Frank Buttacavoli, MD, Speaks about Current Concepts in Prophylaxis and Treatment of Periprosthetic Joint Infections

Surgical site infections remain a devastating complication in arthroplasty as well as the entire field of orthopaedic surgery. Numerous study protocols as well as technology innovations aim to minimize the risk of surgical site infections. AAOS Now Editorial Board member Boris A. Zelle, MD, FAAOS, FAOA, sat down with Frank Buttacavoli, MD, FAAOS, a key opinion leader and recognized expert in this area, to discuss the prevention and treatment of periprosthetic joint infections (PJIs). Dr. Buttacavoli is an associate professor of orthopaedics and chief of adult reconstruction at UT Health San Antonio.

Dr. Zelle: Can you introduce your practice?
Dr. Buttacavoli: I’ve been with UT Health since 2017. I enjoy the subspecialty practice that the university [offers] me. I basically do four procedures: primary and revision total knee and hip. I also take some trauma as well. Last few years have been busier than I’ve wanted. I do about 700 cases per year, with the majority of that being arthroplasty. For better or worse, we are a referral center for complex revision and PJI.

What are the major challenges when it comes to PJIs?
The major challenges with PJIs are trying to be successful at eradicating infection and giving people pain-free total hips or knees. Some of the things that can make that more challenging are certain patient factors, which make them more difficult to treat. Specifically, I find that uncontrolled diabetes, malnourishment, liver disease, severe bone loss, and unfavorable presenting bacteria are often contributing factors to difficulty with treatment.

There are also specific types of infections that are difficult to treat, such as methicillin-resistant Staphylococcus aureus, mycobacterium, and fungus. These can be very challenging, and we have to pursue different avenues, such as chronic suppression, fusion, resection arthroplasty, or even sometimes amputation.

What are things that we, as the treating surgeons, can do to prevent and treat PJIs?
I tend to take care of most of my PJIs with a two-stage treatment method. This often is quite burdensome to patients and families. Looking back at my own data over the past 8 years, we have been successful at eradicating infection in approximately 75 percent of these patients.

Some of the more recently used surgical tools in my arsenal for treating PJIs include irrigating negative-pressure therapy, negative-pressure dressings, augmentation of dead space, and intramedullary canals with antibiotic beads. Probably most important is the multidisciplinary team, helping care for the patient overall in an effort to improve and optimize their general medical health during the process.

Where are the areas in PJI that we need to focus our research, and what developments do you foresee coming?
I am very interested in decreasing the burden of PJI treatment. There is more and more research coming out on one-stage treatments or on other antibiotic-delivery devices to shorten the two-stage process. I hope there’s a future in both these avenues. I’m sure there are some patients who will fit into these categories better than others. We will have to evaluate the data as a field and do a good job evaluating each patient to see who can fall into these treatment possibilities.

I think it’s important in my practice, and for really any practice, to evaluate our success rate. I tend to look closely at my results, especially if I make changes within my practice. Recently on older/sicker patients, I have been trying to retain implants or do one-stage procedures. I’ll have to follow these results closely to see how successful I am, but so far I think in certain patients it has been a much a better option than my standard two-stage treatment.

It’s always a work in progress tackling these challenging issues. Patients present with a wide variety of social and medical issues. My preference is that we get to these patients sooner than later.

As a referral center, we do our best in getting to address all of these complex issues. It’s unfortunate that we see some patients living with an infection for a significant period of time before getting appropriate treatment.

Are there any other insights that you would like to share with AAOS members?
Overall, I hope we can get better at prevention of this complication. John Charnley said a long time ago that the biggest hurdle in joint replacement would be sepsis. It’s a quote I remember from a talk from Javad Parvizi, MD, FRCS. It’s always in the back of our mind as joint surgeons. It’s a phone call that you hate to get from a resident and ER physician.

We all care a lot about our patients, and this is a complication that we hope not to deal with very often, but as joint surgeons continue to deal with it, we hope to get better at it.

Boris A. Zelle, MD, FAAOS, FAOA, is vice chair of research and program director of the orthopaedic trauma fellowship in the Department of Orthopaedics at UT Health San Antonio. Dr. Zelle is a member of the AAOS Now Editorial Board.