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Management of infection at the site of a total knee arthroplasty.

While infection after total knee arthroplasty is a relatively infrequent complication (with a rate of 1% to 2%)1, it can be devastating in terms of patient morbidity and institutional expenses. It has been determined that the cost of treating an infection around a knee replacement results in an estimated net loss of approximately $15,000, and this loss may be doubled for a Medicare patient2,3. The drop in infection rates over the years secondary to improved prevention efforts4 is overshadowed by the dramatic increase in the number of joint replacements being done annually in North America. In an effort to optimize patient care and reduce the overall burden to the health-care system, physicians must continue to improve strategies for treating infection in the presence of prosthetic components. Such strategies should focus on establishing a rapid and accurate diagnosis and developing clear and effective treatment algorithms that yield favorable long-term results according to clearly defined criteria.

The clinical presentation of infection is a very important factor to consider both when the diagnosis is being made and when the appropriate treatment is being determined. Segawa et al.5 proposed a classification consisting of four clinical subgroups (Table I) based on clinical presentation, accounting for the severity of symptoms and the temporal relationship between the index procedure and the onset of infection. Type 1 is characterized by positive cultures after a revision procedure; Type 2, by an acute infection diagnosed within thirty days after an arthroplasty; Type 3, by an acute hematogenous infection in a patient with an otherwise well-functioning prosthesis; and Type 4, by a chronic or late indolent infection. The fundamentals of diagnosis in any of these clinical settings include a high index of suspicion combined with a thorough history and physical examination, plain radiographs, …