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Abstract
Prosthetic joint infections (PJIs) following total joint arthroplasty are a significant and costly complication. To address fragmented care typically seen with separate management, we established a combined infectious disease and orthopaedic surgery clinic at Duke Health in July 2020. This clinic focuses on patients experiencing acute deterioration or multiple PJI episodes, often at the stage where amputation is the only option offered. From July 2021 to March 2024, the clinic completed 974 visits with 319 unique patients. The clinic maintained a low no-show rate of 5.0%. Treatment plans included procedures such as debridement, antibiotics and implant retention (38%), as well as implant explantation and one-stage exchange (32% each), with amputation required in only 4% of cases. The integrated clinic model facilitated real-time, multidisciplinary care, improving patient outcomes and operational efficiency. This approach offers a promising model for managing complex infections.
- INFECTIOUS DISEASE
- Teamwork
- Surgery
- Shared decision making
- orthopaedic surgery
- prosthetic joint infection
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- INFECTIOUS DISEASE
- Teamwork
- Surgery
- Shared decision making
- orthopaedic surgery
- prosthetic joint infection
Introduction
Prosthetic joint infections (PJIs) are a severe complication following total joint arthroplasty, projected to cost an estimated US$1.85 billion by 2030.1 PJIs often result in the failure of the implant and require complex management strategies.2–4 Traditionally, PJIs have been managed in separate orthopaedic surgery and infectious disease clinics, often resulting in fragmented care and delayed treatment. To address this issue, we started one of the few combined infectious disease and orthopaedic surgery clinics in the USA.5 Although similar combined clinics exist globally, their adoption has not been widespread within the USA. This innovative clinic model integrates the expertise of both specialties, enabling real-time collaboration and streamlined care processes, ultimately enhancing patient outcomes and operational efficiency.
Methods
At our large academic referral hospital system, Duke Health in Durham, North Carolina, USA, we established a combined infectious disease and orthopaedic surgery clinic in July 2020. The clinic focused on patients experiencing acute deterioration or multiple PJI episodes, often at the stage where amputation was the only option offered. Infectious disease specialists and orthopaedic surgeons would see patients simultaneously in the same room, providing integrated and coordinated care. Treatment plans and workup were created in collaboration between the two teams.
Prior to the inauguration of the combined clinic, patients would be scheduled to see orthopaedic surgery and infectious disease at separate times in separate locations. Often these visits would be scheduled weeks apart. This process would inevitably delay decision-making regarding the care of the patient. Moreover, communication between infectious diseases and orthopaedic surgery was hindered and also fraught with delays as these conversations could not occur in person.
This observational study focused on the no-show rate and resulting procedures from the clinic. Data from the Duke Integrated Health system were visualised using Tableau (Washington, USA). R studio was used to compute descriptive statistics.
Results
Between July 2021 and March 2024, the combined clinic completed 974 total visits, with 319 unique patients (figure 1). On average, 10–15 patients were seen daily, including 2–4 new patients. Patients were referred from across the country with 143 patients referred directly to the clinic due to sepsis or progression of their symptoms (figure 2). The clinic maintained a low no-show rate of 5.0% throughout the study period.
Type and volume of combined infectious disease and orthopaedic clinic visits from September 2022 to March 2024.
Referral patterns from across the country.
Treatment plans commonly included procedures such as debridement, antibiotics and implant retention or infection and debridement, accounting for 38% of cases. Explantation of the implant and one-stage exchange were each pursued in 32% of cases while amputation was necessary in only 4% of cases.
Discussion
The establishment of our combined infectious disease and orthopaedic surgery clinic has yielded several significant benefits. A key advantage is the facilitation of real-time discussions and decision-making between orthopaedic surgeons, infectious disease specialists and patients (figure 3).6 7 This collaborative approach enhances the quality of care and ensures that patients are fully informed and involved in their treatment plans.
An example protocol for a patient being seen at the combined clinic. *appoinments can made sooner or later depending on clinical course.
Furthermore, the clinic provides valuable educational opportunities for both infectious disease and orthopaedic surgery practitioners. By working together, these specialists can share knowledge and insights, ultimately improving their expertise and the overall quality of patient care.5 The clinic integrates arthroplasty fellows into its operations, providing them with valuable experience and knowledge in managing PJIs. One of the most notable operational benefits is the ability to expedite interventions when necessary. Patients who require urgent care can be ‘fast-tracked’, minimising delays and potentially improving outcomes. This streamlined process contributes to the continuity and consistency of care, as patients are managed within a cohesive, multidisciplinary framework.
The clinic also excels in optimising diagnosis and treatment. By bringing together the expertise of both infectious disease and orthopaedic specialists, we can ensure that patients receive the most accurate diagnoses and effective treatments. This is particularly beneficial for complex cases, as the clinic can match patients with the surgeons who possess the most relevant expertise. These cases often require revision surgeries which increase the risk of complications.8 To further streamline and standardise patient care, we have implemented a shared template that includes the Musculoskeletal Infection Society score, enhancing the consistency of patient assessments.9 Additionally, synovial fluid is collected in blood culture bottles, enabling advanced diagnostic testing and improving the accuracy of infection detection.10 Standardised protocols have been established for follow-up intervals, antibiotic choices and antibiotic duration, ensuring that patients receive consistent and evidence-based care. Criteria for reimplantation or revision surgery are also standardised, providing clear guidelines and optimising surgical outcomes.
Patient satisfaction has been positively impacted by the clinic’s logistical advantages, such as easier parking and more convenient clinic access demonstrated by a no-show rate.11 These seemingly minor improvements can significantly enhance the patient experience, reducing stress and improving overall satisfaction with the care received. Similarly, Carlson et al implemented a multidisciplinary clinic at the University of Utah Hospital in Utah, USA, to improve the treatment of PJI and found improved patient adherence to appointments, reduced travel burdens and enhanced perioperative planning.12 Biddle et al implemented a specialist PJI multidisciplinary team at the Queen Elizabeth University Hospital in Glasgow, UK, which included a pharmacist, a consultant microbiologist, a consultant in infectious diseases and several orthopaedic consultants.13 Their study found a significant reduction in failure rates following revision surgery and postoperative complications. Ntalos et al implemented multidisciplinary infection conferences for the treatment of PJI of the hip and found that these conferences resulted in shorter in-hospital stay and a reduction in both and number of antibiotics required.14 The integrated clinic model also presents numerous opportunities for clinical research. The collaborative environment fosters the generation of research questions and the pursuit of innovative studies, which can further advance the field of orthopaedic surgery and infectious disease treatment.
Future directions for the clinic include building a comprehensive database to facilitate research and track patient outcomes, as well as developing an inpatient component to provide continuous, integrated care for patients with complex PJIs.
Limitations and lessons learnt
Despite the promising results and benefits observed in this study, several limitations should be acknowledged. As an observational study conducted at a single academic institution, the findings may not be generalisable to other healthcare settings with different patient populations, resources or healthcare delivery models. The patient cohort in this study, primarily referred from a specific geographical region, might not reflect the diversity and complexity of cases seen in other regions or institutions. Additionally, the retrospective nature of the study could introduce selection bias, as patients who were more likely to benefit from the combined clinic model might have been preferentially referred. Another limitation is the lack of a control group or comparison with traditional care models. Without a direct comparison, it is challenging to conclusively attribute the observed improvements in patient outcomes and operational efficiency solely to the integrated clinic model. Furthermore, the study did not account for other potential confounding factors, such as variations in surgical techniques, antibiotic protocols or postoperative care, which might have influenced the outcomes. The data collected were limited to specific metrics, such as no-show rates and procedural outcomes, without a comprehensive evaluation of long-term patient outcomes, quality of life or functional recovery. This study did not include patient-reported outcomes, which are crucial for comprehensively understanding the full impact of our clinic on patient well-being, satisfaction and quality of life. While our study primarily focused on clinical metrics such as no-show rates, procedural outcomes and operational efficiency, incorporating patient-reported outcomes would provide a more holistic view of the clinic’s effectiveness. Patient perspectives on pain levels, functional recovery, emotional well-being and overall satisfaction with care are essential components that contribute to the overall success of a healthcare model, especially for complex conditions like PJIs. Despite this limitation, our study serves an important purpose by describing the operational framework and initial outcomes of our combined infectious disease and orthopaedic surgery clinic. This foundational work lays the groundwork for future research that can build on our findings and address the gaps identified.
Future studies should incorporate these aspects to provide a more holistic assessment of the clinic’s impact. Despite these limitations, the study provides valuable insights into the potential benefits of an integrated infectious disease and orthopaedic surgery clinic for managing complex PJIs. Further research, including multicentre studies and randomised controlled trials, is needed to validate these findings and explore the long-term impact of this multidisciplinary care model.
Throughout the establishment and operation of the combined infectious disease and orthopaedic surgery clinic, several key lessons were learnt. First, real-time, multidisciplinary collaboration significantly enhances the quality of care for patients with complex conditions such as PJIs. The integration of infectious disease specialists and orthopaedic surgeons in a single clinic facilitated timely decision-making, reducing delays that often occur with fragmented care. Second, the implementation of standardised protocols for diagnosis, treatment and follow-up care was instrumental in maintaining consistency and optimising patient outcomes. Additionally, the low no-show rate and positive patient feedback highlighted the importance of logistical improvements, such as easier clinic access and efficient scheduling. Furthermore, the clinic model highlights the value of combining clinical care with educational opportunities for arthroplasty fellows. Overall, the experience underscored the potential of integrated, multidisciplinary care models to improve both clinical outcomes and patient experiences in managing complex medical conditions.
In summary, the combined infectious disease and orthopaedic surgery clinic at Duke Health has demonstrated substantial benefits across multiple dimensions, including patient care, professional education, operational efficiency and research potential. This model serves as a promising example for other institutions aiming to improve the management of complex conditions such as periprosthetic joint infections and septic arthritis.
Ethics statements
Patient consent for publication
Ethics approval
This study was approved by the Duke University Health System Institutional Review Board (Pro00115489).
Footnotes
Contributors The clinic was jointly designed and established by JLS, EBG, EFH, WAJ, TMS and the Duke University Health System. KAW wrote the manuscript and crafted the figures. JLS performed the data collection and analysis. Supervision of the project was done by JLS, EBG, EFH, WAJ and TMS. All authors gave approval of the final manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.