**6. Conclusion**

Prosthetic joint infections involve a complex interplay between the biofilm forming microorganisms, host responses and the implant. These infections are an uncommon but devastating complication of arthroplasty. However with given the ageing population the number of patients requiring arthroplasty is set to increase exponentially. Clinical investigation is imperative to increase understanding, improve diagnosis, optimise treatment and ultimately prevent prosthetic joint infections. While 2-stage exchanges remains the most reliable and consistent treatment option in terms of successful outcomes, the advent of more accurate diagnostic tools and combining the use of newer antibiotic agents with debridement and retention of the prosthetic joint should be considered a viable treatment option rather than an alternative. However this works best where a clear treatment protocol has been established, that targets patients at the earliest onset of symptoms, where debridement is aggressive and treatment involves is a combined approach between infectious Diseases Physicians and Orthopaedic Surgeons. Results at our institution attest to the success of such a protocol.

### **7. References**

428 Recent Advances in Arthroplasty

neither daptomycin nor linezolid had activity against adherent MRSA when used as monotherapy. When used in combination with rifampicin, daptomycin at a dose of 30mg/kg (corresponding to a dose of 6mg/kg in humans) cured 67% of cage infections. At this dose, no cases of rifampicin resistance emerged. Results were less encouraging for linezolid; even in combination with rifampicin, linezolid failed to cure any cage infection. Resistance to rifampicin emerged in 8% of cage infections treated with rifampicin-linezolid

For gram-negative infections, ciprofloxacin has been shown to be effective in guinea pig tissue cage models(Widmer, et al. 1991). In a study of 28 patients with bone and joint infections secondary to gram-negative bacilli combination therapy with cefepime and fluoroquinolone obtained a cure in 79% of patients. However only 5 patients in this cohort had a prosthetic joint infection, two were treated with debridement and retention and only one of which was cured (the second patient died from a cause unrelated to the infection)(Legout, et al. 2006). In prosthetic joint infection secondary to gram negative bacilli, debridement and retention has yielded a success rate as low as 27% (Hsieh, et al. 2009b). This contrasts with our results where by infection free survival at 2 years was 94% in gram-negative infections when fluoroquinolone was used in conjunction with debridement and retention (Aboltins, et al. 2011). Again this is in the setting of short duration of symptoms (median 7 days) and prolonged oral antibiotic treatment (median

The duration of antibiotic after debridement and retention varies in reported clinical studies ranging from six months to greater than 4 years. In a study by Laffer et al there was no difference in outcome in patients receiving three to six months of antibiotics compared with greater than six months (91% v 87% success). In this study patients were followed up for a median duration of 28 (range, 2–193) months and 55% of infections were caused by Staphylococcus species(Laffer, et al. 2006). In accordance with consensus guidelines, debridement and retention of the prosthetic joint should be considered in patients with a short duration of symptoms in the absence of implant loosening and soft tissue damage where antibiotics with biofilm activity are available (Laffer, et al. 2006, Matthews, et al. 2009,

Prosthetic joint infections involve a complex interplay between the biofilm forming microorganisms, host responses and the implant. These infections are an uncommon but devastating complication of arthroplasty. However with given the ageing population the number of patients requiring arthroplasty is set to increase exponentially. Clinical investigation is imperative to increase understanding, improve diagnosis, optimise treatment and ultimately prevent prosthetic joint infections. While 2-stage exchanges remains the most reliable and consistent treatment option in terms of successful outcomes, the advent of more accurate diagnostic tools and combining the use of newer antibiotic agents with debridement and retention of the prosthetic joint should be considered a viable treatment option rather than an alternative. However this works best where a clear treatment protocol has been established, that targets patients at the earliest onset of symptoms, where debridement is aggressive and treatment involves is a combined

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**6. Conclusion** 


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**20** 

*Germany* 

**Infections in Hip and Knee Arthroplasty:** 

Peter Schäfer1, Bernd Fink2, Dieter Sandow1 and Lars Frommelt3

Comprehensive algorithms have been devised to improve the management of periprosthetic joint infections of the hip and the knee (Gomez & Patel, 2011a, 2011b; Peel et al., 2011). There is still no single best method for diagnosis, as stressed for instance in a guideline published recently by the American Association of Orthopedic Surgeons (AAOS) (Della Valle et al., 2010). An important reason for this is lacking consensus on how to define arthroplasty infection accurately. Nevertheless, it is beyond dispute that microbiologic techniques play a

The chapter consists of three sections. Firstly, a general introduction to the special nature of arthroplasty infection is given, which highlights the necessity of reliable microbiological diagnostics. Secondly, a critical appraisal of the various technical and interpretive aspects of microbiologic procedures is featured. Thirdly, our own diagnostic approaches are

presented, and a prospect on probable useful developments in the future is offered.

**2. Identification of infected implants: The need for microbiological testing** 

Periprosthetic joint infections are a feared complication of hip and knee arthroplasty. Infection is supposed to be the underlying cause in about 15% of hip revision arthroplasties and 25% of knee revision arthroplasties (Bozic et al., 2009, 2010). Depending on the onset of infection after the primary implantation, periprosthetic infections have been defined as "early" (up to 3 months), "delayed" (3-24 months), and "late" (more than 24 months) after surgery (Zimmerli et al., 2004). However, a different classification makes more sense from the therapeutic point of view. According to this, infections which occur within 4 weeks after arthroplasty implantation are recognized as "early". These are most often caused by highly virulent organisms (e. g. *Staphylococcus aureus*) acquired during or shortly after implantation and can be treated with the prospect of survival of the implant. In contrast, infections which become manifest after more than 4 weeks ("late" infections) require removal of the

**1. Introduction** 

**2.1 Epidemiology** 

key role in assessment for these infections.

*2Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen, Kurt-Lindemann-Weg 10, Markgröningen, 3Institute for Infectiology, ENDO-Clinic Hamburg, Holstenstrasse 2, Hamburg* 

**Challenges to and Chances for the** 

*1MVZ Labor Ludwigsburg, Wernerstrasse 33, Ludwigsburg,* 

**Microbiological Laboratory** 

