Treatment
����The ultimate decision regarding surgical management should be
made by the orthopedic surgeon with appropriate consultation (eg,
Infectious Diseases, Plastic Surgery etc.) as necessary (C-III).
����Consider for debridement and retention of prosthesis patients
diagnosed with a PJI who have a well-fixed prosthesis without a
sinus tract and who are within approximately 30 days of prosthesis
implantation or less than 3 weeks of onset of infectious symptoms
(Figures 2-4) (A-II).
Patients who do not meet these criteria but for whom alternative surgical strategies
are unacceptable or high risk may also be considered for debridement and retention,
but relapse of infection is more likely (B-III).
Two-stage Exchange
����A two-stage exchange strategy is commonly used in the US and is
indicated in patients:
������ who are not candidates for a one-stage exchange
������ who are medically able to undergo multiple surgeries and
������ in whom the surgeon believes reimplantation arthroplasty is possible, based on the
existing soft tissue and bone defects (Figures 2-4) (B-III).
����Obtain a pre-revision sedimentation rate and CRP to assess the
success of treatment prior to reimplantation (C-III).
In selected circumstances more than one two-stage exchange can be successful if the
first attempt fails (C-III).
One-stage Exchange
����A one stage or direct exchange strategy for the treatment of PJI
is not commonly performed in the US but may be considered in
patients with a total hip arthroplasty (THA) infection who have a good
soft tissue envelope, provided that the identity of the pathogens is
known preoperatively and they are susceptible to antimicrobials with
excellent oral bioavailability.
There may be a greater risk of failure if bone-grafting is required and effective
antibiotic-impregnated bone cement cannot be utilized (Figures 2-4) (C-III).
Permanent Resection
����Permanent resection arthroplasty may be considered:
������ in nonambulatory patients
������ patients with limited bone stock
������ poor soft tissue coverage
������ infections due to highly resistant organisms for which there is limited medical
therapy
������ patients with a medical condition precluding multiple major surgeries
������ patients who have failed a previous two stage exchange in which the risk of
recurrent infection after another staged exchange is deemed unacceptable
(Figures 2-4) (B-III).
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