Javad Parvizi, MD, FRCS

Diagnosis of periprosthetic joint infection is still a challenge due to a lack of an absolute test. When a clinician encounters a suspected periprosthetic joint infection case, he or she has to use a combination of tests, all of which can be invasive and expensive. Even with a combination of tests, it is difficult to reach a firm diagnosis in many cases.

The prevalence of obesity in the general population is increasing. Obesity is estimated to affect approximately one-third of adults in the United States. It is estimated that 6.1 million patients who undergo total joint arthroplasty will be obese by 2040.

In 1999, the CDC issued the Guideline for Prevention of Surgical Site Infection. Although the guideline was a series of recommendations for the prevention of surgical site infections made by a panel of experts, they have served the surgical community for many years.

Have you ever considered why honey, a natural product that is so rich in sugar, is resistant to bacterial or fungal growth, even when kept at room temperature for months?

The increasing burden and the immense financial impact of periprosthetic joint infection compel the orthopedic community to seek all potential infection control measures. Based on the teachings of Sir John Charnley and the literature from the early era of total joint arthroplasty, orthopedic surgeons are aware that an ultra-clean OR environment is critical to minimize the number of airborne particulate matters that can contaminate the wound and lead to infection of the implanted foreign material. It is known that airborne and non-airborne bacterial contaminations are the major source of infection in ORs.

Infection is a challenging and frequently devastating complication of orthopedic procedures. As antibiotic resistance continues to increase, especially through the widespread use of antibiotic loaded biomaterials and other mechanisms, the morbidity and mortality associated with the infecting organisms will increasingly become problematic. This health care crisis is so worrisome that the WHO has identified antimicrobial resistance as one of the three greatest threats to human health. A task force charged by the British government to look into this issue also identified emergence of antibiotic resistance as an extremely worrisome problem for the future, when the lives of 15 million people may be at jeopardy.

Analysis of the synovial fluid plays an important role in the evaluation of joint disease and in particular the diagnosis of infection. For decades the orthopedic community has used the white cell count and neutrophil differential of the synovial fluid for diagnosis of septic arthritis and periprosthetic joint infection. The story behind the investigation of synovial fluid is an interesting one.

The orthopedic community continues to be concerned about venous thromboembolism after orthopedic procedures. There is no consensus on the best strategy for the prevention of venous thromboembolism following orthopedic procedures. One undisputable fact is that administration of anticoagulation needs to strike the right balance between its intended mission of preventing venous thromboembolism without causing other unintended problems such as bleeding.

One of the major issues facing orthopedic surgeons who treat patients with periprosthetic joint infection is to determine the optimal timing for reimplantation following a resection arthroplasty. Currently, at least in North America, patients with periprosthetic joint infection are treated with antibiotics for 6 weeks following a resection arthroplasty followed by 2 weeks of a “drug holiday” and reimplantation is performed at that point unless there are “gross” signs of infection.

It may not come as a surprise to learn that treatment of biofilm-related infections consume a massive part of the health care resources worldwide. In the United States, up to 500,000 primary blood stream infections occur annually among 150 million intravascular devices implanted. It is estimated that in 2014, more than $1 billion will be spent to treat periprosthetic joint infection of the hip and the knee.