TJA Benefits from a Multidisciplinary Approach to the Management of Periprosthetic Joint Infections

Total joint arthroplasty (TJA) is one of the most successful elective surgeries in modern medicine, as it reduces pain, restores function, and improves quality of life. Approximately 1 million hip and knee replacements are done every year in the United States. Current epidemiologic models estimate that by 2030, primary total hip arthroplasty and total knee arthroplasty will grow by 71 percent and 85 percent, respectively. TJA represents approximately 10 percent of the Medicare budget, making it one of the most expensive surgical procedures to individuals, insurers, and the government.

Given such economic realities, TJA and, as importantly, its potential complications and subsequent interventions are of practical interest in healthcare and political conversations. Periprosthetic joint infection (PJI) has an incidence of approximately 1 percent and is one of the most devastating potential complications. Management of PJIs involves multiple surgeries, long-term antibiotics, and extended hospital stays. Such morbidity is associated not only with an economic burden but also a psychological and social one on patients. Approximately 15 percent of revision hip arthroplasties and 25 percent of revision knee arthroplasties are secondary to PJI, representing $1.6 billion. Given such implications, there has been growing interest in a PJI multidisciplinary team (MDT) and its utility in improving outcomes.

Successful management of PJI is multidimensional and involves appropriate timely diagnosis, surgical and pharmacological interventions, medical management, and follow-up care. The standard of care for PJI is variable and patient specific; however, its success depends on two major factors: qualified team members from particular subspecialties and efficient and effective collaboration among them. There is variability in how an MDT is defined in the literature, but the general principle is that it comprises the primary managing team (orthopaedic surgeon and infectious diseases specialist); ancillary team members (physical therapists and dieticians); and the liaison team, which coordinates care among team members, patients, clinics, and hospitals.

For an MDT strategy to be successful, patients must be able to easily navigate the various specialists and their respective medical institutions while being limited by their potential socioeconomic barriers. There must be coordination among the patient, medical institution, and healthcare professionals. A nursing liaison fulfills this indispensable role. Nursing liaisons are tasked with navigating patients through the primary and ancillary teams and various clinics and hospitals. They are also responsible for following patients through timely follow-up appointments.

The primary managing team of an MDT involves close collaboration between the infectious diseases specialist and orthopaedic surgeon. The orthopaedic surgeon provides the technical expertise for the various operative interventions, which can involve excision and debridement with polyethylene exchange, single- or two-stage revisions, arthrodesis, and amputations. The infectious diseases specialist formulates and reviews the plan for the selection, method of delivery, and duration of antibiotics for the specific microorganism identified. The early collaboration between the two specialists allows for a more efficient and effective management strategy. This timely shared decision-making process is beneficial for both teams. The infectious diseases specialist will get an understanding of the surgical options, their respective expected outcomes and morbidity, and various technical factors of such operations. The surgeon will identify potential microorganism nuances such as diagnosis of less-virulent organisms, presence of atypical species such as fungi, and recommendations regarding specific antibiotics to be mixed in cement. Such an early bilateral understanding will allow for preoperative planning that would not be possible otherwise.

Successful long-term PJI management is also dependent on overall health and ambulation. Management of pertinent nutritional parameters, such as caloric and protein intake, has significant prognostic weight in the management of PJI. Dietitians provide needed expertise within this area to optimize patients’ nutritional status and maximize the efficacy of surgical and pharmacological interventions. In addition, a metric used to evaluate the successful management of PJI is the patient’s functional status, which is predicated on appropriate ambulation. Such progress requires the incorporation of physical therapists into the MDT in the inpatient and outpatient settings. Appropriate physical therapy and nutritional status are crucial and must be optimized in parallel with surgical and pharmacological treatment modalities for maximized success.

An effective MDT requires consistent dialogue to continuously discuss, formulate, review, and adjust treatment plans. One avenue is a multidisciplinary conference. Such a modality has been used in the oncological world, with different surgeons and medical specialists reviewing complicated cases. By applying similar principles to the PJI setting, the MDT can better coordinate and improve their management strategies.

Although MDT approaches to medical management are not new, their application and effectiveness in the PJI setting are under investigation. In a study at the Queen Elizabeth University Hospital in the United Kingdom looking at 29 PJI cases before and after the implementation of an MDT, investigators found significant reduction in failure rates following revision surgery. Another study of 49 patients out of the University Medical Center Regensburg in Germany found that, after the implementation of an MDT, there was a reduction of 1-year mortality and infection recurrence.

A third study out of Flinders Medical Centre in Australia looked at the outcomes of 44 patients after the implementation of an MDT and compared it to 27 patients prior. They found that the total hospital length of stay and the number of antibiotics used were reduced after implementation of an MDT. Although such studies are promising, they are weakened by small sample sizes, variability in defining an MDT, and the question of clinical versus statistical significance.

TJA is a successful surgery, but a small percentage of patients will develop a PJI. Such a complication represents a psychological, social, and economic burden for the patient and the healthcare system. Its management is multidimensional and necessitates the intelligent use of various medical specialties and institutions. This involves a multidisciplinary structure consisting of orthopaedic surgery, the infectious diseases specialty, nursing liaisons, dietetics, and physical therapy. An efficient and effective use of such a team can maximize outcomes and reduce costs.

Hossein Tabrizi, MD, is an orthopaedic surgery resident at the Michigan State University–McLaren Health Care program in Flint, Michigan.

Ajay Srivastava, MD, FAAOS, is director of the orthopaedic surgery residency program at McLaren Flint and an adult reconstruction orthopaedic surgeon at McLaren Flint and Hurley Medical Center.

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