Early prosthetic joint infection after primary total joint arthroplasty:risk factors and treatment strategies

Total knee and hip arthroplasty are highly successful surgical treatments for advanced osteoarthritis, although approximately 1-2% of these patients develops a prosthetic joint infection (PJI). To prevent the devastating effects of PJI, the studies in this thesis focused on patients at risk for PJI and factors that influence the outcome of PJI treatment. Although prolonged wound leakage is an important risk factor for PJI, there are no evidence-based guidelines on this topic. Our literature review showed that only few papers are available on prolonged wound leakage, which causes a wide variation in the diagnosis and treatment of prolonged leakage, as confirmed by our survey. Currently we are conducting a nationwide study to compare the efficacy of surgical and non-surgical treatment for prolonged wound leakage. Obese patients and oncology patients are also at increased risk for PJI. A literature review showed that there is a lack of evidence on oncologic PJI. Furthermore, we showed that PJIs in obese patients are caused by bacteria that are not covered by prophylactic antibiotics. Therefore, preventive strategies should be improved for obese patients. Regarding PJI treatment we showed that the outcome can be predicted by using the KLIC score. Furthermore, we found that applying local antibiotics in the joint cavity is associated with worse outcome and its use should therefore be discouraged. Finally, we found that the time from total joint arthroplasty to surgical debridement does not predict outcome, by which surgical debridement can be performed up to three months after joint arthroplasty

Debridement, antibiotics and implant retention is a viable treatment option for early periprosthetic joint infection presenting more than four weeks after index arthroplasty

Background. The success of debridement, antibiotics, and implant retention (DAIR) in early periprosthetic joint infection (PJI) largely depends on the presence of a mature biofilm. At what time point DAIR should be disrecommended is unknown. This multicenter study evaluated the outcome of DAIR in relation to the time after index arthroplasty. Methods. We retrospectively evaluated PJIs occurring within 90 days after surgery and treated with DAIR. Patients with bacteremia, arthroscopic debridements, and a follow-up <1 year were excluded. Treatment failure was defined as (1) any further surgical procedure related to infection; (2) PJI-related death; or (3) use of long-term suppressive antibiotics. Results. We included 769 patients. Treatment failure occurred in 294 patients (38%) and was similar between time intervals from index arthroplasty to DAIR: The failure rate for Week 1-2 was 42% (95/226), the rate for Week 3-4 was 38% (143/378), the rate for Week 5-6 was 29% (29/100), and the rate for Week 7-12 was 42% (27/65). An exchange of modular components was performed to a lesser extent in the early post-surgical course compared with the late course (41% vs 63%, respectively; P < .001). The causative microorganisms, comorbidities, and durations of symptoms were comparable between time intervals. Conclusions. DAIR is a viable option in patients with early PJI presenting more than 4 weeks after index surgery, as long as DAIR is performed within at least 1 week after the onset of symptoms and modular components can be exchanged

LEAK study:design of a nationwide randomised controlled trial to find the best way to treat wound leakage after primary hip and knee arthroplasty

INTRODUCTION: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are highly successful treatment modalities for advanced osteoarthritis. However, prolonged wound leakage after arthroplasty is linked to prosthetic joint infection (PJI), which is a potentially devastating complication. On the one hand, wound leakage is reported as a risk factor for PJI with a leaking wound acting as a porte d'entrée for micro-organisms. On the other hand, prolonged wound leakage can be a symptom of PJI. Literature addressing prolonged wound leakage is scarce, contradictory and of poor methodological quality. Hence, treatment of prolonged wound leakage varies considerably with both non-surgical and surgical treatment modalities. There is a definite need for evidence concerning the best way to treat prolonged wound leakage after joint arthroplasty. METHODS AND ANALYSIS: A prospective nationwide randomised controlled trial will be conducted in 35 hospitals in the Netherlands. The goal is to include 388 patients with persistent wound leakage 9-10 days after THA or TKA. These patients will be randomly allocated to non-surgical treatment (pressure bandages, (bed) rest and wound care) or surgical treatment (debridement, antibiotics and implant retention (DAIR)). DAIR will also be performed on all non-surgically treated patients with persistent wound leakage at day 16-17 after index surgery, regardless of amount of wound leakage, other clinical parameters or C reactive protein. Clinical data are entered into a web-based database. Patients are asked to fill in questionnaires about disease-specific outcomes, quality of life and cost effectiveness at 3, 6 and 12 months after surgery. Primary outcome is the number of revision surgeries due to infection within a year of arthroplasty. ETHICS AND DISSEMINATION: The Review Board of each participating hospital has approved the local feasibility. The results will be published in peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER: NTR5960;Pre-results

Arbeidsparticipatie na een totale knie- of heupprothese.

Background and purpose: An increasing amount of people undergoing total knee or hip arthroplasty surgery is still of working age at the time this procedure is performed. However, there is limited information in the literature about returning to work after arthroplasty surgery. Therefore, the purpose of this study was to get more insight into the influence of self-reported preoperative physical functioning on the period of time until return to work after total hip or knee arthroplasty surgery. Subjects and methods: A prospective multi-center cohort study is conducted at University Medical Center Groningen, Martini Hospital Groningen, Medical Center Leeuwarden and Röpcke-Zweers Hospital Hardenberg. In this sub study the data that have been collected before the 9th of April 2013 were used in the analyses. 81 patients scheduled for total knee or hip arthroplasty surgery filled in a questionnaire preoperative and postoperative after six weeks and three months. Self-reported physical functioning was measured with the WOMAC questionnaire. In addition, the period to return to work was asked for in the questionnaire. A multivariate cox-regression analysis was used to examine the predictive value of preoperative self-reported physical functioning as well as the change in self-reported physical functioning between preoperative and three months postoperative on the time to return to work. Age, gender, education level, comorbidity, depressive complaints and BMI were included as co-variables in the analyses. Results: Three months postoperative 63% of the patients undergoing surgery returned to work. The mean period of time until return to work was 58 days (standard deviation 25.06). The WOMAC-score (self-reported physical functioning) three months postoperative was on average 30.03 points (SD 21.17) higher in comparison with the preoperative score. Multivariate cox-regression analyses showed that preoperative self-reported physical functioning had no predictive value for the period of time until reintegration (hazard ratio 1.00, p=0.97), adjusted for BMI (0.96, p=0.16) and education level (HR 2.26, p<0.05). Improvement in self-reported physical functioning between preoperative and three months postoperative was significantly associated with a shorter period of time until return to work (HR 1.03, p<0.05). This association was adjusted for preoperative self-reported physical functioning (HR 1.02, p=0.06), BMI (HR 0.94, p<0.05) and education level (HR 2.01, p=0.09). Discussion and conclusion: 63% of the patients undergoing knee or hip arthroplasty surgery have returned to work after three months. It does not seem possible to use the preoperative self-reported physical functioning to predict the period of time until a patient will be able to return to work after surgery. However, improvement in self-reported physical functioning is significantly associated with a shorter period of time until return to work. More extensive research with more patients is necessary to confirm our findings.