Infection remains the most dreaded complication affecting total joint arthroplasty patients. Infections may be superficial or deep. The usual flora in infected patients are Staphylococus or Streptococcus species, although cases with Pseudomonas and other hospital acquired pathogens have been reported.
Infection should be considered in any patient with a total joint arthroplasty presenting with acute onset pain in the setting of a previously painless functioning joint; or prolongation of the post-operative pain.
The factors associated with increased risk of infection include, skin disease at the operative site, immunosuppression due to systemic illness or prolonged steroid intake, diabetes mellitus, concomitant urinary tract infection, previous surgery in the same region, and inflammatory arthritis.
The use of filtered vertical laminar flow operating rooms, body exhaust suits, proper operation theatre discipline and prophylactic antibiotics (three doses of 1st generation Cephalosporin (Cefazolin / Cefuroxime) starting one hour before surgery with the remaining two doses given within 24 hrs post surgery) have greatly reduced the incidence of infection.
Early evidence of infection can be substantiated by elevated levels of C- reactive protein (CRP).
Early infection (less than 3 months post surgery) is treated with a extensive surgical debridement and the implant is retained, if found well fixed. Implant if found loose is removed, and a two stage revision surgery is planned.
Treatment of late onset infected arthroplasty depends on the duration, as well as the microbial flora involved. For chronic infections options include- implant removal followed by two stage revision arthroplasty, resection arthroplasty or arthrodesis.
In two stage revision arthroplasty, the first step consists of removal of all the implants, extensive debridement followed by antibiotic impregnated cement spacer. The second stage is carried out when there is no clinical and laboratory indication of active infection. The definitive components are inserted with antibiotic loaded bone cement.
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