Prosthetic Joint Infection PJI
“
PJI remains one of the most challenging and devastating cause
of implant failure following arthroplasty. A lot of efforts have
been done to define and plan for the intervention.
According to the Journal of arthroplasty, the estimated annual
cost for treatment of PJI for hips and knees in US {2002-2017}
”
is 326 Million and estimated to jump to 1.85 billion by 2030 ,
this because of the increased incidence of THA and TKA.*(1)
:Risk Factors
:Modifiable Risk factors •
Obesity and increase BMI -1 •
Immuosuppressant patients -2 •
SSI and SIRS 4- Smoking 5- Anaemia -3 •
Metabolic Syndromes 7- CKD and DM 8- Poor oral hygiene -6 •
Inflammatory arthropathies …..etc-9 •
:Non Modifiable factors •
Increasing age( more than 75 y)*(1,2) Male gender* (3) •
•
:Special Risk Factors
DMARDs: can be held for one or two therapy cycles prior surgery. Re initiation once the -1
.wound healed as general rule
Revision surgeries has higher infection rates incontrast to primaries*(8,9) -2
due to the prolong surgery time and abnormal tissue coverings
Prolong surgical time carry a risk of 9% increase in infection for each 15 minute increase in -3
surgical time.*(10)
Perioperative infections as chest infections and symptomatic UTI( asymptomatic pyuria or -4
bacteriuria does not appear to increase the risk to develop PJIs)*(11,12)
:Epidemiology
According to the National Library of Medicine the percentages of PJI is increased from 1.99 •
to 2.18% for hip arthroplasties and from 2.05 to 2.18% for knee arthroplasties in the period
from ( 2001- 2009) using Nationwide Inpatient Sample.*(4)
The percentage of shoulder and elbow arthroplasty that get infected is based on systemic •
reviews mainly. Shoulder PJI carry infection rates similar to those of hips and knees PJIs
with rates between 0.8% to 1.1% *(5,6). The rate of elbow PJIs is found to be 3.3% *(7).
The reason of increased elbow PJIs in contrast to those of the shoulder is due to the
increased numbers of patients with RA receiving elbow arthroplasty and the limited soft
.tissue coverings * (8)
:Prediction Scores
According to the National Library of Medicine 18 risk assessment tools for PJIs were •
reviewed and with exception of HPRO and KPRO which launched by National health care
safety, and show promises to be used in the clinical settings, non of the other tools can be
.considered to be usefull for using in clinical settings
Deficient data on whether there is a reliable tool for prediction of PJIs for shoulders, elbows •
.or Ankles
:Causative Micro-organisms
:In a 6 – year – study time from 2016-2022 the following organisms are commonly Isolated •
Co-agulase negative staph ( most common) -1 •
Staphylococcus aureus-2 •
Streptococcus species -3 •
Enterococcus species-4 •
G-ve Bacilli-5 •
Enterobacteria species-6 •
.This order is from the commonest to less common •
:Source of Infection
:Direct Invasion -1 •
From SSI, wound dehiscence , sinus tract to the joint capsule or extension from surrounding •
.soft tissue infection or osteomyelitis
:Haematogenous spread -2 •
.From long standing remote infections as chest infection, UTI or oral infections •
:Classifications
Time of onset ( Coventry et al): Widely acceptable -1 •
-:A) Acute •
Occurs within 3-6/52 or the first 90 days following joint replacement. Staph. Aureus is •
commonest cause. Infection not yet invade prosthesis Bone interface. Immature biofilm
:B) Chronic •
More than 90 days following implantation. Staph species are also the commonest isolated •
.organisms. Infection invaded prosthesis bone interface. Mature biofilm
:Modified PJI –TNM Classification-2
Is modified PJI –TNM classification clinically
?implementable
No Previous study assessed the therapeutic implementation and outcome for this •
.classification
Rupp and Trampuz were the first two to assess the therapeutic benefit of this classification •
and published their results in Pub Med in 2019 “ The Classification is generally appropriate
to differentiate between acute and chonic infections by distinguishing between
immature( acute) and matue ( chronic) biofilm formation. It also provides an objective tool
to estimate for the invasiveness of surgery, probability of reimplantation and mortality
during the first 12 months following surgery. However , because of its complexity and the
variety of subtypes, it would be helpful if simplification done for this classification to
”facilitate it’s implementation in clinical routine use
Mc Pherson Staging System-3
This classification system is currently recommended by the MSK infection society for •
.grading PJI
Despite that this classification was also advocated by the International Consensus group on •
Orthopaedic Infections and advised further development on it, a lot of studies question the
reliability of this system to predict patient outcome. But it is still widely used and
.continuously reported in current scientific literature
It assigns DAIR or first stage revision for stage I , II, while assigning 2 nd stage revision for •
stage III. By this it ignores the virulence of the organism and the possibility of re acute
infection. ( most common drawback in literature)
Tasukayama et al Clssification •
Pellegrini et al classification •
JS- BACH classification •
MSIS criteria for PJIs •
.…………Etc •
:Diagnosis
:The European Bone and Joint Infection Society ( EBJIS) -1 •
A) Infection unlikely ( All findings Negative) •
:B) Infection Likely if two or more of the following findings are present •
Radiological finding of loosening within the first 5 years of implantation * •
Previous wound healing Problems * History of recent fever or bacteraemia * •
Purulence around the prosthesis * CRP more than 10mg/L * •
Synovial fluid leukocyte greater than 1500 cell/ uL or PMN greater than 65% * •
ve Microbilological Culture for synovial fluid or single positive tissue culture + * •
More than one CFU/ml of any microorganism * •
Presence of five or more neutrophil in a single HPF * •
Posotive WBC Scintigraphy * •
:C) Infection Confirmed If any one of these is present •
Sinus tract with evidence of communication to the joint or visible proethesis * •
Synovial Leukocytic count greater than 3000* •
Synovial PMN greater than 80%* •
Synovial fluid +ve for Alpha defensing* •
Two or more positive samples with the same microorganism* •
Greater than 50 CFU/ml of any organism * •
Five or more neutrophils in five or more HPF* •
MANAGEMENT
The aim of management should focus on eradicating the infection and restoring the pain free •
function of the limb
At present , treatment stratigies for PJIs are based on progression of infectious process and •
operative involvement
Long term antibiotic suppression is an option if operative interventions are precluded or •
.failed
Management is Multidisciplinary teamwork involves infectious disease specialists, •
microbiologists , plastic surgeons and orthopaedic surgeons
Typically, DAIR is considered to be the treatment of choice in patients with short duration of •
symptoms which allows implant preservation , shorter hospital stay and less impairment of
joint function. It is suitable for early PJIs in those with good bone and soft tissue conditions.
:Several factors were identified to influence DAIR success rates
Sinus tract presence greatly reduce the rate of DAIR success and some scholars reported -1 •
.that sinus tract is absolute contra indication for DAIR(14)
CRP greater than 15-22mg/L (15,16), some studies greater than 100mg/L(17), the relation -2 •
.between CRP and DAIR failure is still to be investigated
Previously failed DAIR (18) . Higher failure rates following previously failed DAIR -3 •
Type of Microorganism. Three folds failure rates has been reported by Weston et al (19) in -4 •
DAIR done for staphylococcus infection incontrast to 84% success rates of DAIR done for
streptococcal infections reported by Ribera A et al and 79% success rate for G-ve organisms
(20)
Timming of surgery. Higher success rates were found in DAIR done in the early 13/52 -5 •
following surgery 78%- 83% by Grammatopoulos(21). 91% success rates reported by Sendi et
al if it is done in the first 21/7 (22) in contrast to lower success rates ( 60%) if it is done after 90
.days as reported by Jacobsen and Husted (23)
Post DAIR duration of Antibiotics: The Infectious Disease Society of America ( IDSA) -6 •
advises 2-6 weeks intravenous therapy followed by 3 months after hip surgeries and 6 months
after knee surgeries oral antibiotics depending on sensitivity. For Culture –ve PJIs Vanc or
combined rifampicin and ciprofloxacin has high success rates as reported by Sousa et al and
.Aboltins et al respectively
One stage revision possesses the higher advantages nowadays as it avoids multiple major •
invasive surgeries and prolong hospitalization seen in two stage. However it needs strict
:criteria
A) it needs healthy patients •
B) Healthy soft tissue coverage •
C) Minimal or Moderate bone loss •
D)The infective organism Identified •
.E) The antibiotic Sensitivity is identified •
The risk of recurrence of infection in one stage revision was found to range between 0- 11% in
.58 reviewed studies
Two Stage Revision is the * Gold Standard* for the management of PJIs , since it is advocated to provide •
effective infection eradication, although it is complex procedure which itself can result in bone and soft tissue
damage. It involves removal of implants +accurate and aggressive debridement + sampling for histological
and microbiological studies. Implant Sonication should also be done , however this requires special packaging
and should be planned a head of surgery. Once explantation done , new sterile drapes should immediately
applied. Cemented spacer containing antibiotic then applied. This followed by Interim period of antibiotic
.therapy depending on the sensitivity or in case of culture negative PJIs empiric therapy can be used
The interim period is still debatable however it should be at least between 2-6/52 or till clinical improvement •
is evident and the inflammatory marker ( CRP, ESR) normalizes ( still debatable). After that a period of
antibiotic holiday for 4/52 during which weekly check of inflammatory markers is carried out and once these
remain normal+ the patient is clinically well the decision of reimplantaion should be done immediately. But
(Till now there is insufficient evidence that ceasing antibiotics with normal inflammatory markers is a
confirmation of infection eradication and to time no reliable marker to prove eradication of infection at time of
implantation)
The optimal time for second stage is still debatable. Some authors as Hardley and Grossman recommended •
12/52 before definitive reconstruction. Others as Busato recommend several months to years. However
Aalirezaie et al, showed through his retrospective study that delaying of definitive reconstruction beyond
12/52 does not improve infection eradication rates, and also Vielgut et al showed that patients who treated
between 4-11/52 had greater success rates incontrast to those who treated before 4/52 or after 11/52
.repectively
Post two stage revision antibiotics can be used according to the guidelines of the Infectious Disease Society of
America ( IDSA). Interestingly a study that was published in the bone & joint journal and involved 105 patients
with PJIs , questioning the appropriate duration for antibiotics following 2 stage revision concluded that no great
difference between short course group( antibiotics used for 3/52) which provide infection control rates near to
long course group( antibiotics used for up to 3/12).It also advised furthure research to be done to investigate the
.duration of antibiotics post 2 stage revision in population with high virulence organisms causing PJIs
COMMON ERRORS 20
Delayed diagnosis: Infection should be ruled out in any patient with persistent wound leakage , painful joint and swollened warm limb rather than wait and see -1 •
.policy which will compromise DAIR success rates by giving time for bacteria to form mature biofilm
Use of swab samples: This should be avoided. Previous report showed low sensitivity of swab culture (53%-76%) and usually associated with misidentification of -2
causative organism. Moreover swaps from sinus tracts are misleading as they produce a false +ve polymicrobials from skin flora
Use of CRP and ESR to rule out infection: Normal levels do not exclude infection. Perez-Prieto et al found that 1/3 of PJIs has normal CRP and 2/3 of them has norml -3
.ESR. The MSIS,IDSA and ICM on orthopedic infections all underline that –ve test results do not exclude possibility of infection
Arthrocentesis to identify causative organism: Synovial fluid culture has been found to have low sensitivity and specifity and over reliance on it can lead to miss cases of -4
.PJIs. Moreover knowing the causative organism preop – or not- will not help to reduce reinfection rates
Misinterpreting macroscopic purulence as infection in presence of MOM bearings: MOM bearings , Hypersensitivity reactions and aseptic inflammation can also -5
produce pseudopurulence with joint pain,high CRP similar to infection
Inadequate periprosthetic tissue sampling: IDSA recommend at leaset 3 or optimal five or six, but Peel et al found that 5 or more samples did not improve diagnostic -6
.accuracy and recommended 3 samples in BCBS or four conventional tissue samples
Disregarding distant source of infection: It is the second most common cause for PJIs after peri-operative contamination and should be suspected if inflammatory -7
markers levels do not fall after PJIs treatment or if symptoms present acutely after prolong pain free period after intial implanatation. Common sites of primary are skin and
.soft tissues(15%), heart valves( 13%), urinar tract (12) oral cavity (11%) and GIT ( 7%)
Erros during retrieval of samples: samples should be obtained during sharp dissection avoiding the use of electrocautery to avoid false +ve results caused by thermal -8
artefact. Samples should be from different areas in the surgical field where signs of infection are more pronounced. Surgical equipment should be changed for each sample
harvested to avoid cross contamination. If synovial fluids is transferred in EDTA tube immediate hand mixing is necessary to avoid coagulation of sample that will
.influence synovial WBCS
Conservative treatment with antibiotics in early infection: it is common practice to prescribe antibiotics in case of fever, chills or wound drainage following -10 •
arthroplastic surgery, but antibiotic alone will not eradicate infection and the cornerstone is prompt surgery followed by antibiotics. Long term suppression therapy should
.be reserved for patients whom further surgical treatment is unadvisable
Antibiotic treatment prior to microbiological diagnosis: Antibiotics use before sampling compromise the diagnostic accuracy of synovial fluid culture and also of -11 •
perioperative tissue culture and it is the most important cause of culture –ve PJIs. If antibiotic is already in use and diagnostic sampling was planned, antibiotics should be
.withheld for 2/52 prior to sampling
Failure to individualize treatment -12 •
Arthroscopic lavage for treatment of PJIs: it does not allow access to all parts of the joint so it will not allow sufficient washing or sampling and it showed four times -13 •
.high failure rates in contrast to the standaed DAIR
Insufficient debridement: is a common reason for treatment failure. Old scars, sinuses, osteolytic region, sequestra and devitalized tissue all should removed until -14 •
bleeding margins are obtained
High pressure pulse lavage: it is commonly used in PJIs surgery. The success rate in treating orthopaedic implant related infection is similar when using high pressure -15 •
and low pressure pulse lavage ( 81.6% vs. 84.4%) respectively. Several in vitro studies have shown that pulse lavage may not be suitable for PJIs especially in case of
DAIR not only because pulse lavage is ineffective in removing biofilms from the implant surface but it can also propagate bacteria deep into soft tissues causing
.increased bacterial retention
Errors using ALBC spacers: ALBC spacers help to provide high dose of antibiotic+ acting like a filler of dead space preventing presence of void filling hematoma , -16 •
:increase joint stability and avoiding joint contracture. The antibiotic used should have the following characteristics
It needs to stay thermostable enough to keep effective (ii) should not interfere with the polymerization of cement )i( •
It has to be able to elute from the bone cement after hardening (iv) It has to be hydrosoluble to diffuse into surrounding tissues )iii( •
.It has to be in powder form as the liquid antibiotics decrease the mechanical strength of the cement )v( •
Antibiotic holiday: it is still debatable whether antibiotic holiday confirm eradication before reimplantation.The duration of -17 •
.the holiday itself is still debatable
•
Antibiotic selection: This paper do not recommend the use of antibiotics in prosthesis free interval but rather intiate them -18 •
after reimplanation.In one stage and DAIR ,antibiotics can be used once wound become dry and drains removed. Avoid
.prescribing antibiotics with poor oral bioavailability and poor bone penetration
Inadequate management of soft tissues: in complete closure of joint arthroplasty is associated with increased risk of -19 •
.infection, so plastic surgeons should be consulted promptly for adequate closure
Lack of specialized multidisciplinary team: Orthopaedic surgeon should not choose the antibiotic cocktail without -20 •
.consulting with the microbiologist and the infectious disease specialist
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Thank you
