Infection is the most serious complication after arthroplasty, with an incidence of 0.5% to 1% after initial hip replacement and 1% to 2% after initial knee replacement. Once it occurs, if it is not controlled in time, it often causes joint pain and even wasting or amputation, which is a catastrophic complication that brings great physical pain and high medical costs to patients, and is a difficult challenge for orthopaedic surgeons’ skills. 4 cases (hip 4 cases) in other hospitals, and the clinical efficacy of the treatment was satisfactory, as reported below.
1. Materials and methods
1.1 Case data
There were 13 cases in this group, 9 males and 4 females, aged 57-77 years old. There were 9 cases of artificial total hip arthroplasty and 4 cases of artificial total knee surface replacement. Primary diseases: aseptic necrosis of the femoral head in 8 cases, femoral neck fracture in 1 case, rheumatoid arthritis of the knee in 3 cases, and osteoarthritis of the knee in 1 case. Time of infection onset: 10-23 d postoperatively. Referring to the modified Tsukayama staging of periprosthetic hip infection, all cases were type IB (i.e. early postoperative deep infection).
Clinical manifestations: all 13 cases had fever (temperature >38.5℃), local pain or deep pressure pain and swelling in the incision, and redness of the incision in 11 cases. Deep puncture: yellow thin pus was extracted in 4 cases, and light yellow thin pus was extracted in 9 cases. Bacterial culture results of the puncture fluid: Staphylococcus aureus in 4 cases, Staphylococcus epidermidis in 3 cases, Staphylococcus wolfram in 2 cases and Escherichia coli in 2 cases, and no bacterial growth in 2 cases. The WBC, ESR and CRP examination of the patients were all elevated to different degrees.
1.2 Treatment method
①Once the incisional infection was confirmed, local puncture was performed immediately and the puncture fluid was sent for culture and drug sensitivity test.
(2) At the same time, norethindrone vancomycin 0.8g was given immediately as an intravenous drip, and then replaced by sensitive antibiotics after the results of drug sensitivity test. All cases were treated with oral rifampicin capsules 0.6g for 8 weeks.
The pus and necrotic tissues were thoroughly removed, and the non-important tissues that were difficult to determine whether there was inactivation were decisively excised until the blood supply was good, without replacing the polyethylene lining or spacer, and were treated with “hydrogen peroxide – saline – saline”. Iodine volt – saline” repeatedly 3 times, the last time iodine volt soaked 15-30min, then put 0.8g of local vancomycin, place 1 flushing tube and 1~2 drainage tubes, suture the incision, test flushing to detect whether the flushing drainage is unobstructed and whether there is water leakage from the incision.
④Postoperatively, it was given (saline 500ml + gentamicin 8U) x 10 bottles/d continuous flushing, and the irrigation was kept under appropriate pressure with iodophor 20-40ml twice a day for 30 minutes for 11-14 d. After stopping flushing, negative pressure drainage was applied for 24-48 h.
⑤ Drainage fluid was taken for bacterial culture on the 7th, 9th and 11th d of flushing. 500 ml of pure saline was used to flush the specimen before taking it, and it was kept for 30 min before taking it in order to increase the probability of positivity.
2. Results
All the patients’ early infections were controlled, and after 7-10 d, they began to have no fever, pain relief, and good local incision healing, but there was still a little necrotic tissue draining out of the drainage tube (no bacteria in the smear and culture), and the drainage tube was removed after 11-14 d. The drainage tube was placed 5-7 d after removal, and the sutures were removed after 14-18 d of incision healing. 13 cases were followed up for 1-10 years, and no infection was seen. No recurrence of infection and good joint function were observed. The hip joint was evaluated by the Harris efficacy scoring system: 6 cases were excellent and 3 cases were good. The knee joint was evaluated by the KSS scale: 2 cases were excellent and 2 cases were good.
3. Discussion
3.1 Early and vigorous anti-infective treatment and a full course of anti-infective therapy are very important. It has been suggested that once an incision with an insert is infected, bacteria will often accumulate and adhere to the surface of the insert, and different bacteria will begin to form a bacterial biofilm in 12 h to several weeks [6]. Once the mature bacterial biofilm is formed, the bacteria inside are able to evade the action of antibiotics or the body’s immune system, and it becomes difficult for antibiotics to kill the bacteria that gather inside the biofilm adhering to the surface of the built-in material.
Therefore, once an incisional infection is suspected or diagnosed, early and vigorous anti-infective measures are essential. If the opportunity to control the infection is not taken early, the likelihood of success is greatly reduced once the mature bacterial biofilm is formed and the infection is controlled. Therefore, once we consider incisional infection, in addition to immediately performing local puncture and sending the puncture fluid to culture plus drug sensitivity test, instead of waiting for the results to come out before using antibiotics, we immediately give norethindrone vancomycin 0.8g IV Bid at the same time, and then switch to other sensitive antibiotics after the results of drug sensitivity test come out.
By the same token, the bacteria need to be completely eradicated to prevent their resurgence, and once they have resurged they will mutate and become more difficult to eradicate, so a full course of anti-infective therapy is even more important to prevent the recurrence of infection. Our strategy is to administer sensitive antibiotics intravenously for 4 weeks, followed by 4 weeks orally, and then extended for another 4 weeks if necessary.
3.2 Early and thorough debridement with continuous irrigation and drainage is one of the important measures Once the incisional infection is diagnosed, the incision should be opened without hesitation, pus and necrotic tissue should be thoroughly removed, and non-essential tissue structures that are difficult to determine whether they are inactivated should be decisively excised until the blood supply is good, while continuous irrigation and drainage should be performed to continue to remove necrotic tissue and bacteria, to eliminate the main lesions, and to allow antibiotics to successfully The foundation and difficulty for the success of antibiotics in eradicating bacteria is reduced.
3.3 Iodine volt intermittent retention irrigation with antibiotic treatment contributes to the formation of a local sterile environment is a key measure of success We use iodine volt 20-40ml appropriate pressure retention irrigation 30min twice a day, so that iodine volt penetration to every corner of the lesion, the purpose is to use iodine volt to kill local bacteria, do not give bacteria in the surface of the prosthesis and necrotic tissue latent opportunity to live, eliminate the bacteria that can not be eliminated by antibiotics The aim is to eliminate the bacteria that cannot be eliminated by antibiotics, and to cooperate with antibiotics to completely eliminate the bacteria and to contribute to the formation of a sterile local environment to prevent the resurgence of bacteria.
We believe that this is the key to the success of anti-infection treatment. Sun Xu et al. have reported good results in the treatment of early infection after prosthetic joint replacement using intraoperative irrigation with iodophor and intermittent postoperative irrigation. Cao Li et al. reported good results with iodophor soaking for more than 5 min during the first stage revision of post-arthroplasty infection.
In conclusion, the treatment of early post-arthroplasty infection is effective with multiple measures of “systemic antibiotic treatment, thorough local debridement, continuous irrigation and drainage, and intermittent retention of iodophor irrigation”. This treatment plan is worth promoting and can be extended to the treatment of early infection in the incision after other orthopaedic internal fixation procedures.