Retrieval Of Diagnostic Samples
Several pitfalls during tissue sampling can increase the risk of false-positive or false-negative results. First, tissue samples should be obtained using sharp dissection, avoiding the use of electrocautery in order to limit false-positive results due to thermal artifacts in histopathologic analysis . Second, samples should be retrieved from the areas where signs of infection are more pronounced and from different areas of the surgical field . Third, surgical instruments should be changed for each tissue sample to avoid a risk of cross-contamination between samples, which could impact culture results . Fourth, sonication of the removed implants in polyethylene bags increases the risk of microbial contamination leading to a false-positive result . Finally, when transferring synovial fluid into an EDTA tube, thorough immediate hand mixing is necessary to avoid coagulation of the sample, as this would influence the synovial WBC .
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Overdependence On Diagnostic Criteria
All guidelines on PJI should be considered auxiliary tools for physicians diagnosing infection a few cases of PJI may be missed, or cases of aseptic loosening may be mistakenly diagnosed as PJI, as the sensitivity and specificity of the diagnostic criteria proposed by scientific societies do not reach 100%, and the percentage of patients diagnosed with PJI within a patient cohort varies considerably depending on the diagnostic criteria used .
Fig. 3
Percentage of patients diagnosed with periprosthetic joint infection using the diagnostic criteria proposed by different scientific societies criteria, IDSA criteria, and the proposed European Bone and Joint Infection Society criteria. Data extracted from references
Implications For Clinicians And Policymakers
On the basis of our findings, we suggest that healthcare professionals focus on optimising education and supportive care strategies to enable earlier recognition of signs and symptoms of infection. An increased vigilance for recent arthroplasty patients and more consideration of their concerns should be encouraged. Patients expressed a requirement for more supportive interventions both during revision treatment , and in the longer term as the impact of PJI can persist long after surgical treatment. We recommend future research focuses on designing and evaluating improved care strategies for people with PJI. We are also conducting further research to explore decision-making and preferences for type of revision treatment.
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What Does Current Guidance Say On This Issue
NICE guidance on total hip replacement for end-stage arthritis notes that infection is one of several causes of surgical revision, which can be more complex and carry greater risks than primary hip replacement. NICE does not recommend a specific choice of prosthesis, aside from advising that the expected revision rate should be less than 5% at 10 years. They also warn that metal-on-metal replacements may be associated with soft tissue damage.
NICE osteoarthritis guidelines state that Patient-specific factors should not be barriers to referral for joint surgery. They state that risks and benefits of surgery should be communicated.
Arthroscopic Lavage For Treatment Of Pji
Arthroscopic lavage of an infected prosthetic joint does not allow access to all parts of the joint, particularly the posterior part of the knee joint and the polyethylene liner backside in knee as well as other joints. In addition, it does not allow for exchange of mobile parts, reflecting insufficient debridement as mentioned above . In prosthetic hip joints, debridement is insufficient without dislocation of the femoral head, which is difficult to perform without arthrotomy. Byren et al. observed four times higher failure rate following arthroscopic lavage than standard DAIR surgery. Hyman et al. described favorable results in a series of eight patients with late acute hip PJIsall patients were, however, managed with chronic antibiotic suppression in addition to arthroscopic lavage. Arthroscopy has a limited role in the diagnostic workup of a painful prosthesis, allowing for inspection of the components in search of instability and wear, exclusion of non-infectious causes, visualization of the synovium, and retrieval of samples for microbiology and histology in selected cases . Importantly, arthroscopy is an invasive intervention, which is associated with a small risk of infection therefore, the indication for diagnostic arthroscopy should be considered carefully.
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Insufficient Debridement Or Incomplete Exchange Of Implants
A common reason for treatment failure is inadequate debridement. All diseased or devitalized tissue and bone should be removed during surgery. This includes old scar tissue, sinus tracts, osteolytic regions, sequestra, and any devitalized tissue until bleeding margins are obtained. In infections with mature biofilm, all foreign material including cerclages and bone cement should be rigorously removed. Although some series have documented partial exchange of implants with acceptable results, particularly in cases in which a prosthetic component is so well-fixed that its removal could result in significant bone loss and compromise of fixation at the time of the later prosthesis reimplantation and the causative organisms are not multidrug-resistant, in immunocompetent patients without sinus tracts, this option should be the exception rather than the norm , and surgeons should be aware that this could compromise treatment success.
Hip Or Knee Replacements Infection Statistics
Infection is a rare, but serious complication after total joint replacement surgery. It occurs in one to three percent of patients nationally though, our most recent review of infection data at the University of Utah Center for Hip and Knee Reconstruction showed an infection rate better than the national average at 0.5 percent .
Sampling Recruitment And Consent
To reduce recall bias, we only approached patients who had received revision treatment up to 12months previously. Lists of patients attending outpatient clinics were reviewed by a member of the clinical care team. This team member then examined referral and follow-up letters to identify patients who had received one-stage or two-stage revision treatment for infection after hip arthroplasty in the previous 12months. Potential participants were sent information packs, and asked to complete and return a reply form to the research team if they were interested in taking part. The researcher then contacted potential participants and arranged to visit them to discuss the study and to conduct an interview if they agreed to take part. Immediately before interview, potential participants had the opportunity to ask questions about the study before providing their written consent to participate, including to audio-recording and publication of anonymised quotations. All interviews took place in patients homes, except one that took place on hospital premises.
Sample characteristics
Failure To Individualize Treatment
Table 1 Classification, characteristics, and treatment strategies of PJIFull size table
In patients too frail or too sick for surgery that have low functional demand or who reject surgical treatment, improvement of the patients quality of life should be the goal of treatment, with or without the use of antibiotics. The success rate of suppressive antimicrobial therapy has been reported to be between 23 and 83% . In a series of six patients in stable condition and with well-fixed prostheses treated expectantly withholding antibiotic therapy, Giacometti Ceroni et al. reported that 83.3% of patients were pain-free and without systemic symptoms after a mean follow-up of 6.7 years .
Diagnosis And Therapeutic Strategy
PHI diagnosis was based on the presence of one or more fistulae, which is a major criterion for periprosthetic joint infection diagnosis , and confirmed by the results of microbiological cultures of preoperative joint aspiration and/or intraoperative samples. For infection recurrence, the diagnosis was established through the same workup as the initial diagnosis.
The pathogen was considered causative of PHI when it was isolated from 2 different intraoperative specimen samples or joint fluid aspirates. The diagnosis and surgical strategy for all patients were validated during the weekly multidisciplinary consultation meeting, involving at least one orthopedic surgeon, one infectiologist, and one microbiologist.
At least 2 weeks after discontinuing any ongoing antibiotic therapy, preoperative aspiration of the joint fluid was done in the Department of Radiology under fluoroscopic guidance and strict sterile conditions. In addition, two joint washing-aspirations with the saline solution were performed. Specimens were intended for the determination of differential white blood cell counts and microbial identification.
Joint aspiration was completed with media contrast injection to view the fistula pathway via arthrography.
One-stage exchange arthroplasty was the surgical technique adopted in this series. It involved the excision of the old scar and the fistula pathway through the former incision or a new one to permit a double approach.
Treatment Of Joint Infection
Treatment is easy when caught early to a superficial infection or infections just affecting the soft tissues of the joint or the skin but not yet has deep down into the artificial joint itself. Treatments include oral antibiotics or intravenous antibiotics both routes have a high success rate. For an infection that gains a deeper access into the body and hits the joint itself, more times than not, require beyond the superficial tissues and gain deep access to the artificial joint almost always require surgical treatment.
Do Joint Replacements Put You At Risk For Infection And Sepsis
Most people who undergo joint replacements heal well, without any complications. However, any type of surgery does increase your risk of developing an infection, which can in turn cause sepsis.
Risks include developing pneumonia following surgery or contracting a healthcare-acquired infection during your stay in the hospital. As well, some people who undergo joint replacements may be older and/or have underlying disease conditions, such as diabetes or COPD, that may make them susceptible to infections.