General Information

Infection after total joint surgery can be a serious occurrence. In our experience, and across the country, the risk of infection after total joint surgery is approximately 1/2% or less. This is equivalent to 1 case in 200 having an infection occur after surgery. In most cases, these infections can be cured. They may require the patient to be hospitalized longer, treated with antibiotics for a longer period, or perhaps even to undergo a second operative procedure.

Signs of A Possible Infection

The signs of a possible infection are:

• a temperature elevation (especially if prolonged)
• localized swelling, redness, or tenderness
• purulent (pus) drainage from the incision
• any change in color or odor of drainage from the incision

Prevention of Infection

When a patient is hospitalized for a total joint replacement, the prevention of infection begins in the operating room. Surgery itself is performed in a sterile environment in the operating room, with special air filters to help provide clean air that is free of most bacteria. In addition, patients receive antibiotics throughout their surgery via the IV line which is started upon admission to the surgical area.

During the hospitalization period, patients continue on their IV antibiotics for 24-48 hours as a preventive measure. In addition, careful examination of the incision, observation of any drainage, and monitoring of the patient's temperature are all preventive measure taken throughout hospitalization by the nurses and physicians caring for the patient.

At the time of discharge patients are given a list of discharge instructions which contains the signs of infection and whom to call if these signs become apparent.

Long range post-operative prevention of infection is maintained by total joint patients taking oral antibiotics prior to procedures which could possibly introduce bacteria into the bloodstream. Once a patient has undergone total joint surgery, he/she should always inform other physicians that they have a joint replacement.

Treatment of Infection

If a patient does develop an infection after total joint replacement surgery, it is either a superficial (localized) infection or a deep infection. Treatment for the infection will be based on several critieria. These criteria are:

• the type of organism causing the infection
• the organism's sensitivity to antibiotics
• the length of time of the infection
• the condition of the patient's bone

Once the diagnosis of the type of infection is made, treatment is done in one of the following ways:

• Antibiotic Therapy - Treatment for a superficial or localized infection consists of antibiotics given either by mouth or by IV. Treatment may be anywhere from 3 days to 1-2 weeks.
  
  
• Incision and Drainage - For more serious localized infections an I & D (incision and drainage), or "cleaning out" of the surgical area may be performed. This is a limited surgical procedure in which the wound is washed out and the patient is treated with antibiotics IV. In this procedure all of the original prosthetic components are retained.
  
  
• Direct Exchange - For a deep infection which has not advanced to the bone, the recommended treatment is to perform a "direct exchange." In this surgical procedure the total joint components are removed, the surgical area is cleaned, and new total joint components are inserted. These procedures are performed at the same time, and the patient is treated with IV antibiotics before, during, and after the surgery.
  
  
• Delayed Exchange - This treatment is performed for deep infections in which the bone is involved. In the first surgery, all total joint components are removed. The surgeon may then insert a temporary prosthesis which is a "spacer" made of cement and treated with antibiotics. This temporary prosthesis is left in place for a period of time (usually 6-8 weeks), during which the patient is also maintained on IV antibiotics. A second surgical procedure is then done in which the surgeon inserts new total joint components. This 2 stage treatment of infection will necessitate separate hospital admission for each surgical procedure.
  
  
• Fusion/Girdlestone - If a total joint replacement patient's infection cannot be eliminated or if the condition of the bone is too severe to allow for the exchange treatments discussed above, the patient and surgeon may decide that the preferred option is to remove all of the total joint components permanently. In the case of a total knee patient, the procedure to be performed is called a fusion, and in the case of a total hip replacement the surgery would be a girdlestone procedure. The goal in both procedures is to provide a stable, solid, infection-free lower extremity which will allow the patient to perform activities of daily living. However, neither procedure allows normal joint function. Comfort and reasonable activities are still possible. Surgical fusion of a knee or girdlestone procedure of the hip is performed in less than 10% of all infection cases after total joint surgery or 1 in 2,000 cases.

In Summary

As stated above, the occurrence of an infection after total joint surgery can be a serious event. Infection may occur immediately after total joint surgery, after the patient goes home, or even years later. For this reason if an infection develops in any part of a total joint replacement patient's body, this should be addressed. All total joint replacement patients are advised to consult their physician if they experience any signs of an infection. In addition, these patients are advised to make any physicians they may see aware that they have a total joint replacement. Careful follow-up of total joint patients and appropriate communication between the patient and their physicians are always the best measures in the prevention of infection.