Total Knee and Hip Peri-Prosthetic Infections, Failure to Recognize Risks


Are all total joint peri-operative infections considered expected possible complications of these procedures and not the result of negligence? Of course not. Indeed there are cases where all attempts at identifying risk factors and prevention measures are done and still infection occurs without fault or negligence on the part of the surgeon.

Peri -prosthetic joint infection is a serious complication of total joint replacement resulting in significant morbidity, including pain, loss of function, and potential removal of the prosthesis. Evidence based published studies have shown the impact and varying increases in the occurrence of postoperative total joint infections with known risk factors. Risk factors identified and supported by the evidence include prior infection of the joint(knee), superficial surgical site or limb infection(hip and knee), obesity, extended operative time(> 2.5 hrs,hip and knee), and immunosuppression (knee). Other risk factors of great concern are smoking (for knees), positive nasal cultures for Staph, and low albumin and or cirrhosis. Current evidence –based practice standards and the standard of care demand that physicians use the best available evidence in their clinical decision making.

The STANDARD OF CARE in performing joint replacement surgery is that the surgeon, not the referring primary care physician should determine risk factors for a patient considering a total joint arthroplasty.

The STANDARD of CARE would the dictate that the surgeon has an obligation and the duty to discuss these risk factors and the probability of the patient getting a post op infection in the scenario of taking all precautions possible. NEGLIGENCE would be found when a surgeon makes no effort to identify the known published risk factors and does not discuss risk factors with the patient, and then the patient develops a post operative joint infection. The literature reports 40-60% of all post operative total joint infections could be prevented by following the standard of care. For example, The Veteran’s Affairs Medical Center has algorithms for risk factor identification and limits up to an acceptable or not values such as positive nasal cultures, diabetic A1C levels below 7.5, BMI at 40 or below, and off any nicotine products for 2 mos. prior to surgery.

REFERENCES

1. Guide to the Elimination of Orthopedic Surgical Site Infections. An APIC Guide 2010.
2. Prevention of Prosthetic Joint Infections, Wolters Kluwar Health Clinical Solutions, Larry M. Baddour, MD: Ellie Berbari, M.D.
3. Prevention of Surgical Site Infection. PTY Ching, MD
4. The Diagnosis of Peri-prosthetic Joint Infections of the Hip and Knee, Guideline and Evidence Report Adopted by the American Academy of Orthopedic Surgeons Board of Directors---Subsection Risk Factors June 18, 2010.


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