The Infected Joint Arthroplasty. Introduction

It was a pleasure to invite members of the European Bone and Joint Infection Society to join with us for the afternoon meeting of the Specialist Societies Day during the EFORT event in Barcelona; Dr. Walenkamp, President of the Infection Society, introduced the programme.

It was decided that an appropriate topic would be to concentrate on some of the more difficult aspects of the bacteriology of which we are increasingly aware which present new problems in both prevention and management of the established infection.

My task was to preface the main presentation by Professor Peters’ the account of which is to be published in this Journal in full. The reader will appreciate his authority in the particular field of bacterial colonisation that relates to arthroplasty work. While the control and prevention of infection has improved enormously since the 1960’s when it actually threatened the large scale development of prosthetic arthroplasty, there is always a residual incidence that needs to be improved upon. That was the purpose of our Meeting. After his presentation, a number of specific questions were posed by Professor Hamblen and these are summarised below.

The prevention of infection depends upon skilled minimally traumatic surgery, the exclusion of contamination by perhaps clean air facilities and the administration of antibiotics. With regard to the latter, the use of antibiotic-loaded acrylic cement and the potential dangers of this is some circumstances is cogent to Professor Peters’ paper and is particularly thought-provoking. My current view is that there is no need for its use given clean air and systemic antibiotics for the primary arthroplasty in an otherwise uncompromised patient. For the revision arthroplasty or cases with a previous history of operative treatment, the disadvantages are outweighed and I will use it for the cemented arthroplasty. The one-stage exchange arthroplasty for established infection is a procedure to be used selectively and two happenings have had the effect of reducing drastically this procedure in Sheffield: the two-stage or delayed exchange has become more indicated because of the incidence of particularly resistant organisms (notably coagulase-negative cocci) and also the increased requirement for bone grafting. Quite apart from the dreadful loss of bone stock into which many patients in UK are allowed to drift, the survival of the cemented revision following infection, has a limited mechanical survival (25% of mine have failed (not necessarily sufficiently to require further surgery) at 13 years) this being because of the unsuitable bone bed for cement intrusion. One successful technique to improve fixation is by impaction grafting but this precludes the one stage exchange.

Particularly in Europe, there is an increasing range of techniques for revision arthroplasty both for infected an non-infected cases particularly utilising uncemented prostheses.

Nevertheless the basic problems of infection remain and as we improve, it becomes exponentially more difficult to improve further. The refinements brought to our attention by Professor Peters were especially valuable.