An Australian Algorithm to Guide the Surgical Management of Chronic Prosthetic Joint Infection: A Multi-Disciplinary Team Approach

Chronic prosthetic joint infection (PJI) is a leading cause of failure for total joint arthroplasty. Historically, two-stage revision arthroplasty has been considered the gold standard approach to chronic PJI, however, emerging evidence suggests that one-stage revision arthroplasty may be underutilized. To our knowledge, there have been no previously published guidelines for the surgical management of chronic PJI in Australia, resulting in significant heterogeneity in management within and across centers. We aim to review contemporary concepts in the surgical management of PJI and develop an evidence-based algorithm to optimize the management of chronic hip and knee PJI, incorporating a multidisciplinary team (MDT) approach. A review was conducted to identify existing articles discussing surgical management of chronic PJI, specifically contraindications to one-stage revision arthroplasty. Absolute contraindications for one-stage revision include difficulty in treating organisms, significant soft tissue compromise, and concurrent sepsis. Relative contraindications include lack of preoperative identification of organism, presence of a sinus tract, fungal infections, significant bone loss, and immunocompromise. In determining the management of patients with a relative contraindication, MDT discussion with the consideration of patient's overall local, host, and microbiological profile is necessary. Using gathered evidence, absolute and relative contraindications for one-stage revision arthroplasty were developed into an algorithm. The algorithm is designed to assist our PJI MDT in making optimized decisions when choosing between a one-stage versus two-stage approach. Ongoing follow-up is underway to determine the effect of implementing this algorithm on patient outcomes, eradication rates, and revision rates within our center.