Decision-making process in periprosthetic infection treatment management: a multimodal approach

Background: Periprosthetic joint infection (PJI) remains a significant complication in orthopedic surgery, necessitating complex multi-specialty management to prevent irreversible tissue damage and functional loss. Despite established protocols, debate persists regarding the optimal surgical methodology for infection eradication and limb salvage.

Objective: This review evaluates current surgical strategies for managing musculoskeletal infections, focusing on indications, success rates, and clinical outcomes of various intervention levels ranging from implant retention to terminal procedures.

Key Points: Debridement, antibiotics, and implant retention (DAIR) is indicated for acute infections (<3 weeks) involving low-virulence pathogens and stable implants, with higher success in hip (60-83%) versus knee (55-70%) arthroplasty. One-stage revision offers improved functional outcomes in selected patients with identified organisms and adequate soft tissue. Two-stage revision remains the standard for chronic or recalcitrant infections, utilizing articulating or intramedullary spacers to manage bone loss. For failed limb salvage, resection arthroplasty and arthrodesis serve as intermediary options; arthrodesis demonstrates infection eradication rates exceeding 90% but carries a 40% complication rate. Above-knee amputation and hip disarticulation are reserved as last-resort measures for unrelenting sepsis or massive bone loss. Amputation is associated with high mortality (50% at 5 years) and significant functional impairment, with only 44% of patients utilizing prostheses.

Conclusion: Successful PJI management requires a staged approach tailored to patient comorbidities, pathogen virulence, and soft tissue integrity. Surgical attempts at limb salvage should generally not exceed four to six procedures, after which the functional benefits of further reconstruction diminish relative to definitive terminal procedures.