Infection after TKR

Posted by emintexas @emintexas, Apr 3, 2019

I had a TKR revision last October and three weeks later came down with staph infection. IV antibiotics then oral antibiotics were working, after a reopen and clean out, until I got a stomach bug in Feb 2019 and antibiotics couldn't stay in my system. Staph came raging back and now am facing removal and antibiotic spacers put in. I have a lot of questions for anyone else who has gone through this. First of all, I'm 56, healthy – other than my stupid knee – and an executive running a large department. I only missed a week with the revision, I did great and felt like a million bucks. I didn't drive for about three weeks, but could walk just fine. With the mobility spacer, can you walk? Can you drive at some point? I am really struggling with putting my life on hold for this and want to know if there is anyone out there who has had this done, is about my age and what your experience was. I can't stand being "taken care of" although my husband will do it, if I let him. 🙂 thank you!

Interested in more discussions like this? Go to the Joint Replacements Support Group.

Hello @emintexas, welcome to Connect. We have had a lot of members discuss antibiotic spacers after getting infection post-hip replacement. I urge you to check out an in-depth conversation between members on that subject here, https://connect.mayoclinic.org/discussion/what-kind-of-mobility-can-i-expect-with-an-antibiotic-spacer-in-my-hip/. Although they may not be talking about a knee replacement specifically, I suspect that many of the issues you are wondering about and have concerns about are similar.

@emintexas, has there been any discussion on how long the antibiotic spacer will need to be in? Is it until they feel the infection is under control or gone?

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Hi @emintexas – I want to join @JustinMcClanahan in welcoming you to Connect. It sounds as if you have been through the ringer. I know this must be terribly inconvenient and scary and I'm sorry you are having to go through it. I had a knee replacement in January and I'm happy to say my recovery was uneventful – and even at that its not something you want to go through. Can I ask what caused you to have to have the revision? As Justin mentioned, I think you will find good information on the thread he recommended. Wishing you the best of luck.

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I had TKR in July, 8 weeks later I convinced the Dr there was a problem( after terrible pain and swelling. I had a staph epi infection. He operated and put in spacer with antibiotics and then we had to do six weeks of IV home antibiotics. It was an awful experience. I still have spacer in… I can walk…. pain everyday , especially when I get up and down. During this ordeal I got a blood clot in my arm from the pic line. I had three months of Eliquis.
Long story, the Dr wants to wait til after September to talk about surgery to put knee parts in.
I am now planning to go to Mayo clinic to get them to do surgery , if they will.
I am a female 60 years old. I retired in January, was not able to work, I was selling advertising.
Good luck….. keep us informed.

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Titia131, I’m so sorry to hear about all of these complications you’ve had and are still dealing with. Let us know how things progress.

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TKA 10/17 constant low level pain, swelling
Arthroscopy 10/18 scar tissue release, synovial fluid suggested infection (high CRP, WBC, cloudy) but culture negative after 1 week
Joint stable, good ROM but continued pain dismissed by several surgeons.
2/2022: Night after a strenuous Friday hike, I woke up with extreme pain in the knee, unable to bend it or bear any weight. I had excruciating rigors, body aches and a fever. I figured Covid but tests negative. I saw my NP on Monday. Bloodwork consistent with knee infection. First orthopedist appt. Tuesday when I was feeling somewhat better. Synovial fluid cloudy, bloodwork showed high CRP, white cell percentage consistent with infection. In spite of my belief that this was a chronic infection, ortho deemed it acute and did D.A.I.R. surgery and replaced the plastic parts. 1 week in hospital. On moderate pain meds I was able to race around the hospital floor with my walker and walk unaided. High octane IV antibiotics in hospital and with PICc line for 6 weeks at home. 2 months out my knee is still painful but my wound has healed quickly and I have full ROM and extension. Getting stronger with PT.
Here is my issue. Cultures grew propionibacterium acnes (now a Cutibacterium), a slow growing gram positive anaerobic bacteria which indicates that my infection is chronic and not acute. The only cure is surgery to remove and replace the implant. But my orthopedist has decided that surgery is too risky because of my 3 prior procedures and that the only course of treatment is lifelong antibiotics. I am 72, not overweight, physically and mentally active, no significant health issues other than mild asthma and osteoarthritis with some mild osteoporosis. The Ortho left it up to the infectious disease PA to give me the bad news Why??? This is not the preferred treatment unless someone is unable to tolerate further surgery. Previous DAIR makes replacement less curative but should not preclude it. I suspect they are afraid of legal issues and just do not want to deal with me anymore. 2 year survival with this treatment at 2 years is 68% at best. I am already having side effects from meds. I have tried to contact other revision specialists but none have returned my calls/messages. Discouraged. Advice?

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@rebeccamary

TKA 10/17 constant low level pain, swelling
Arthroscopy 10/18 scar tissue release, synovial fluid suggested infection (high CRP, WBC, cloudy) but culture negative after 1 week
Joint stable, good ROM but continued pain dismissed by several surgeons.
2/2022: Night after a strenuous Friday hike, I woke up with extreme pain in the knee, unable to bend it or bear any weight. I had excruciating rigors, body aches and a fever. I figured Covid but tests negative. I saw my NP on Monday. Bloodwork consistent with knee infection. First orthopedist appt. Tuesday when I was feeling somewhat better. Synovial fluid cloudy, bloodwork showed high CRP, white cell percentage consistent with infection. In spite of my belief that this was a chronic infection, ortho deemed it acute and did D.A.I.R. surgery and replaced the plastic parts. 1 week in hospital. On moderate pain meds I was able to race around the hospital floor with my walker and walk unaided. High octane IV antibiotics in hospital and with PICc line for 6 weeks at home. 2 months out my knee is still painful but my wound has healed quickly and I have full ROM and extension. Getting stronger with PT.
Here is my issue. Cultures grew propionibacterium acnes (now a Cutibacterium), a slow growing gram positive anaerobic bacteria which indicates that my infection is chronic and not acute. The only cure is surgery to remove and replace the implant. But my orthopedist has decided that surgery is too risky because of my 3 prior procedures and that the only course of treatment is lifelong antibiotics. I am 72, not overweight, physically and mentally active, no significant health issues other than mild asthma and osteoarthritis with some mild osteoporosis. The Ortho left it up to the infectious disease PA to give me the bad news Why??? This is not the preferred treatment unless someone is unable to tolerate further surgery. Previous DAIR makes replacement less curative but should not preclude it. I suspect they are afraid of legal issues and just do not want to deal with me anymore. 2 year survival with this treatment at 2 years is 68% at best. I am already having side effects from meds. I have tried to contact other revision specialists but none have returned my calls/messages. Discouraged. Advice?

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Hello @rebeccamary, I know some decisions really don't make a lot of sense sometimes when the doctors can't do a good job explaining the whys and specifics for the treatments. I was not familiar with the procedure and found of couple of articles on the topic that may be helpful but I'm not sure.

The Role of Long-Term Antibiotic Suppression in the Management of Peri-Prosthetic Joint Infections Treated With Debridement, Antibiotics, and Implant Retention: A Systematic Review:
https://pubmed.ncbi.nlm.nih.gov/31955984/

"2021 — intravenous antibiotics after DAIR, or lifelong antibiotic suppression in patients with failure to clear infection and retention of infected."
— Cost-effectiveness of Single vs Double Debridement and Implant Retention for Acute Periprosthetic Joint Infections in Total Knee Arthroplasty: A Markov Model: https://www.arthroplastytoday.org/article/S2352-3441(21)00150-3/pdf

I'm tagging @sueinmn to see if she may have some thoughts on why the surgery would be considered risky this time around.

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@rebeccamary

TKA 10/17 constant low level pain, swelling
Arthroscopy 10/18 scar tissue release, synovial fluid suggested infection (high CRP, WBC, cloudy) but culture negative after 1 week
Joint stable, good ROM but continued pain dismissed by several surgeons.
2/2022: Night after a strenuous Friday hike, I woke up with extreme pain in the knee, unable to bend it or bear any weight. I had excruciating rigors, body aches and a fever. I figured Covid but tests negative. I saw my NP on Monday. Bloodwork consistent with knee infection. First orthopedist appt. Tuesday when I was feeling somewhat better. Synovial fluid cloudy, bloodwork showed high CRP, white cell percentage consistent with infection. In spite of my belief that this was a chronic infection, ortho deemed it acute and did D.A.I.R. surgery and replaced the plastic parts. 1 week in hospital. On moderate pain meds I was able to race around the hospital floor with my walker and walk unaided. High octane IV antibiotics in hospital and with PICc line for 6 weeks at home. 2 months out my knee is still painful but my wound has healed quickly and I have full ROM and extension. Getting stronger with PT.
Here is my issue. Cultures grew propionibacterium acnes (now a Cutibacterium), a slow growing gram positive anaerobic bacteria which indicates that my infection is chronic and not acute. The only cure is surgery to remove and replace the implant. But my orthopedist has decided that surgery is too risky because of my 3 prior procedures and that the only course of treatment is lifelong antibiotics. I am 72, not overweight, physically and mentally active, no significant health issues other than mild asthma and osteoarthritis with some mild osteoporosis. The Ortho left it up to the infectious disease PA to give me the bad news Why??? This is not the preferred treatment unless someone is unable to tolerate further surgery. Previous DAIR makes replacement less curative but should not preclude it. I suspect they are afraid of legal issues and just do not want to deal with me anymore. 2 year survival with this treatment at 2 years is 68% at best. I am already having side effects from meds. I have tried to contact other revision specialists but none have returned my calls/messages. Discouraged. Advice?

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Thanks for getting right back to me and for the complete articles. The issue in my case is that both the orthopedic surgeon and infectious disease NP agree that my infection is chronic and not acute. This literature clearly confirms that D.A.I.R. is not appropriate. I do not question his call for only D.A.I.R. at initial presentation. Only that now it is most likely chronic, they do not recommend revision and are loathe to tell me why.

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@rebeccamary

Thanks for getting right back to me and for the complete articles. The issue in my case is that both the orthopedic surgeon and infectious disease NP agree that my infection is chronic and not acute. This literature clearly confirms that D.A.I.R. is not appropriate. I do not question his call for only D.A.I.R. at initial presentation. Only that now it is most likely chronic, they do not recommend revision and are loathe to tell me why.

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I am sorry you're going through all of this. I can't imagine, but I wonder if there is a teaching hospital in your area with a fabulous reputation that you can go to? I have visited multiple doctors about my knee and hip, and few went beyond the "you need knee and hip replacements." In fact, so far, out of maybe 7 doctors I have seen for this (yes, I'm that reluctant), not ONE has gone beyond, "You need surgery, your hip(s) and knee(s) are gone." Sometimes I suppose we just gotta trust the doctor. I know a person who had foot surgery and came down with an infection — went in for more surgery and is still recovering after months at home. Sometimes these things can't be helped. I wish I could offer you more advice. I used to say to doctors when I first visited them when I was in better health, "I don't like doctors." I've stopped doing that. Because that's not going to make them my 'friend.' Not sure that this helps, but my heart goes out to you…knowing how scared you are — sometimes though at a certain point we have to make a decision. Again, I am so sorry you're going through this. May you have comfort from above…

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@cindiwass

I am sorry you're going through all of this. I can't imagine, but I wonder if there is a teaching hospital in your area with a fabulous reputation that you can go to? I have visited multiple doctors about my knee and hip, and few went beyond the "you need knee and hip replacements." In fact, so far, out of maybe 7 doctors I have seen for this (yes, I'm that reluctant), not ONE has gone beyond, "You need surgery, your hip(s) and knee(s) are gone." Sometimes I suppose we just gotta trust the doctor. I know a person who had foot surgery and came down with an infection — went in for more surgery and is still recovering after months at home. Sometimes these things can't be helped. I wish I could offer you more advice. I used to say to doctors when I first visited them when I was in better health, "I don't like doctors." I've stopped doing that. Because that's not going to make them my 'friend.' Not sure that this helps, but my heart goes out to you…knowing how scared you are — sometimes though at a certain point we have to make a decision. Again, I am so sorry you're going through this. May you have comfort from above…

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I saw an orthopedic surgeon in Charlotte (OrthoCarolina) who specializes in prosthetic joint infections He agrees with me that my Charleston surgeon should have removed the knee prosthesis but, considering that antibiotics are suppressing the infection at present, he will follow me with lab work every 3 months. He recommends lifetime antibiotics and 2 stage removal and reimplantation if the infection gets worse. He said I have a 40% chance at best of avoiding surgery. I trust Dr. Fehring and will heed his plan. Even if he is at least 3 1/2 hours away. So glad I found him.

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@rebeccamary

TKA 10/17 constant low level pain, swelling
Arthroscopy 10/18 scar tissue release, synovial fluid suggested infection (high CRP, WBC, cloudy) but culture negative after 1 week
Joint stable, good ROM but continued pain dismissed by several surgeons.
2/2022: Night after a strenuous Friday hike, I woke up with extreme pain in the knee, unable to bend it or bear any weight. I had excruciating rigors, body aches and a fever. I figured Covid but tests negative. I saw my NP on Monday. Bloodwork consistent with knee infection. First orthopedist appt. Tuesday when I was feeling somewhat better. Synovial fluid cloudy, bloodwork showed high CRP, white cell percentage consistent with infection. In spite of my belief that this was a chronic infection, ortho deemed it acute and did D.A.I.R. surgery and replaced the plastic parts. 1 week in hospital. On moderate pain meds I was able to race around the hospital floor with my walker and walk unaided. High octane IV antibiotics in hospital and with PICc line for 6 weeks at home. 2 months out my knee is still painful but my wound has healed quickly and I have full ROM and extension. Getting stronger with PT.
Here is my issue. Cultures grew propionibacterium acnes (now a Cutibacterium), a slow growing gram positive anaerobic bacteria which indicates that my infection is chronic and not acute. The only cure is surgery to remove and replace the implant. But my orthopedist has decided that surgery is too risky because of my 3 prior procedures and that the only course of treatment is lifelong antibiotics. I am 72, not overweight, physically and mentally active, no significant health issues other than mild asthma and osteoarthritis with some mild osteoporosis. The Ortho left it up to the infectious disease PA to give me the bad news Why??? This is not the preferred treatment unless someone is unable to tolerate further surgery. Previous DAIR makes replacement less curative but should not preclude it. I suspect they are afraid of legal issues and just do not want to deal with me anymore. 2 year survival with this treatment at 2 years is 68% at best. I am already having side effects from meds. I have tried to contact other revision specialists but none have returned my calls/messages. Discouraged. Advice?

Jump to this post

Glad you trust him, that's important. I just wonder about lifetime antibiotics, if the infection is gone why would you need them? I'm sure you're eating, etc., properly to enhance your body's coping mechanism.

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