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Take her to the operating room urgently for debridement and polyethylene exchange
9%
305/3345
Prescribe oral antibiotics and follow up in clinic
1%
44/3345
Admit the patient for an explant and placement of an antibiotic cement spacer
78%
2617/3345
Aspirate the patient's knee and call her in a few days if cultures and studies are positive
294/3345
Offer a one-stage revision given the acuity of likely infection from her index procedure
40/3345
Select Answer to see Preferred Response
This patient has a prosthetic knee infection likely > 1 month given the history of drainage and open ulceration. A two-stage revision is recommended given the chronicity of infection. All prosthetic joint infections require surgical debridement if the patient is healthy enough for surgery, and replacement of the components is indicated if the infection chronic (> 4 wks from surgery or from onset of acute hematogenous spread). Chronic infections are thought to include bacterial invasion of the bone-prosthesis interface, and a simple I&D and polyethylene exchange is less likely to disrupt the biofilm. A two-stage revision with interval placement of an antibiotic-eluting spacer and treatment for osteomyelitis (6 wks IV antibiotics) is the gold standard for chronic infections in patients healthy enough to undergo multiple surgeries. Parvizi et al. reviewed the literature on diagnostic strategies for assessing periprosthetic joint infections and compared these data to a single large-volume institution's findings. Joint fluid aspirates with high cell counts and high percentage-neutrophils as well as positive FDG-PET scans have high sensitivities for diagnosing periprosthetic infections. While properly performed aspirates and intraoperative cultures have near perfect specificities (0.97, 1.0 respectively), they found a 10-14% false negative rate. They go on to describe their institutional diagnostic protocol defining numerical cutoffs based on predictive value thresholds. Koyonos et al. found through single-institution retrospective review that irrigation and debridement alone was an ineffective way to definitively treat periprosthetic joint infections for acute post-op infections (<4 wks from surgery 69% failure), acute delayed infections (>4 wks onset symptoms, 56% failure), and chronic infections (>4 wks symptoms, 72% failure). Figure A shows an open ulceration over a standard midline TKA incision. Incorrect Answers: Answers 1, 5: An isolated I&D or single-stage revision would not adequately treat the osteomyelitis and bone-prosthesis interface biofilm Answer 2: Her periprosthetic infection is best treated with surgical debridement and IV antibiotics Answer 4: While aspiration may yield important culture results, the clinical examination is indicative of a periprosthetic infection that will require a two-stage revision surgery
2.3
(10)
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