As surgeons we tend to prioritize "eradication" of bacteria as the top priority in the management of our patient with an infected joint replacement.
Because the functional outcomes of revision arthroplasty are rarely perfect, it's tough knowing if the bugs are gone unless we do yet another operation and find that multiple tissue cultures are negative.
The patient, however may have a different priority: preserving function of their joint.
And the decision to use a single or two stage revision, recognizing the potential downsides of a spacer.
All of this is to support reasonable efforts to minimize the risk of PJI including optimization of health and nutrition, smoking cessation, and avoiding recent cortisone injections as stressed in this post and to consider the information in the slide below from a recent presentation on the topic.
I learned this lesson the hard way 25 years ago. One of my patients with rheumatoid arthritis of the elbow had a good functional result from a cemented total elbow arthroplasty. Unfortunately, she sustained a cat scratch on the ipsilateral forearm. This led to a sinus draining from her elbow that did not resolve with a washout and antibiotics. I convinced her that the best treatment of her infection would be complete component and cement removal. Her soft bone made this procedure difficult and resulted in fragmentation of her remaining bone.
While this procedure resolved her drainage, she had a virtually complete loss of function of her arm. She declined further surgery. She said she would have rather lived with the drainage than living with a flail elbow.
The authors of Successful Management of Periprosthetic Joint Infection Following Total Joint Arthroplasty, as Defined by the Patient have noted that the literature on the subjective experience of patients undergoing treatment for periprosthetic joint infection (PJI) following total joint arthroplasty (TJA) is scarce, and treatment success is defined without consideration of patient values.
They undertook a study to characterize the experience of 27 patients undergoing PJI management, to identify factors that patients associate with successful treatment and to assess alignment with a 2019 outcome-reporting tool (ORT) by the Musculoskeletal Infection Society (MSIS). Included patients had 1 to 5 year followup after their most recent revision surgery.
Patients participated in interviews that documented their experiences with primary TJA, PJI diagnosis and management, and patient perceptions of the success of their PJI management.
21 (78%) reported considerable mental health impacts during the period from PJI onset to treatment conclusion. In defining successful PJI management, patients consistently emphasized the importance of function, pain relief, mobility, and independence. Nine (33%) of the patients did not agree with their MSIS ORT classification of success versus failure.
Patients endorsed feelings of invalidation and a delay to diagnosis during PJI onset. They described a lack of understanding and preparedness for PJI, which contributed to negative emotions such as sadness, anger, and surprise at the time of PJI diagnosis. During the operative course and rehabilitation, patients struggled with physical limitations; this was especially noted among patients who underwent 2-stage revision. A common theme was the negative impact on patient mental health.
The authors of Successful Management of Periprosthetic Joint Infection Following Total Joint Arthroplasty, as Defined by the Patient have noted that the literature on the subjective experience of patients undergoing treatment for periprosthetic joint infection (PJI) following total joint arthroplasty (TJA) is scarce, and treatment success is defined without consideration of patient values.
They undertook a study to characterize the experience of 27 patients undergoing PJI management, to identify factors that patients associate with successful treatment and to assess alignment with a 2019 outcome-reporting tool (ORT) by the Musculoskeletal Infection Society (MSIS). Included patients had 1 to 5 year followup after their most recent revision surgery.
Patients participated in interviews that documented their experiences with primary TJA, PJI diagnosis and management, and patient perceptions of the success of their PJI management.
21 (78%) reported considerable mental health impacts during the period from PJI onset to treatment conclusion. In defining successful PJI management, patients consistently emphasized the importance of function, pain relief, mobility, and independence. Nine (33%) of the patients did not agree with their MSIS ORT classification of success versus failure.
Patients endorsed feelings of invalidation and a delay to diagnosis during PJI onset. They described a lack of understanding and preparedness for PJI, which contributed to negative emotions such as sadness, anger, and surprise at the time of PJI diagnosis. During the operative course and rehabilitation, patients struggled with physical limitations; this was especially noted among patients who underwent 2-stage revision. A common theme was the negative impact on patient mental health.
The authors concluded that success in treating PJI as defined by patients does not align with success as defined by clinicians. They advocate providing comprehensive support to patients throughout the PJI management process. They also encouraged improved patient education at the time of initial consent for arthroplasty surgery regarding the risk and clinical manifestations of PJI, allowing for earlier detection of symptoms and setting realistic expectations about the possible outcomes and the potential need for additional surgeries.
Finally, consideration of the patient's functional outcome from treatment for PJI plays into the surgeon's decision regarding how much bone integrity to risk in attempting to remove implants and cement at the time of revision of an infected arthroplasty.
And the decision to use a single or two stage revision, recognizing the potential downsides of a spacer.
All of this is to support reasonable efforts to minimize the risk of PJI including optimization of health and nutrition, smoking cessation, and avoiding recent cortisone injections as stressed in this post and to consider the information in the slide below from a recent presentation on the topic.
Infection is a risk with all surgeries, particularly ones in which implants are inserted - it merits our best efforts in prevention and thoughtful treatment.
Clear and Present Danger
Cooper's hawk waiting for prey in our backyard
June 2021
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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)
Shoulder rehabilitation exercises (see this link).