Approach to managing arthroplasty device infections

An arthroplasty device is a prosthetic device used for total or partial replacement of a joint. Arthroplasty device infections (prosthetic joint infections) are associated with significant morbidity. Infection may occur at any time after placement of an arthroplasty device—always consider the possibility of an arthroplasty device infection in a patient with an arthroplasty device in place and symptoms and signs involving the joint or surrounding skin and soft tissue (eg warmth, erythema, pain, swelling, joint effusion, sinus). Cellulitis and wound infection are common misdiagnoses for arthroplasty device infections.

If an arthroplasty device infection is suspected, urgently refer the patient to the surgeon who implanted the joint for assessment. Initiation of antibiotics before appropriate investigations are undertaken may compromise the diagnosis and treatment of an arthroplasty device infection. Unless the patient has symptoms or signs of sepsis or septic shock, do not start antibiotics while awaiting urgent review. Use of digital technology (eg sending a photo of the affected joint to the surgeon) should be encouraged to expedite referral. If urgent review by the surgeon who placed the joint is not possible, refer the patient to a tertiary centre.

Sepsis or septic shock is rarely associated with arthroplasty device infections. In patients with symptoms or signs of sepsis or septic shock, rapid implementation of sepsis care, including prompt administration of antibiotics, is vital to optimise survival—see Empirical therapy for arthroplasty device infection in patients with symptoms or signs of sepsis or septic shock.

Cure of arthroplasty device infections usually requires extensive surgical debridement, with or without removal of the prosthesis, followed by prolonged antibiotic therapy. Optimising investigations for arthroplasty device infections is critical to confirm the diagnosis and increase microbiological yield to direct prolonged antibiotic therapy. Early multidisciplinary input, involving both a surgeon experienced in arthroplasty and an infectious diseases physician or clinical microbiologist, is essential to guide investigations and management of arthroplasty device infections.

The choice of orthopaedic surgical strategy for arthroplasty device infections depends on several factors, including the classification of the infection, whether the prosthesis is loose and the patient’s circumstances. The most commonly employed orthopaedic surgical strategies are exchange arthroplasty and debridement and implant retention (DAIR), both of which have curative intent. The duration of antibiotic therapy varies with different orthopaedic surgical strategies.

In selected cases where the joint cannot be salvaged, excision of the arthroplasty device or amputation may be required for cure of infection.

Patients who are not fit for surgery with curative intent, or in whom extensive revision surgery is not technically feasible, may be considered for treatment with long-term suppressive antibiotic therapy.