Abstract
The authors review the currently available treatments according to analysis of the literature. In the event of prosthetic infection, protocols available at the moment are: specific antibiotic therapy without débridement, débridement with conservation of the prosthesis, one-stage replacement of the prosthesis, débridement with definitive prosthesis removal, arthrodesis,amputation or disarticulation. The choice of the treatment must be based on the analysis of local and general factors: type of infection, clinical presentation, quality of soft tissues, prosthetic implant condition, pathogens involved, function of the knee extensor mechanisms and patient’s expectations and functional requirements.
We re-evaluated the literature reports. Antibiotic therapy in infected hip prostheses yielded a successful outcome in 64% of the cases. Arthrotomic débridement in total hip prostheses showed a successful outcome in a variable percentage from 74% to 14%; in contrast, arthroscopic débridement showed a successful outcome in 100% of cases. In total knee replacement the arthrotomic débridement showed a success rate of 32.6% and arthroscopic débridement 52.2%.
The mean percentage of success in replacement in one stage with antibiotic cement and preoperative antibiotic therapy was 82% in THA [1], and 71% in TKA [6]. The mean percentage of success in replacement in two stages with spacer cement and perioperative antibiotic therapy was more than 90% in THA and 91% in TKA. Prosthesis replacement in two stages showed the best rate of positive results. The antibiotic therapy was effective in all patients with positive cultures intraoperatively.
Arthrotomic or arthroscopic débridement is a valid procedure, but must be performed within 2 weeks from the appearance of the symptoms. Knee arthrodesis is preferable in the presence of pathogens resistant to antibiotics and is indicated in patients with high functional requirements. The Girdlestone arthroplasty is indicated in hip treatment when antibiotic-resistant pathogens are involved. Amputation and disarticulation are indicated only in patients with a poor survival prognosis.
The management of prosthetic infections represents a challenge to the entire multi-disciplinary team (i.e. specialists in microbiology, radiology, infectious diseases and orthopaedics) both in achieving a correct diagnosis (infection versus aseptic loosening) and in choosing an adequate therapeutic strategy.
