Periprosthetic Joint Infection After Hip and Knee Arthroplasty: A Review for Emergency Care Providers

Abstract

Periprosthetic joint infection is among the most common modes of failure of a total hip or knee arthroplasty and can be a common concern when patients present to the emergency department for care. The initial evaluation for periprosthetic joint infection includes a history and physical examination, followed by radiographs (to rule out other causes of pain or failure) and then serum erythrocyte sedimentation rate and C-reactive protein testing. If the erythrocyte sedimentation rate and C-reactive protein level are elevated or if the clinical suspicion for infection is high, the joint should be aspirated and the fluid sent for culture, as well as for a synovial WBC count and differential, with optimal threshold values of 3,000 WBC/μL and 80% polymorphonuclear cells, respectively. Recent work has shown that optimal cutoff values for patients presenting in the early postoperative period (within the first 6 weeks postoperatively) are different, with a C-reactive protein level greater than or near 100 mg/L (normal <10 mg/L), indicating the need for aspiration, with synovial fluid WBC thresholds of 10,000 WBC/μL and 90% polymorphonuclear cells. Antibiotics should not be administered before joint aspiration unless the patient has systemic signs of sepsis because even a single dose may cloud the interpretation of subsequent tests, including cultures taken from the joint. Furthermore, superficial cultures taken from wound drainage are discouraged because they can similarly cloud diagnosis and treatment. The rising prevalence of total joint arthroplasty makes proficiency in the assessment and early management of periprosthetic joint infection important for the emergency physician to optimize clinical outcomes.

Evaluation and Management of Septic Arthritis and its Mimics in the Emergency Department

“…Additionally, anticoagulation is a relative contraindication, but should be weighed against the much higher risk associated with missing a case of septic arthritis 66. Prosthetic joints should be discussed with orthopedic surgery prior to aspiration 67. If unable to obtain fluid on the initial aspiration, several techniques may be used to increase the likelihood of success.…”

Sevoflurano tópico en infección superficial por SARM tras artroplastia de rodilla. Caso Clínico

“…13 Pero esa paciente fue tratada con ciprofloxacino y rifampicina porque era alérgica a penicilinas y el tratamiento fue inicialmente ambulatorio por vía oral. Esos antibióticos son una buena combinación en el tratamiento de las infecciones estafilocócicas, 5,7 que son los microorganismos más frecuentemente implicados. 13 En cuanto al tratamiento quirúrgico de las IPAs, se recomienda que se realice precozmente, incluso cuando el diagnóstico sólo es de sospecha.…”

“…2 Existen buenas tasas de éxito reportadas cuando el DAIR se realiza antes de las 4-6 semanas postoperatorias. 7,14 En nuestro caso, aunque finalmente no se intervino por los motivos ya explicados, sí se estableció la indicación quirúrgica porque estábamos en torno al mes postoperatorio o dos semanas desde el inicio de los síntomas, según se considere. En cuanto al sevoflurano, esa opción terapéutica es novedosa y merece ser comentada con más detalle.…”

Intraoperative chlorhexidine irrigation to prevent infection in total hip and knee arthroplasty

“…Despite our best efforts, PJI occurs in approximately 0.8%-1.9% of total knee arthroplasty (TKA) and 0.3%-1.7% of total hip arthroplasty (THA) [4] . PJI after TKA is the single leading cause of early revision, accounting for 25.4% of revisions within the first 2 years after surgery and 7.8% thereafter [5] . THA infections are the third leading cause of revision accounting for up to 14.8% of revision surgeries [4] , [5] .…”

“…PJI after TKA is the single leading cause of early revision, accounting for 25.4% of revisions within the first 2 years after surgery and 7.8% thereafter [5] . THA infections are the third leading cause of revision accounting for up to 14.8% of revision surgeries [4] , [5] . The demand for TKA and THA is projected to increase by 137% and 601%, respectively, from 2005 to 2030 [6] .…”