Treatment of the Infected Total Knee Arthroplasty
Infection after total knee arthroplasty represents perhaps the worst complication of this operation that a surgeon must treat. Only through identification of various risk factors and development of prophylactic regimens has the incidence of infection decr
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Treatment of the Infected Total Knee Arthroplasty Russell E. Windsor The Hospital for Special Surgery - New York
Infection after total knee arthroplasty represents perhaps the worst complication of this operation that a surgeon must treat. Only through identification of various risk factors and development of prophylactic regimens has the incidence of infection decreased. Successful treatment depends on a team approach, with cooperation of an orthopaedic surgeon, plastic surgeon, and an infectious disease specialist. Incidence of Infection
The incidence of infection after total knee replacement ranges from 1.1% to 12.4% (1, 2, 3, 4, 5). The Mayo Clinic reported a 1.2% incidence of infection out of 3,000 primary total knee replacements (6). Higher infection rates were reported with cemented linked hinges, such as the GUEPAR prosthesis (1). Patients with rheumatoid arthritis, who often are immunologically suppressed, have a greater infection risk (7). Wilson et al. (5) studied 4,171 total knee arthroplasties, 67 of which became infected. The risk of infection increased in men with rheumatoid arthritis, in patients with skin ulceration, and in patients having undergone prior knee operations. Skin infections were the most common source of infection (8). In addition, infection was associated with obesity, recurrent urinary tract infections, and oral corticosteroid use, although the correlation did not achieve statistical significance (9). Prevention of Infection
Tooth extraction causes a bacteremia, which may hematogenously seed a total knee replaceT. P. Sculco et al. (eds.), Knee Arthroplasty © Springer-Verlag/Wien 2001
ment (10) . Antibiotic prophylaxis in dental procedures is universally recommended, but is still debated. Prospective reports have shown the risk of hematogenous seeding of bacteria around prosthetic joints. Although antibiotic prophylaxis in dental procedures is universally recommended, it is still debated (11). However, the current standard of care in this regard is to protect the patient undergoing dental procedures with prophylactic antibiotics. Currently, it is recommended that during the first 2 years after surgery, patients receive antibiotic prophylaxis 1 hour before the dental manipulation. It is no longer recommended to repeat the dose 6 hours later, as was defined in the past. Although it is relatively safe to discontinue prophylaxis 2 years after total knee replacement for dental procedures, antibiotics are still recommended when other operations on the urinary tract or bowel are undertaken (12) . Patients with chronic renal insufficiency and neoplasm requiring chemotherapy are at risk for infection due to chronic neutropenia and , in some cases, compromised immunity. Diabetes mellitus may pose an increased risk of infection due to the increased risk of woundhealing problems. Superficial wound necrosis may at times communicate with the deeper tissues of the knee and lead to deep infection (13). Psoriatic ulcerations may be difficult to sterilize and it is generally recommended to avoid m
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