Periprosthetic Joint Infection (PJI) is a devastating complication of the Total Joint Arthroplasty (TJA). It presents a great challenge for the clinician to diagnose and manage it appropriately, with significant morbidity for the patients and cost for health care providers. The purpose of this study is to review and examine the role of multi-disciplinary team (MDT) approach in diagnosis and management of prosthetic joint infection (PJI) and how this approach can influence outcomes. All published literature examining the role of multidisciplinary care in the management of PJI and the influence of this approach to the management and outcomes of patients with this diagnosis were included. Studies published in languages other than English were excluded. There is a paucity of data on the influence of multidisciplinary care on outcomes of the management of PJI. Evidence suggests that the MDT has important role in ensuring all factors in the management of this complex group are considered and best possible care is delivered. Multicentre randomised clinical trials are required to assess the influence of MDT’S on outcome as well as important questions around the structuring of these teams.
- prosthetic joint infection
1. Introduction and background
Prosthetic joint infection (PJI) affects about 1–3% of patients undergoing total joint arthroplasty . In some units the infection rate is reported to be as high as 5% . It is one of the most devastating complications and poses significant challenges for the patient, health care providers and the treating institution. The financial cost of treating a single case of PJI can be as high as £100,000 . Costs for patients are even higher, with long hospital stay, multiple operations, associated pain and suffering, reduced life quality as well as risks associated with surgical morbidity and mortality. Diagnosis and management of PJI remains controversial and complex. There is no universal definition of the PJI. The definition of PJI proposed by the International Consensus Meeting on Periprosthetic Joint Infection is the most universally accepted one . Other definitions also exist. George et al.  acknowledged 7 definitions produced by various consensus meetings. This illustrates that PJI remains a debatable and controversial topic and diagnosis is not straight forward. There is no one single test that can adequately diagnose PJI. Up to 10% of cases undergoing revision for aseptic loosening are later found to have prosthetic joint infection . PJI can present in variety of ways and at varying phases from the time primary arthroplasty implantation. Tsukayama et al. proposed a classification system that divided PJI into four categories .
It can be challenging for an individual surgeon to make an accurate diagnosis when faced with a patient with a painful arthroplasty. One way of addressing this has been to manage this complex group of patients with a multidisciplinary team. Failure to make a timely and accurate diagnosis can significantly compromise therapeutic options and have a negative impact on the result of surgical treatment . Furthermore, if PJI is not recognised, it may lead to systemic symptoms such as bacteraemia and septicaemia.
PJI can be challenging to treat, and patients may need a number of major surgical procedures, coupled with antimicrobial treatment for several weeks to eradicate the infection . Treatment of PJI of the knee may be associated with a long period of disability with possible immobilisation of the knee. This may lead to a poor functional outcome. Recurrence of the infection is high and reported between 8% and 70%  and complications associated with surgery are common. Furthermore, PJI is associated with significant mortality. Berend et al.  reported that 11% patients treated for PJI with a 2 stage regime died between the first and second stages of surgical treatment. Zmistowski et al.  found that the 5-year survivorship of patients with PJI is worse than for some common cancers including breast cancer or testicular cancer. For this reason PJI must be managed expeditiously, providing patients with all available expertise to achieve the optimum outcome. Added to this is the psychological burden associated with the issues described and its impact on post operative function . This combination of the knowledge that there has been a complication or suboptimal outcome, multiple surgical procedures, prolonged hospital stay, prolonged disability and associated medical comorbidities as well as social isolation and pain illustrates multiple issues which can be associated with patients presenting with PJI and the multiple facets which require management in a synchronised manner. These factors have been acknowledged in other aspects of orthopaedic surgery and it is acknowledged that optimal outcomes result from a multidisciplinary approach to management [12, 13].
2. Treatment options for PJI
The physical, but also psychological needs of patients should be addressed. PJI may be emotionally difficult to cope with and lead to sequalae such as depression and anxiety . Many patients struggle with the impact that the treatment of PJI has on their personal and family lives’. Patients’ depression may require treatment and support during the treatment as well as during the recovery phases .
3. The role of the MDT
Ideally personnel should be present in the same location in order to provide a seamless, clinically and cost-efficient service to patients with PJI. They should be involved in all stages of the management pathways including, diagnosis, treatment (both surgical and non-surgical) and long term follow up. The multidisciplinary approach has made a significant difference in care of oncology patients. Time to diagnosis and clinical outcomes have all been shown to improve when the MDT functions well well [21, 22]. There is no published evidence to the authors’ knowledge on the management of PJI with this approach however the principles of diagnosis and factors influencing management and outcomes of patients with PJI are similar. It seems intuitive therefore that a similar approach to treatment might produce similar outcomes.
4. What comprises a multidisciplinary team?
Most published studies examining the benefits of MDT’s have focused on clinical results . There is a relative paucity of data on the components of the MDT. An important principle of care delivery in this setting is consideration of the wholistic needs of the patient and including appropriate specialists to address these issues. In the context of PJI the following team members are required:
5. Examples of multidisciplinary teams
At the authors’ institution, there is an established referral network for complex cases including those presenting with PJI. Clinicians from the region can refer any patient who needs complex arthroplasty assessment and treatment, including those with PJI to a centralised hub. There is a standardised referral proforma and MDT coordinator who promptly responds to all referrals. There is a weekly MDT attended by complex arthroplasty surgeons, a CNS and radiologists with an interest in musculoskeletal medicine. Cases are discussed and either advice is provided or a decision on transfer of the patient to the Hub Hospital is organised. In complex cases when surgery is required, surgical planning is performed and details such as surgical approach, instruments and required implants are all discussed. Each week between 10 to 20 cases are discussed. Advice of plastic surgeons, vascular surgeons and microbiologists is available on request. There is also a monthly MDT meeting attended by the same team of complex arthroplasty surgeons as well as microbiologists with an interest in bone and joint infection and outpatient antibiotic treatment (OPAT) team. All cases undergoing treatment for infection are discussed, plans for surgical and non-surgical treatment are established and progress of treated patients is discussed. This ensures that most appropriate treatment plan is made for each individual.
The East Midlands Specialist Orthopaedic Network (EMSON) (Nottingham, UK) was established and its success has been reported . All referrals are received by email by the MDT coordinator. The meetings are conducted using secure videolink, with complex arthroplasty surgeons from Nottingham University Hospital and microbiologists attending while consultants from neighbouring hospitals dial in to discuss challenging cases. During first 6 months 166 cases were discussed, 43% of which the initial plan was amended as the result of the discussion. In several cases, there was a significant alteration to the treatment plan. Referring surgeons are also encouraged to come to tertiary centre with the potential for joint consultant operating. This improves the experience of all clinicians involved.
6. Why should we adopt a Multidisciplinary approach
The potential benefits of care delivered via a MDT approach can be experienced on a variety of levels:
7. Challenges to the establishment of a multidisciplinary team
The treatment of PJI is labour and resource intensive. Patients often stay on the ward for extended periods and face a higher risk of surgical and medical complications that non-infected cases. It is likely that the number of referrals and number of treated patients will increase over time which increases this burden .
Vaneghan et al. have shown that the cost of surgical treatment is significantly higher than septic revisions . There is a potential risk of rapid depletion of financial resources. Renumeration strategies need to be established prior to starting this type of service [18, 33].
The logistics and practical aspects of establishing a MDT requires careful attention to detail. An understanding of what is required on a practical level is important. Meetings of large numbers of specialists takes these services from other departments. To the authors’ knowledge there has been no definition of the optimal constituents a MDT or of the minimal number of specialists required or whether the teams involved in diagnostic and therapeutic parts of the patient journey should be different.
Job planning for all the members of the team should be coordinated to allow all members to meet or dial in to discuss cases. Surgeons, radiologists, microbiologists and other health care professionals involved in PJI management need to find time during their busy weekly schedule for MDT to work. Furthermore, when transfer of the patient is necessary to the specialist centre, logistical arrangements need to be in place to avoid delays.
Another unexplored aspect of delivering care in this way is the issue of responsibility and autonomy. The MDT moves away from the heirarchical system in which decisions are made by one senior individual towards one where there is shared decision making. This raises the subject of accountability. When a decision is taken by a group, who is responsible and who, if anyone, is accountable when things go wrong? For the same reason there can be a perceived risk to the autonomy of the referring surgeon. These issues have not been addressed.
In conclusion the management of PJI is complex and multifactorial. Multidisciplinary management has resulted in improved clinical results in similar settings setting such as tumour surgery however establishment of multidisciplinary care presents significant challenges to the treating institution.