Specificities of total hip and knee arthroplasty revision for infection

Abstract

Hip or knee revision for infection requires careful planning of the debridement phase. Bacteriological sample management needs to be planned. Multidisciplinary decisions have to be taken as to 1- or 2-stage strategy, reconstruction technique and soft-tissue management. Surgical resection should be complete while economical. There must be no shortcomings in the technical procedure. Implant removal and surgical debridement are the keys to curing the infection, and planning is essential to optimize this phase. Bacteriological techniques are well codified. Wide-spectrum curative antibiotic therapy should be initiated immediately after intraoperative sampling and secondarily adapted to culture findings. A high-level microbiology laboratory is indispensable to good quality treatment. Prophylactic antibiotic therapy is controversial, but probably contributive. Two-stage exchange has not demonstrated superiority in curing infection. A 1-stage procedure may be preferred if all prerequisites are met. In the knee, any need for flap coverage should be planned for rather than encountered intraoperatively. The principles of reconstruction are unchanged by infection, but extended resection may require a larger revision implant. The temptation to oversimplify has to be resisted, and non-escalation or indeed "de-escalation" in implant size should be sought. Bone defect management is unaffected by infection. Fixation technique is at the surgeon's discretion. Pain relief and functional results are probably less good than after exchange without infectious context. The creation of regional complex bone and joint infection centers in France (CRIOACs) constitutes a considerable advance in periprosthetic infection management, and an opinion should be systematically requested; transfer is to be considered on a case-by-case basis.

Keywords: Hip arthroplasty; Infection; Knee arthroplasty; Prosthesis exchange.