Abstract
The infected joint arthroplasty continues to be a very challenging problem. Its management remains expensive, and places an increasing burden on health care systems. It also leads to a long and difficult course for the patient, and frequently a suboptimal functional outcome. The choice of a particular treatment program will be influenced by a number of factors. These include the acuteness or chronicity of the infection; the infecting organism(s), its antibiotic sensitivity profile and its ability to manufacture glycocalyx; the health of the patient; the fixation of the prosthesis; the available bone stock; and the particular philosophy and training of the surgeon. Although there have been multiple developments to enhance our ability to effect two-stage techniques whilst limiting inpatient stay, cost and patient morbidity - these include functional spacers, the use of local as well as systemic antibiotics, and home intravenous therapy programmes – there is nevertheless still a considerable morbidity and mortality to the two-stage process, and a massive cost to the patient who has to have two operations with an unpredictable interval period in between and to the local tissues which have already been damaged and are violated on two occasions. The push for one-stage surgery has generally been from centers who are passionate about that technique and has involved a combination of knowing the organism in question prior to surgery, a very radical debridement, the use of hinge / tumor-type implants and prolonged antibiotic therapy post-surgery. The last decade has seen an evolution whereby we have recognised that treatment may be tailored to the patient. There is a big difference between a relatively healthy host and someone with multiple comorbidities, and a big difference between infection with a relatively benign organism and polymicrobial infection with multi-resistant bacteria or fungi. There has, therefore, been increased interest in the use of single-stage revision in order to decrease morbidity, potentially decrease mortality and to decrease cost to the health care system. Single stage revision may have economic and functional advantages, however. We have devised a protocol that dictates the type of revision to be undertaken based on host, organism and local factors.
Whilst we believe that there is a role for both single- and two-stage techniques in our armamentarium, we have gradually evolved to increasing use of single-stage surgery. We use antibiotic-loaded cement whenever possible but can reconstruct most cases using semiconstrained implants without resorting to a hinge.
We continue to see a lower reinfection rate in these carefully selected patients, with high rates of infection control and satisfaction and better functional and quality of life scores than our two-stage revision cases. We use hinge reconstruction in less than 20% of cases.
