Evaluation and Management of Periprosthetic Joint Infection-an International, Multicenter Study

Abstract

Background: Controversies still exist regarding the optimal diagnostic and therapeutic strategies in patients with prosthetic joint infections (PJI).

Questions/purposes: How effective are preoperative and intraoperative cultures in isolating organisms and how do these culture results compare to one another? What are the results of surgical treatment of PJI in the hip and knee in an international, tertiary referral center cohort?

Patients and methods: One hundred sixteen patients (N = 59 hip PJI, N = 57 knee PJI) were recruited prospectively to registries at three international, tertiary referral centers between December 2008 to November 2011. Retrospective review of prospective registry data including demographics, microbiology results, and operative reports was performed.

Results: Preoperative synovial fluid aspiration yielded an organism in only 45.2% and 44.4% of cases, respectively, for knee and hip PJI. False-negative rates of preoperative aspiration relative to intraoperative culture were 56% and 46% in hip and knee PJI, respectively, with discordance rates of 25% and 21.4%, respectively. Rates of negative intraoperative cultures were 15% in hip PJI and 20.7% in knee PJI. Open debridement with prosthetic retention was the most common initial revision procedure performed (48.3% of hip PJI and 63.8% of knee PJI). This method of revision was successful in 41.3% of hip PJI and 59.4% of knee PJI. Initial failure rates for prosthetic revision was lower than debridement with prosthetic retention but remained substantial in both hip PJI (initial success of one-stage exchange 60% and two-stage exchange 70%) and knee PJI (initial success of one-stage exchange 80% and two-stage exchange 75%).

Conclusion: Diagnosis and treatment of PJI remains challenging with difficulty in isolating the offending organism and with high rates of prosthetic revision and initial treatment failures. Future advances in organism isolation and international standardization of treatment protocols may improve patient outcomes.

Keywords: prosthetic joint aspiration; prosthetic joint infection; single-stage revision arthroplasty; synovial fluid culture; two-stage revision arthroplasty.

Fig. 1

Flowchart depicting the initial treatment protocols followed in prosthetic joint infection of the hip and their failure rates in acute versus chronic infection. Subsequent procedures performed, overall rates of prosthetic retention, and ultimate infection status at final follow up of the patient are included.

Fig. 2

Flowchart depicting the initial treatment protocols followed in prosthetic joint infection of the knee and their failure rates in acute versus chronic infection. Subsequent procedures performed, overall rates of prosthetic retention, and ultimate infection status at final follow up of the patient are included.