How Should Antibiotics Be Used in Primary and Revision Hip and Knee Arthroplasty? An Introduction

Abstract

Joint arthroplasty is a highly successful surgical treatment for symptomatic arthritis of the hip and knee. Despite excellent pain relief and prosthesis survival of approximately 90% at 20 years, complications occur [[1]Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR)Hip, Knee & Shoulder Arthroplasty: 2021 Annual Report. AOA, Adelaide2021: 1-432https://aoanjrr.sahmri.com/annual-reports-2021Google Scholar]. Deep periprosthetic joint infection (PJI) is among the top 2 causes of failure around the world after primary and revision, hip and knee replacement at both short-term and long-term follow-up [1Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR)Hip, Knee & Shoulder Arthroplasty: 2021 Annual Report. AOA, Adelaide2021: 1-432https://aoanjrr.sahmri.com/annual-reports-2021Google Scholar, 2Meyer J.A. Zhu M. Cavadino A. Coleman B. Munro J.T. Young S.W. Infection and periprosthetic fracture are the leading causes of failure after aseptic revision total knee arthroplasty.Arch Orthop Trauma Surg. 2021; 141: 1373-1383Crossref PubMed Scopus (9) Google Scholar, 3Le D.H. Goodman S.B. Maloney W.J. Huddleston J.I. Current modes of failure in TKA: infection, instability, and stiffness predominate.Clin Orthop Relat Res. 2014; 472: 2197-2200Crossref PubMed Scopus (183) Google Scholar]. In distinction to many other problems, such as dislocation and polyethylene wear that can be directly influenced by improvements in surgical technique and prosthesis design, surgeons may find it more frustrating to reduce surgical site infections. It is important to remember that appropriate use of prophylactic antibiotics, introduced over 50 years ago, remains the single most effective intervention available [[4]Burke J.F. The effective period of preventive antibiotic action in experimental incisions and dermal lesions.Surgery. 1961; 50: 161-168PubMed Google Scholar]. In our well-intentioned pursuit of completely eliminating PJI we can sometimes fall victim to the more is better philosophy. Indeed, over the past few years we have seen the introduction of new delivery methods, dosing schedules, and adjunctive products that encourage us to expand our use of prophylactic antibiotics without conclusive evidence. Additionally, our own success has led us to implement change before results from level 1A studies are available. Although PJI remains a persistent concern, the absolute rate of PJI after hip and knee arthroplasty remains low. Consequently, proving the value of new interventions remains problematic due to the large number of patients and extended follow-up duration required for definitive studies [[5]Thompson K.M. Oldenburg W.A. Deschamps C. Rupp W.C. MD Smith C.D. Chasing zero: the drive to eliminate surgical site infections.Ann Surg. 2011; 254: 430-436Crossref PubMed Scopus (65) Google Scholar]. Furthermore, the distinctions among prophylactic, treatment, and suppressive use of antibiotics have become blurred at times. It is important to remember that overuse of antibiotics has potentially significant consequences including the emergence of antibiotic resistance at the individual and societal levels, and individual patient side effects that can have serious consequences, such as acute kidney injury and allergic reaction [[6]Kheir M.M. Dilley J.E. Ziemba-Davis M. Meneghini R.M. The AAHKS clinical research award: extended oral antibiotics prevent periprosthetic joint infection in high-risk cases: 3855 patients with 1-Year follow-up.J Arthroplasty. 2021; 36: S18-S25Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar]. In this series of papers, drawn from presentations from the AAHKS Annual Meeting Symposium: Antibiotic Use in Primary and Revision Total Hip and Knee Arthroplasty, we will discuss the most effective uses of antibiotics before, during, and after surgery in order to reduce deep PJI. Each paper, authored by an expert in the field, will summarize the published data and clinical guidelines pertinent to the topic and distill the information to pragmatic advice that is ready for use in your practice. Download .docx (.02 MB) Help with docx files Conflict of Interest Statement for Clarke