Thromboprophylaxis and haematomas

This chapter discusses thromboprophylaxis and haematomas within periprosthetic joint infection. The issue of venous thromboembolism is important for all surgical patients and, as such, those undergoing arthroplasty must undergo a careful and accurate risk assessment. Prolonged surgery and delayed postoperative mobilization are risk factors and are common to most major joint arthroplasty. Use of prophylactic agents to prevent thrombosis must be balanced with the avoidance of haematoma formation as the latter contributes to a risk of prosthetic joint infection. Should deep vein thrombosis occur then swift methods of diagnosis and treatment must be in place.

Assessing risk of prosthetic joint infection

This chapter discusses assessing the risk of prosthetic joint infection (PJI) and includes discussion on high-risk patients (classified by age, skin colour, extracellular matrix, cellular turnover, diabetes, obesity, rheumatoid arthritis, previous periarticular fractures and skin disorders). The aim is to allow the practitioner to identify high-risk patient attributes that can be positively influenced such that the risk of PJI is reduced. There are some patients with more than one risk factor and, as such, every effort must be made to reduce each even if there is a marginal gain in each. Delaying elective surgery until the risks of PJI are reduced must be encouraged but must be balanced with alleviating patient symptoms.

Specific microbiology issues relating to prosthetic joint infection

This chapter discusses specific microbiology issues relating to prosthetic joint infection (PJI) and includes discussion on antibiotic prophylaxis (including elective joint replacement in the uninfected case), choice of ‘prophylaxis/treatment’ in the infected, or presumed, infected case, a suggested framework for a safe practice, antibiotic use in PJI in the age of resistance, background on rising antibiotic resistance, approach to one- and two-stage surgical management, outpatient antibiotic therapy and when to use it, monitoring/stopping rules, the particular problems of Pseudomonas and Candida in PJI, and myths and facts about what ‘immunosuppression’ actually means in practice (including MRSA), and a conclusion.

Pathways for established prosthetic joint infection

This chapter discusses pathways for established prosthetic joint infection (PJI) and includes discussion on management of acute infection, surgical management of acute infection (including arthroscopic debridement and implant retention strategies), formal revision surgery, and management of chronic low-grade infection (including management of low-grade infection, antibiotic suppression, and free flaps). The main emphasis of this chapter is to guide the team on what are safe and accepted treatments for patients with confirmed PJI. The most important decision is whether the underlying implant should be retained or replaced. The latter can be in a single or multiple stages.

Revision arthroplasty networks

This chapter discusses revision arthroplasty networks and includes discussion on the proposed model for revision networks, the proposed operating framework, and aims of the revision network. The risks of prosthetic joint infection are known to be higher when undertaking revisional arthroplasty. To reduce these risks the correct decisions must be made during the lead-up to the revisional surgery. The aim is to encourage centres to set up networks to allow discussion of all revisional cases in this forum. The result should be that all patients benefit from best practice.

Introduction

This chapter introduces the book and discusses the definition of periprosthetic joint infection, classification of surgical site infections, incidence of prosthetic joint infection (PJI) in total knee replacement, quantifying PJI, and the burden of PJI. The aims are to unify our understsanding of this condition, to bring into sharp focus the need for vigilance, and to raise the profile of this condition amongst allied specialties. Whilst remaining reatively low, the incidence of PJI is not zero. Prevention is far better for the patient, surgeon, and the National Health Service and must remain the goal of the operating surgeon.

Preoperative assessment

This chapter discusses preoperative assessment and includes discussion on assessing risk factors for prosthetic joint replacement, vascular issues for major joint replacement, what risk assessment for vascular complications should include, acute limb ischaemia, vascular injury, general cardiovascular considerations, pressure area ulceration, and amputation and rehabilitation. The importance of this aspect of patient care cannot be overstated. Pre-incision improvement in patient physiology to improve the chances of primary wound healing will reduce the chances of prosthetic joint infection.

Case histories

This chapter provides several typical cases encountered in patients who develop infection in prosthetic joints after surgery. Both the assessment and the definitive management are considered, as well as the microbiology profiles and the need for protracted antibiotics. The aim is that the decision-making process is enhanced. Although the treatment pathways are specific to those cases outlined, the surgical principles should remain constant for all cases. Comprehensive membrane resection remains a key event when surgically eradicating prosthetic joint infection (PJI). This act improves with experience. To improve outcomes for cases of PJI we encourage data collection within networks.

Considering safe patient pathways

This chapter discusses consideration of safe patient pathways. It includes discussion on skin necrosis, safe raising of fasciocutaneous flaps around the joints, tips and tricks to avoid iatrogenic skin necrosis, prosthetic joint infection negative-pressure dressings to reduce risk, and pathways for skin necrosis. The aim is to improve the safety and viability of the access incisions with the intention of enhancing primary healing of those incisions. This advice on tissue handling must be in addition to the holistic assessment of the patient as a ‘host’ for the arthroplasty implant.