Periprosthetic Knee Infection - Part 1: Risk Factors, Classification and Diagnosis

Barretto, João Maurício; Campos, André Luiz Siqueira; Ooka, Nelson Hiroyuki Miyabe

doi:10.1055/s-0041-1729935

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Revista Brasileira de Ortopedia

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Update Article • Rev. bras. ortop. 57 (02) • 2022 • https://doi.org/10.1055/s-0041-1729935 copy

Periprosthetic Knee Infection - Part 1: Risk Factors, Classification and Diagnosis

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Infection is one of the most feared complications in the postoperative period of knee arthroplasties. With the progressive aging of the population and the increased incidence of degenerative joint diseases, there is an exponential increase in the number of arthroplasties performed and, consequently, in the number of postoperative infections. The diagnosis of these should follow a hierarchical protocol, with welldefined criteria, which lead to diagnostic conclusion, thus guiding the most appropriate treatment. The aim of the present update article is to present the main risk factors, classifications and, mainly, to guide diagnostic investigation in an organized manner.

Keywords:
arthroplasty; replacement; knee; surgical site infection; risk factors; diagnosis

Factor	Degree	Description
Type	I	Acute infection (< 4 weeks postoperatively)
	II	Acute hematogenous infection (< 4 weeks of symptoms)
	III	Chronic infection (> 4 weeks of symptoms)
Host factors (comorbidities and immunity)	A	Not compromised
	B	Compromised (1-2 comorbidity factors)
	C	Very compromised (> 2 comorbidity factors) or one of the factors below:∘ Neutrophil count < 1,000∘ CD4 count < 100∘ Intravenous drug user∘ Active infection elsewhere∘ Tumor or dysplasia of the immune system
Local Factors	1	Not compromised
	2	Compromised (1-2 comorbidity factors)
	3	Very compromised (> 2 comorbidity factors)

Factor	Description
Systemic host involvement (comorbidity or immunity)	Age >80 years old
	Alcoholism
	Dermatitis or active chronic cellulitis
	Permanent catheter
	Chronic malnutrition (albumin < 3.0 g/dL)
	Chronic nicotine use (inhaled or oral)
	Diabetes mellitus (requiring drug treatment)
	Liver failure (cirrhosis)
	Use of immunosuppressive drugs (corticosteroids, methotrexate, cyclosporine)
	Malignancy (active or history)
	Pulmonary insufficiency (SaO2 < 60% in room air)
	Chronic renal failure on dialysis
	Systemic inflammatory disease (Rheumatoid Arthritis, Systemic Lupus Erythematosus)
	Systemic immune impairment by infection or immunodeficiency (AIDS, acquired immunodeficiencies)
Involvement of the affected limb (wound and limb conditions)	Active infection (> 3-4 months)
	Multiple incisions - skin bridges
	Loss of soft tissue due to previous trauma
	Subcutaneous abscess (extension > 8 cm²)
	Cutaneous synovial fistula
	Previous periarticular fracture or previous joint trauma (crushing)
	Previous local irradiation
	Peripheral vascular insufficiency - arterial or venous

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E-mail: rbo@sbot.org.br

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[1] Address for correspondence João Maurício Barretto, PhD, Rua das Laranjeiras, 550/1001, Rio de Janeiro, RJ, 22240-006, Brasil (e-mail: joao.barretto1@gmail.com).