Sukeik, MTS; (2017) Management of Periprosthetic Hip and Knee Joint Infections after Lower Limb Arthroplasty. Doctoral thesis , UCL (University College London).

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Abstract

INTRODUCTION: Infection after lower limb arthroplasty is a serious complication with significant consequences for both patients and healthcare systems. Management is often challenging and frequently leads to a suboptimal functional outcome. Revision surgery remains a very expensive procedure to the patient and healthcare systems and no matter how much progress in diagnostic and treatment methods are achieved, the cost and morbidity of infected cases suggest that preventative measurements are the single most important factor in managing this problem. On the other hand, tertiary referral centres with well established strategies for treatment of infections may improve the rates of eradicating infection and overall outcomes. Therefore, the hypothesis of this thesis was that preventative and management strategies undertaken will improve the outcome of infection control. Studies included focused on prevention of infection but also explored the strategies and novel approaches implemented at University College London Hospital to improve the outcome of eradicating infection after hip and knee arthroplasties. MATERIALS AND METHODS: A comprehensive review of the current literature was initially conducted. This was followed by a number of studies to investigate prevention and treatment strategies of periprosthetic hip and knee joint infections: a) A randomised controlled trial has been conducted to compare postoperative wound complications of triclosan impregnated sutures and conventional non-coated sutures in patients undergoing primary hip and knee arthroplasties. Triclosan has been shown to reduce bacterial adherence to sutures and to decrease microbial viability both in vitro and in animal models with a high safety profile. However, the majority of evidence comes from case series and trials in other surgical specialties. Hence, the aim of this study was to investigate whether triclosan coated sutures will reduce wound healing complications in hip and knee arthroplasty surgery. b) A meta-analysis of tranexamic acid effect on wound healing complications and infections after primary total hip arthroplasty has been conducted. The role of tranexamic acid in reducing blood loss and allogeneic blood transfusions has been previously investigated. However, taking into account that allogeneic blood transfusions have been linked to an increased rate of wound and systemic infections, I conducted this meta-analysis with the aim of investigating whether tranexamic acid will reduce wound healing complications including infections after primary hip arthroplasties which has not been previously studied. c) Late periprosthetic infections invariably lead to implant removal with a two stage revision strategy being the treatment of choice in most centres whereas early infections and acute haematogenous infections may be managed with implants retention and serial debridements. Accordingly, I have conducted the following studies to investigate the efficacy of strict strategies and novel approaches implemented over the last 10 years at University College London Hospital in treating PJIs: 1) Is Single-stage Revision According to a Strict Protocol Effective in Treatment of Chronic Total Knee Arthroplasty Infections? The aim was to determine infection control rates associated with the single-stage approach when applied in a highly selected group of patients and compare them with results of the two-stage procedure. 2) Periprosthetic Joint Infections after Total Hip Arthroplasty: The Ten Year Outcomes of an Algorithmic Approach. The aim was to present the strategy applied for treatment of various subgroups of periprosthetic joint infection at a centre of excellence and report the outcome of infection rates. RESULTS: Contrary to the evidence from other surgical specialties that triclosan coated sutures are effective in preventing periprosthetic joint infections, no such effect was seen in the randomised controlled trial conducted. In fact, triclosan coated sutures were associated with higher rates of wound complications (P=0.03). Tranexamic acid on the other hand, led to a 3% reduction in the risk of developing wound complications including infections compared to the control group (Risk difference -0.03, 95%, confidence interval CI -0.05 to -0.01, P-value 0.01). This protective effect of tranexamic acid against infections has not been previously reported in the literature. In a highly selected population, none of the 28 patients who underwent a single stage revision developed recurrence of infection whereas five out of 74 patients (7%) in the two-stage revision group developed reinfection. The results of single-stage revision in this retrospective study reflect the strict inclusion criteria, surgical technique and multi-disciplinary approach which were associated with high rates of eradicating infection. However, randomised controlled trials are necessary to confirm those results in comparison to other treatment modalities. The use of a strict strategy driven by an experienced multi-disciplinary team working simultaneously at a centre where infection is being dealt with on a regular basis has resulted in high rates of infection-free survival with 188 out of 204 patients (92%) achieving successful eradication of their infections and returning to their expected functional level with no evidence of recurrence or loosening, wearing away, or malpositioning on follow-up radiographs. This compares well with evidence from the literature confirming that centres of excellence only can achieve as high infection eradication rates as reported in this study. CONCLUSION: The results of the included studies suggest using tranexamic acid but not triclosan coated sutures in routine primary hip and knee arthroplasty surgery to reduce wound healing complications and infection. Treating periprosthetic joint infections requires a multi-disciplinary team approach working at a tertiary centre dealing with infections on a regular basis. Single-stage revision in acute and chronic joint infections is appealing and gaining the momentum but randomised controlled trials are necessary to confirm its efficacy against other treatment modalities.

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