|Year : 2018 | Volume
| Issue : 3 | Page : 57-61
Postoperative infection of elbow joint replacement
Xipeng Wang1, Kiyokazu Fukui1, Mitsuteru Yokoyama2, Masanobu Tsuchiya2, Ayumi Kaneuji1
1 Department of Orthopaedic Surgery, Hospital of Kanazawa Medical University, Ishikawa, Japan
2 Department of Orthopaedic Surgery, Kanazawa Keiju Hospital, Ishikawa, Japan
|Date of Submission||10-Jul-2018|
|Date of Acceptance||18-Sep-2018|
|Date of Web Publication||28-Sep-2018|
Dr. Ayumi Kaneuji
Department of Orthopaedic Surgery, Hospital of Kanazawa Medical University, 1-1 Daigaku, Uchinada-machi, Kahoku-gun, Ishikawa 920-0293
Source of Support: None, Conflict of Interest: None
Currently, elbow arthroplasty is used to treat elbow joint fracture, tumor, arthritis, and many other elbow-related diseases. However, due to the characteristics of the elbow joint, the success rate of elbow arthroplasty is lower than knee arthroplasty. The most common complication of this surgery is prosthesis infection and loosening. The focus of this case is on prosthesis infection after the elbow arthroplasty surgery.
Keywords: Complication, elbow replacement, infection of the prosthesis
|How to cite this article:|
Wang X, Fukui K, Yokoyama M, Tsuchiya M, Kaneuji A. Postoperative infection of elbow joint replacement. Transl Surg 2018;3:57-61
| Introduction|| |
Research status of artificial elbow joint replacement: many medical experts believe that the human body's elbow is one of the most complex joints of all joints. Among the normal functions of the human body, the function of the elbow joint is more important than the wrist joint and shoulder joint. The function of the elbow joint can also affect functions of the shoulder joint and wrist joint. Although elbow joint is nonweight bearing joint, the weight of the upper limb is less than that of the shoulder joint, but the static load of the elbow joint can reach six times of the weight. In clinical, many diseases can influence the elbow joint, the most common one is rheumatoid arthritis, which accounts for 20% to 60% of the elbow joint lesions. At the same time, other lesions include inflammatory joint diseases, such as the primary osteoarthritis, the crystallization of the joint disease, hemophilia, and joint infection. In addition, elbow injuries (mainly trauma), elbow fractures accounted for about 7% of adult fractures, elbow dislocation is ranked second in the joint dislocation, behind the shoulder joint. Therefore, the elbow joint and shoulder joint are more prone to traumatic arthritis. Clinical lesions of elbow joint mainly lead to pain, activity limitation and joint deformity, the effect of upper limb function, reducing of the quality of life. Elbow arthroplasty is a treatment for severely affected elbow joints, which is effective for pain relief and recovery activities. It is a terminal treatment for elderly patients, especially in elderly patients with comminuted humeral fractures and fracture nonunion. Cases achieved satisfactory results.
Worldwide, elbow arthroplasty has been developed for >30 years, and the survival rate of the prosthesis is close to that of total knee arthroplasty. From the perspective of surgical results, most of the functions of elbow arthroplasty were significantly improved, and the pain was significantly relieved., In Japan, the orthopedic research institute believes that the success of elbow joint replacement surgery must achieve elbow joint pain, active stability, joint wear, and tear, and can withstand certain pressure and torsion. However, due to the characteristics of the elbow joint, the incidence of complications of total elbow arthroplasty is higher than total knee arthroplasty. The most common postoperative complications are implant infection, loosening, and dislocation of the prosthesis. In this article, we present cases of infection after total elbow arthroplasty in Japanese hospitals and discuss the complications of total elbow arthroplasty.
| Case Report|| |
Ethical committee approval was obtained from Kanazawa Medical University Ethical Committee. The participant was informed about the study and signed the informed consent form. Female, 88-year-old patient. Suffered from the left elbow pain with limited activity in the local hospital for treatment, who had a history of hypertension, high blood lipids and had a bilateral knee replacement surgery. For admission examination results: “O” and the results of an anti-rheumatoid factor, erythrocyte sedimentation rate, C-reactive protein were negative. Slight swelling of the elbow joint, no obvious local tenderness, elastic ring, can touch and more than a hard nodule, elbow joint movement slightly limited, flexion 90°, 10° straight [Figure 1], muscle strength V grade, wrist joint function normal. The narrow gap of the elbow joint and isible joint multiple bone hyperplasia from X film examination.
Patients in the perfect related underwent artificial elbow joint replacement surgery, according to patient age and characteristics of joint prosthesis, complete removal of intraarticular excess fibrous scar tissue and osteophytosis surgery, proximal humerus and ulna osteotomy and selected supporting prosthesis implantation firmly and postoperative see elbow joint activities of normal [Figure 2]. The patient was advised to avoid large load on her elbow joint and complete scientific exercises for 3 months. Six months after surgery, the patient feels ipsilateral elbow joint discomfort and pain, to the hospital to check found elbow prosthesis ulna end of infection [Figure 3]. Admission underwent elbow prosthesis ulna end removal surgery in the proximal humerus good, ulna end to be implanted steel wire fixed to maintain elbow morphology [Figure 4]a. In patients with a month or so, a trauma, resulting in the elbow prosthesis again, as shown in [Figure 4]b. Operation physicians according to intraoperative findings of the ulna end to end wire, ulna prosthesis removal, reimplantation [Figure 4]c. After about 2 years, again hospitalized patients, at present patients with elbow out visible part of the prosthesis prolapse, and elbow joints can not be normal activities, the loss of part of the function [Figure 5]. Finally, after the discussion of the medical department, decided to remove part of the joint prosthesis, control of infection, treatment of osteoporosis treatment, surgical removal of the humerus part of the humerus [Figure 6]. Take the current exclusion treatment, elbow joint function to maintain fixed branch. After the film is shown [Figure 7].
|Figure 4: Development of the elbow joint after surgery. X-ray of the elbow joint (a). X-ray after dislocation of elbow joint (b). X-ray after elbow joint prosthesis fracture (c)|
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|Figure 5: After 2 years, patients with elbow out visible part of the prosthesis prolapse, and elbow joints cannot be normal activities|
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| Discussion|| |
From this case, we can see that patients underwent the initial total elbow arthroplasty, after repeated postoperative infection, prosthesis loosening, dislocation, and then infection, two fractures, and so on. After repeated operations the result is not satisfactory, as the patient has lost the function of the elbow joint, reducing the patient's quality of life.
Infection can be divided into early and late infection after joint replacement., Early infection is related to the operation, and the incidence of infections can be reduced by strictly regulating the operation technique, shortening the operation time (reducing the exposure time of the patients), the wound healing and postoperative wound drainage, and the use of antibiotics before and after the operation. If infection occurs, adequate drainage and irrigation should be performed as soon as possible. Prevention of infection is obviously an important consideration. A thorough history and physical examination to identify sources of potential infection, such as infected diabetic foot ulcers, is paramount before undergoing any arthroplasty surgery. Furthermore, a recent advisory statement provided by the American Academy of Orthopaedic Surgeons discussed routine prophylaxis with Keflex, amoxicillin, or clindamycin (if penicillin allergic) for 2 years following before various procedures, such as dental cleaning. RJoint replacement surgery routine prophylaxis after joint replacement surgery 2 years following may be also considered in some patients who have immune suppression due to certain medical conditions or immunosuppressive medications. Finally, adding prophylactic antibiotics to cemented arthroplasties has been advocated, especially in revision surgery. In China, a lot of experience of the surgeon suggested that if determine the postoperative infection and feasible wound sustained infusion of antibiotics when necessary clear necrotic tissue of the wound. Pseudomonas, Klebsiella, and Escherichia More Details coli. Occasionally, mixed infections with anaerobes such as Enterococcus and Peptococcus are present. Finally, fungal infections such as Mycobacterium tuberculosis and Candida albicans are infrequent but may be present, especially in the immune compromised host. An important consideration with regard to etiology is the virulence of the organism. Previous investigators have cited increased difficulty with the eradication of certain bacteria. Some authors have proposed differing treatment recommendations depending on which microorganism(s) are present. In an early, often cited publication, someone reported results with single staged resection and reimplantation hip arthroplasty and found that Gram-negatives including Klebsiella, Proteus, and Pseudomonas groups were associated with a high rate of failure. In this study, it was found that approximately 50% of these Gram-negative infections failed treatment. However, these results must be viewed cautiously, since many patients in this study did not receive intravenous antibiotics postoperatively, which is the current standard of care. A few small series in the literature have shown reduced efficiency in treating specific organisms such as coagulase positive Staphylococcus, and certain Gram-negatives. However, due to the lack of solid evidence-based medicine, the decision to retain versus remove the implant should not be based primarily on the specific type of bacteria encountered, but rather on the duration of symptoms.,,,,
| Conclusions|| |
The relevant literature was informed that the cause of infection was mainly: (1) patients with other basic diseases, such as diabetes, pulmonary infection, hypertension, and so on, these factors are considered to increase the probability of infection after surgery. Therefore, perioperative preparation is particularly important, preoperative preparation should be sufficient to minimize postoperative wound infection; (2) operation time: the shorter the operation time, the less bacterial growth of the wound, exposure to antibiotics, reducing unnecessary injuries, and reduce the incidence of postoperative complications., (3) A large number of foreign literature reports show that high-level laminar flow operation room joint replacement surgery can significantly reduce the incidence of postoperative infection; the patient's surgery will also affect postoperative wound healing. (4) The application of antibiotics: the use of prophylactic antibiotics, the inhibition of these bacteria. Classifying infection into acute versus late infection aids in the treatment plan. For acute infections presenting within 2–4 weeks of symptom onset, irrigation, and debridement with polyethylene liner exchange and retention of components may be possible. When attempting component retention, thorough debridement and rapid treatment of the infection before the accumulation of any biofilm is paramount for a successful outcome. Other important prognostic factors include the virulence of the microorganism as well as the immune status of the host. Despite expeditious management, irrigation and debridement of acute total hip and knee infections frequently lead to recurrent infection. Thus, patients should be counseled accordingly. Further management may be needed following an initial attempt at component retention. These options include resection arthroplasty with or without re-implantation, long-term antibiotic suppressive therapy, arthrodesis and even above the knee amputation in rare circumstances. For chronic infections, a successful outcome depends on several factors including the baseline health status of the patient, implant removal with a thorough debridement followed by culture-specific antibiotic treatment. Furthermore, methods of monitoring for persistent infection include following laboratory values such as the C-reactive protein, erythrocyte sedimentation rate, and cultures from joint aspirations. Whether to perform a direct exchange versus a delayed revision arthroplasty for chronic total hip and knee infections can be debated. Several published series have reported successful outcomes with single stage procedures when patients are carefully selected. However, the majority of chronic infections in the United States are treated with two-stage resection, since this method has consistently provided the highest cure rates, with many current studies demonstrating 90% success. However, longer operation time and greater surgical exposure increased the risk of contamination. However, the use of prophylactic antibiotics is still the only effective method to prevent postoperative infection. Prophylactic use of antibiotics is generally 48 h before the operation and use of antibiotics. At the same time, surgeons should also pay attention to operation and strict aseptic concept. Antibiotics are used to ensure a local drug concentration and to reach an effective level in operation.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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