Understanding Joint Replacement Infections: Prevention, Symptoms, and Treatment

Symptoms:

The signs and symptoms of an infected joint replacement may include:

Increased pain or stiffness in a previously functional joint
Swelling around the joint
Warmth and redness near the surgical wound
Wound drainage, which may include blood, pus, or other fluids
Fever, chills, and night sweats
Fatigue or general malaise

Doctor Examination:

When a joint infection is suspected, early diagnosis and appropriate treatment are crucial for preserving the implant. During your visit, your doctor will review your medical history and perform a thorough physical examination.

Tests:

Imaging Tests: X-rays and bone scans can help determine whether an infection is present in the joint replacement implants.
Laboratory Tests: Certain blood tests can help identify the presence of infection. In addition to routine blood work, such as a complete blood count (CBC), your surgeon may order specific tests that measure inflammation in the body, including:
- C-reactive protein (CRP)
- Erythrocyte sedimentation rate (ESR)

Although these tests do not definitively confirm an infection, elevated CRP and/or ESR levels increase suspicion of an infection. If these values are within normal ranges, an infection is unlikely. Additionally, your doctor may sample fluid from your joint to detect signs of infection. This procedure involves using a needle to draw fluid from the hip or knee joint, which is then analyzed under a microscope for bacteria. The sample is also sent to a laboratory where it is cultured to identify bacterial or fungal growth. The fluid is also examined for the presence of white blood cells. In a healthy joint, the fluid contains a small number of white blood cells. A high number of white blood cells, particularly neutrophils, can indicate an infection. The fluid may also be tested for specific proteins that are commonly found in the presence of infection. Other diagnostic tools, such as Synovasure, may also be used to test the synovial fluid. This test detects a particular protein within the fluid that can help confirm the presence of an infection.

Treatment:

Nonsurgical Treatment:

In some cases, the infection may only affect the skin and soft tissues surrounding the joint, without spreading to the artificial joint itself. This type of infection is known as a "superficial infection." If detected early, your doctor may recommend intravenous (IV) or oral antibiotics. This approach is generally effective for treating early-stage superficial infections.

Surgical Treatment:

Infections that extend beyond the superficial tissues and reach the artificial joint typically require surgical intervention.

Debridement: For infections that are detected early (within several days of onset) or those that develop within weeks of the original surgery, a surgical washout may help eliminate the infection. This procedure, called debridement, involves removing all contaminated soft tissue and thoroughly cleaning the implant. Plastic liners or spacers may be replaced, and intravenous (IV) antibiotics are typically prescribed for about six weeks to help clear the infection.
Staged Surgery: If the infection has been present for a longer duration'especially in cases of late infections (those occurring months to years after the joint replacement)'staged surgery is usually necessary.

The first stage of this procedure includes:

Removal of the infected implant
Washout of the joint and surrounding tissues
Insertion of an antibiotic spacer
Administration of intravenous (IV) antibiotics

An antibiotic spacer is placed in the joint to maintain its normal alignment and function while simultaneously treating the infection. It also helps to reduce discomfort and enhance mobility during the treatment process.

(Top) These X-rays show an original knee replacement from the front and from the side.'(Bottom)'An antibiotic spacer has been placed in the joint during the first stage of treatment for joint replacement infection.

Spacers used in staged surgery are made from bone cement that is infused with antibiotics. These antibiotic-loaded spacers release medication into the joint and surrounding tissues, gradually helping to eliminate the infection over time. Patients undergoing staged surgery typically require at least 6 weeks of intravenous (IV) antibiotics, and sometimes longer, before a new artificial joint can be implanted. Orthopaedic surgeons collaborate closely with infectious disease specialists to guide the treatment process. These specialists are responsible for determining:

The specific antibiotics to be used
Whether the antibiotics will be delivered intravenously (through a tube inserted into the arm) or orally (taken by mouth)
The appropriate duration of the antibiotic therapy

Additionally, they will monitor the patient's progress through periodic blood tests to assess the effectiveness of the antibiotics. Once the orthopaedic surgeon and the infectious disease specialist confirm that the infection has been resolved'typically after at least 6 weeks of treatment'the patient will be considered for a new total hip or knee implant, a procedure known as revision surgery. This is the second stage of treatment for joint replacement infection. During revision surgery, the surgeon will:

Remove the antibiotic spacer
Perform another washout of the joint
Implant new total knee or hip components

An antibiotic spacer in a hip joint.

Single-Stage Surgery:

In single-stage surgery, the infected implants are removed, the joint is thoroughly washed out (debrided), and new implants are placed all in one procedure. Although single-stage surgery is less common than two-stage surgery, it is gaining recognition as a viable option for treating infected total joints. Ongoing research is evaluating the effectiveness and long-term outcomes of this approach.

Prevention:

Several measures are taken by your healthcare team during the original joint replacement surgery to minimize the risk of infection. Some of these methods have been scientifically proven to reduce the risk, while others are believed to help but have not yet been conclusively proven. The most important known strategies for preventing infection after a total joint replacement include:

Antibiotics before and after surgery: Antibiotics are administered within one hour before surgery (usually once in the operating room) and are continued at intervals for up to 24 hours following the procedure.
Short operating time and minimal operating room traffic: A shorter surgery time, achieved through the efficiency of the surgeon, helps lower infection risk by reducing the exposure time of the joint. Limiting the number of people entering and exiting the operating room is also believed to reduce the risk of infection.
Strict sterile techniques and sterilization of instruments: The operating site is meticulously sterilized, instruments are autoclaved (sterilized), and the implants are carefully packaged to ensure their sterility.
Preoperative nasal screening for bacterial colonization: Some evidence suggests that testing for bacteria, particularly Staphylococcus species, in the nasal passages several weeks before surgery may help prevent infections. In hospitals that perform this test, patients with Staphylococcus in their nasal passages are treated with an intranasal antibacterial ointment prior to surgery. Identifying the type of bacteria in the nasal passages can also guide the choice of antibiotics for the procedure.

Additionally, there are several steps you can take at home to further reduce your infection risk:

Preoperative chlorhexidine wash: Washing with chlorhexidine solution (often provided as soaked cloths) in the days leading up to surgery has been shown to help reduce infection risk. This is particularly useful for patients who carry antibiotic-resistant bacteria on their skin or in their nasal passages. Your surgeon will discuss this option with you.
Skin assessment: In the weeks leading up to your surgery, notify your doctor of any skin irritations, such as cuts, scratches, rashes, or bug bites, on the limb that will be operated on. Any break in the skin can provide a gateway for bacteria to enter the body and potentially cause an infection, which may lead to the cancellation of the procedure. On the day of surgery, perform a skin assessment, checking areas like the groin, underarms, behind the knees, and under the breasts. Report any abnormalities to your doctor.
Shaving the surgical area: Do not shave the surgery area yourself. If shaving is necessary, it will be done in the hospital setting to avoid any risk of infection.

Long-Term Infection Prevention:

If you have had a joint replacement, your surgeon may prescribe antibiotics before certain dental procedures to protect the implants from bacteria that may enter the bloodstream during dental work and potentially cause infection. The American Academy of Orthopaedic Surgeons (AAOS) has developed guidelines regarding the use of antibiotics before dental procedures. In general, most patients do not require antibiotics before dental work, as there is little evidence supporting their effectiveness in preventing infection. The AAOS continues to conduct research and develop guidelines to assist healthcare professionals in diagnosing and preventing surgical site infections and periprosthetic joint infections.

Understanding Joint Replacement Infections: Prevention, Symptoms, and Treatment

Description:

Cause:

Symptoms:

Doctor Examination:

Tests:

Treatment:

Nonsurgical Treatment:

Surgical Treatment:

Single-Stage Surgery:

Prevention:

Long-Term Infection Prevention:

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