Abstract
The treatment of orthopedic implant infections is often difficult and complex, although the chances of successful treatment with a properly selected diagnostic, surgical and antibiotic treatment protocol have recently increased significantly. Surgical treatment is a key factor in the treatment of infections of orthopedic implants, and any errors in this respect often lead to worse clinical outcomes.
Surgical errors. The most important and frequent surgical errors include:
-
- conservative treatment of periprosthetic infections with antibiotics alone: successful treatment requires adequate surgical procedure combined with long-term antimicrobial Th that is active against biofilm microorganism. Without adequate surgical procedure just the suppression of symptoms is usually achieved, rather than eradication of the infection.
-
- delayed surgical revision: in acute infections, early surgical intervention plays a critical role, especially by patients where retention of the prosthesis is expected. Early evacuation of postop haemathoma after primary or revision surgery is important in order to prevent the possibility of infection. It is important to take into consideration, that a postop apparently superficial surgical site infection may be indicative of deeper infection involoving the implant.
-
- insufficient debridement during surgical revision: thorough and extensive debridement is the most critical predictor of success (removal of the haemathoma, abscess formations, fibrous membranes, sinus tracts, devitalized bone and soft tissue, removal of all cement, cement restrictors, foreign and prosthetic material; eventual exchange of modular components and liners). Finally meticulous irrigation of the op region is obligatory.
-
- inadequate intraoperative sampling for bacteriological and histological analysis: tissue samples from the areas with the most florid inflammatory changes have to be taken and sent for bacteriological and histological examination (3–6 samples). Removed implants or parts of them have to be sent to sonication. Swab cultures have low sensitivity and should be avoided.
-
- the importance of selecting the appropriate surgical strategy for the individual patient cannot be overemphasized: not having, following and treating patients with PJI accordingly to an algorithm that is proven and successful one usually leads to unsuccessful clinical results.
We present illustrative cases with each common surcical error combined with proper solution.
Treatment of PJI is a demanding procedure, the goal is a long-term pain-free functional joint, that can be achieved by eradication of the infection. For a successful clinical outcome an appropriate diagnostic, surgical and antimicrobial procedure for the individual patient has to be selected.
