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By Nathan Wei
Arthritis is the most common cause of disability in the United States.
With the aging of the Baby Boomer population, arthritis, particularly degenerative arthritis- also known as osteoarthritis- will be increasing in incidence.
It is estimated that currently, a minimum of 20 million American suffer from osteoarthritis. Conservative management of this condition includes non-steroidal anti-inflammatory drugs, (NSAIDS), exercise, thermal modalities (heat or ice), lifestyle modification such as weight loss, and injections of either glucocorticoids (steroids) or viscosupplements (lubricants).
More recently the use of platelet rich plasma and autologous stem cells (a patient’s own stem cells) appears promising.
Unfortunately, for patients that fail these modalities, surgery with joint replacement is one of the few options left.
Risk factors for infected joint replacements include the following: obesity, smoking, multiple surgical residents participating in the procedure, male gender, rheumatoid arthritis, and diabetes.
Obviously, lack of sterile technique can be a risk factor.
One of the most dreaded complications of this procedure is infection.
According to the latest National Healthcare Safety Network data (2006-2008), the rate of infection following knee replacement was 0.9% and the rate following hip replacement was 1.3% (Barnes CL. Am J of Orthop. 2011; 40: 2-5)
In 2007 Kurtz and colleagues reported that more than 600,000 combined knee and hip replacements were performed in the US each year. The number is projected to exceed 4 million by the year 2030 (Kurtz S, Ong, K, Lau E, et al. J BoneJoint Surg Am. 2007; 89: 780-785).
Infections following joint replacement can lengthen hospital stay by 2 weeks, double the readmission rate, and triple the costs (Whitehouse JD, Friedman, ND, Kirkland KB, et al. Infect Control Hosp Epidemiol. 2002; 23: 183-189)
So how is the diagnosis of this devastating complication made? Criteria established by the Musculoskeletal Infection Society Workshop appear to be the most definitive criteria (Parvizi J. Am J Orthop. 2011; 40: 614-615)
They include the following:
1. A sinus tract (meaning a channel leading from the infected joint replacement to the skin) or
2. A bacteria isolated from culture from 2 separate tissue samples, or
3. When 4 of the following 6 are present:
a. Elevated erythrocyte sedimentation rate – ESR- (sed rate) or C-reactive protein (CRP)
b. Elevated white blood cell count in joint fluid
c. Elevated neutrophil percentage. Neutrophils are the white blood cells most often present in an acute infection.
d. Purulence (pus)
e. Isolation of a bacteria in I culture of tissue or fluid
f. More than 5 neutrophils per high power field (under a microscope).
This complication is devastating since it can cause permanent disability as well as death. Other symptoms such as fevers, chills, unusual swelling and redness around the operative site, an excessive amount of pain, and an unusually high white blood cell count in the peripheral blood.
Also, one symptom that is rarely mentioned in the literature but which we commented on a lot as residents, is the “dwindles.” A patient who is just not doing well.
However, there is still no substitute for a positive set of cultures from the joint replacement site. Once these are obtained the likelihood of joint infection is almost 100 per cent.
About the Author: Nathan Wei, MD FACP FACR is a board-certified rheumatologist and nationally known arthritis authority and expert. For more info:
Arthritis Treatment
and
Arthritis Treatment Center
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