Diagnosis And Treatment Of The Infected Joint Replacement

As the design and technique of Prosthetic Replacement of Joint improved since 1970's, the operation had been accepted by a lot of persons, and many patients benefited from it. However, the operation also brought complications, which effected the prognosis, and infection is the most disastrous one among them. The Infection after Prosthetic Replacement of Joint not only effected the patient's physiologic situation, but also worsened their psychological and economic state. And the diagnosis and treatment of the Infection after Prosthetic Replacement of Joint became a more troublesome problem that we had to face.According to some articles, the rate of infection after Prosthetic Replacement of Joint had fallen from 10% to 1%. While because the number of drug-resistance bacteria increased, some rare pathogenic bacteria appeared and the situation of the host changed, some of the infections were hard to control.The infection was a protecting membrane which was generated after bacteria adhered to the surface of prosthesis. The membrane was composed of glucoprotein, glycans and other materials in the local circumstance. If bacteria reached the surface of the prosthesis, the membrane generated and separated it from the normal tissue and antibiotic, and thus the bacteria grew and the inflammations got worsen.At present, the diagnose of the infection was based on the patient's symptoms and signs, laboratory examinations,imaging results, puncture and bacterial culture and frozen section. The means of the treatment were as follows: Antibiotic treatment without surgery, One-stage revision, Second-stage revision, Resection arthroplasty and Arthrodesis and so on.Something important about the diagnosis and treatment of the Infection after Prosthetic Replacement of Joint were found through summarizing and analyzing the cases, and would help and light a lamp in the road of diagnose of the infection, andalso gave some proposals of the treatment after comparing the ways of curing and their indications. The data of the correlated cases were as follows: 7 cases with the clinical diagnosis of Infection after Prosthetic Replacement of Joint. 2 patients'infections occurred among 7~10W after operation. The patients mainly manifested hyperpyrexia and joints pained, which action aggravated the pain and disordered the movement. The laboratory examinations showed that : WBC increased , ESR was more than 30mm/1h, and the CRP was more than 10mg/L, and the cell which got from the puncture was positive. 2 cases were late onset infection. The patients complained pains after movement. 1 had no sinus tract and 1 had sinus tract. 3 cases were advanced stage infection,2 cases were considered to be aseptic loosening, while during the revision turned out to be purulent liquid around the prosthesis and by means of the test through operation at last they got the right diagnosis—infection.another one had sinus tract.Methods and results of the treatment : (1) Antibiotic treatment without surgery. 5 patients received this, and 2 of them were cured and not reinfected. 3 patients'infections were not controlled and chose the other ways. This told us antibiotic treatment without surgery didn't work well,except for the acute cases. While considering it could lessen the load of patients'psychology and economy and get rid of the pain of operation, antibiotic treatment for 4~6W was recommended first for the acute cases according to the result of bacterial culture and antibiotic saitivity. (2) Debridement and prosthesis reservation: cut some inflammatory tissues, kept the prosthesis and gave systematic antibiotic treatment and local clysis. 1 worked of the 2 patients who received this treatment,another one had a sinus tract. As far as the times of clysis were concerned, 2~5times clysis per week were a great hit. Also this would get the local scar worse and if this treatment didn't control the infection, the scar made operation hard to go further. In the past,the indications of debridement and prosthesis reservation was recommended as follows: antibiotic saitivity showed many antibiotics worked , antibiotic treatment didn't work within6w and the patients couldn't afford an"big"operation and the course of disease was short. Prosthesis reservation made it hard to cut the inflammatory tissues out, therefore the rate of reinfection was high. But after the follow-up visit,we found that if the patient had no sinus tract,this treatment could be recommended. (3) One-stage revision: this was to remove the infected prosthesis and cleared the inflammatory tissue, cut the sinus tract out and at last put a new one.According to some reports if give sensitive antibiotic 3~6w before the revision, The healing rate can be higher than 84%. In the 7 objects ,2 received this One-stage revision, they recovered well and didn't have a fever, flare ,pains and sinus tract. The advantages :to operate one time ,recovering fast, shortening the time in hospital, lessening the load and also the reinfectional rate was lower then the 2 ways superior. The disadvantages : the reinfectional rate was higher than the Second-stage revision. Therefore if the infection is not very serious,this method can work well.On the other hand,if infection is serious,the doctor must follow the indications: it was: the pathogen is sensitive to some antibiotic ; the bacterium didn't produce . multiglycoprotein compound; the patients didn't have the predisposing factors of infections, such as: Rheumatoid arthritis, diabetes mellitus, couldn't afford a second surgery.(4)Second-stage revision:This is considered into the best method.Fitst, remove the infected prosthesis and cleared the inflammatory tissue, cut the sinus tract out.Then, some time should be taken before we exchange the new one. we have one case in which the patient reinfect after have the Second-stage revision twice.The patient must wait for at least 1 year before the revision,and the doctor must sure the WBC and CRP are nomal.By analysising the cases and following-up the patients,we can conclude that:①If the patient only had pains,but had no symptom of infection,and the library test result is negative,the doctor could never consider that there is no infection.In the revision,biopsy is absolutely necessary.②For the acute infected cases,antibiotic treatment without surgery should be used as a role.③For the patients who have nosinus tract, the method of debridement and prosthesis reservation can work well.④For the patient whose symptom is light,one-stage revision can work well.⑤The spacing time of second-stage revision should be longer than 1 year.Before implant the prosthesis ,WBC and CRP should be normal.