Infection of a total arthroplasty is a serious complication that typically requires complex treatment of the infection and frequently revision surgery. Charles Davis, III, M.D, Ph.D., Penn State Hershey Bone and Joint Institute, says, “Infection is highly suspected in any patient with a recent total joint arthroplasty, when the site continues to drain for more than seven days post-operatively, as well as in a patient with a long-standing arthroplasty that shows a pattern of recurrent drainage, or with a sudden onset of severe joint pain, swelling, redness, and heat.” As the chief of hip and knee joint arthroplasty, Davis sees many suspected cases of total joint arthroplasty infections. “Management of patients with infections is difficult for both the physician and the patient. Treating the infection, placement of a new device, and postoperative recovery may take six to twelve months.”
The heavy disease burden of this problem has led Davis and his team to launch an aggressive protocol aimed at prevention. An infectious disease specialist, Crystal Zalonis, D.O., has been central in planning and implementing all preventive and infection treatment efforts. We focus on preoperative, intraoperative, and postoperative measures to prevent infection. Perioperative preventive steps focus on optimizing blood glucose levels and reducing bacterial carriage. “One key to minimizing infection risk is maintaining tight blood glucose control. In diabetic patients, if preoperative hemoglobin A1c (HbA1c) is more than seven, we defer surgery for a time, until better glucose control is achieved. In the acute postoperative period, blood glucose levels are monitored for all total arthroplasty patients, diabetic and non-diabetic alike. Blood glucose levels are carefully managed for all patients after surgery,” explains Davis.
Preoperative interventions also aim to reduce carriage of methicillin-resistant s. aureus (MRSA) and other potentially harmful bacteria. “We obtain nasal swabs from all patients; those with MRSA are treated with mupirocin ointment. Patients also apply Hibiclens® wipes for two to three days prior to surgery to reduce dermal bacterial colonization.”
Should a patient present with an infected total arthroplasty, Davis recognizes the importance of specialized expertise, and a team approach.
“Our team spends many hours thinking about and managing hip and knee arthroplasty infections. Our clinic is unique in that (Dr.) Zalonis is a full-time member of our team. She sees patients in the clinic alongside the treating orthopaedist. We draw on her infectious disease expertise to direct clinical decisions regarding appropriate antibiotic treatments, addressing urgent problems, such as sepsis, and avoiding potential drug reactions linked to patient comorbidities. Our focus on infection as well as the extensive experience and expertise of our team allows us to provide high-quality sophisticated care to our patients with infection.”
Over the past four years, the arthroplasty team has met every six months to review patient outcomes. “The improvements we’ve seen in infection rates and revision outcomes are probably the net result of many small changes in our perioperative care routine, rather than due to any single intervention. We continuously evaluate the process, so that patients have successful outcomes,” notes Davis.
Charles M. Davis, III, M.D., Ph.D.
Associate professor, orthopaedics and rehabilitation
Chief, hip and knee joint arthroplasty
FELLOWSHIP: Adult reconstruction, Mayo Clinic, Rochester, Minnesota
RESIDENCY: Orthopaedic surgery, Mayo Clinic, Rochester, Minnesota
Ph.D: Vanderbilt University, Nashville, Tennessee
MEDICAL SCHOOL: Vanderbilt University School of Medicine, Nashville, Tennessee