PERIPROSTHETIC JOINT INFECTION IN PATIENTS WITH RHEUMATIC DISEASES: THE PROBLEMS OF DIAGNOSIS, PREVENTION, AND TREATMENT

Abstract

One of the most menacing complications of large joint total endoprosthesis (TE) in patients with rheumatic diseases (RD) is the development of periprosthetic infection (PI), progression of which may give rise not only to limb loss, but also death. At the same time, early diagnosis and adequate surgical care make it possible not only to arrest the infectious process, but also to preserve an implanted joint.Objective: to define criteria for the diagnosis, prevention, and treatment of PI after hip and knee joint (HJ and KJ) TE in patients with RD.Subjects and methods. In 2009 to 2013, 654 KJ and 549 HJ TE was performed in the V.A. Nasonova Research Instituteof Rheumatology performed KJ (n = 654) and HJ (n = 549) joint ERs.Results and discussion. PI developed in 12 (3.63%) and 8 (2.95%) patients after KJ and HJ ER, respectively. Early, delayed, and late PI was seen in 11, 6, and 3 patients, respectively. Eleven patients with early PI underwent joint revision/ debridement with preservation of an endoprosthesis and replacement of HJ endoprosthetic inserts and heads. The operations were completed with the collagen hemobiotics being left in the wound and its drainage. Systemic antibiotic therapy was used for 4–6 weeks. No recurrent infection was observed in 9 cases. Two patients underwentresurgery, by setting suction-irrigation systems. Nine patients with delayed or late PI had the following operations: A single-stage revision operation (the endoprosthesis was removed and a new one was implanted) was performed in two cases of stable endoprosthetic components and accurately verified low-virulent microorganisms susceptible to certain antibiotics. It was imperative to use cement with an antibiotic, collagen hemobiotics, and systemic antibiotic therapy for 6 weeks. The other 7 patients with unstable endoprosthetic components underwent two-stage revision: Stage 1, endoprosthetic removal and antibiotic-loaded spacer implantation; 6-12 weeks after postoperative wound healing, 6 patients underwent Stage 2, removal of the spacer and implantation of a new endoprosthesis. Following Stage 1, one female patient developed generalized infection and, because of her advanced age and comorbidities, underwent amputation followed by exoprosthetic replacement.Conclusion. The practical application of the current diagnostic criteria allowed to reveal early slowly progressive PI, perform early surgical treatment without endoprosthetic removal in 11 patients, and prevent recurrent infection in 81.8% of the patients. The described treatment policy for PI turned out to be effective and prevented recurrent infection in 70% of the patients during 1 to 5 years.

Keywords

• total endoprosthesis
• rheumatic diseases
• infection
• complications