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Özşahin A, Koçak-Tufan Z, Güner R, Buzğan T, Tecimel O, Taşyaran MA. Analysis of Prosthetic Joint Infections, Risk Factors for Treatment Failure and Effect of Teicoplanin in Treatment: A Single-Center, Retrospective, Observational Study. INFECTIOUS DISEASES & CLINICAL MICROBIOLOGY 2025; 7:66-76. [PMID: 40225715 PMCID: PMC11991701 DOI: 10.36519/idcm.2025.464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2024] [Accepted: 01/16/2025] [Indexed: 04/15/2025]
Abstract
Objective This study aimed to identify the risk factors for treatment failure in prosthetic joint infections (PJIs) and the most appropriate approach to these infections, especially the effect of teicoplanin on treatment response. Materials and Methods The data of patients who were followed up with a diagnosis of Gram-positive or culture-negative PJI for seven years in a tertiary-care referral hospital were included in the study retrospectively. Results One hundred sixty-nine PJI attacks were included in the study. The overall infection eradication rate was 82.7%. Preoperative hemoglobin (Hb) and hematocrit (Hct) levels were higher, and C-reactive protein (CRP) levels were lower in treatment responders ( p=0.006, p=0.003, and p=0.021, respectively). The relationship between CRP and treatment response emerged in the second week, while a significant decline in the erythrocyte sedimentation rate (ESR) levels was seen at the end of treatment. Treatment was successful in 91.7% of cases that underwent two-stage revision surgery and 89.4% in those who used teicoplanin for more than two weeks. In multivariate analysis, two-stage revision surgery and the use of teicoplanin for more than two weeks increased treatment success. Conclusion Hb, Hct, and CRP levels could help to predict the treatment response in the preoperative period, and in the postoperative follow-up, CRP could predict the treatment response earlier. Although one-stage surgeries seem practical, the patient's best interests are paramount, and two-stage revisions should be selected whenever needed. Finally, teicoplanin, a practical once-daily, well-tolerated antibiotic, was associated with high treatment success rates in Gram-positive and culture-negative PJIs.
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Affiliation(s)
- Aybegüm Özşahin
- Department of Infectious Diseases and Clinical Microbiology, Recep Tayyip Erdoğan University, Training and Research Hospital, Rize, Türkiye
| | - Zeliha Koçak-Tufan
- Department of Infectious Diseases and Clinical Microbiology, Ankara Yıldırım Beyazıt University School of Medicine, Ankara Bilkent City Hospital, Ankara, Türkiye
| | - Rahmet Güner
- Department of Infectious Diseases and Clinical Microbiology, Ankara Yıldırım Beyazıt University School of Medicine, Ankara Bilkent City Hospital, Ankara, Türkiye
| | - Turan Buzğan
- Department of Infectious Diseases and Clinical Microbiology, Ankara Yıldırım Beyazıt University School of Medicine, Ankara Bilkent City Hospital, Ankara, Türkiye
| | - Osman Tecimel
- Department of Orthopedics and Traumatology, Ankara Yıldırım Beyazıt University Faculty of Medicine, Ankara Bilkent City Hospital, Ankara, Türkiye
| | - Mehmet A. Taşyaran
- Department of Infectious Diseases and Clinical Microbiology, Yüksek İhtisas University School of Medicine, Ankara, Türkiye
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Auñón Á, Bernaus M, Veloso M, Font-Vizcarra L, Esteban J, Mijangos M, Hernández N, Achaerandio A, Baeza J, Argüelles F, Rojas R, Sánchez J, Martínez-Roselló A, Monfort M, Martínez J, Corredor A, de Espinosa JML, Castellanos J, Martínez Pastor JC, Alías A, Boadas L, Muñoz-Mahamud E, Sabater M. Outcomes of the Subsequent Periprosthetic Joint Infection Revisions after a Failed Debridement, Antibiotics and Implant Retention: A Multicentric Study of 197 Patients. Surg Infect (Larchmt) 2025; 26:57-62. [PMID: 39612194 DOI: 10.1089/sur.2024.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2024] Open
Abstract
Background: The impact of prior unsuccessful debridement, antibiotics, and implant retention (DAIR) procedures on subsequent revisions is uncertain, with conflicting evidence. Despite 85% consensus against the second DAIR procedure following the 2018 International Consensus Meeting, a 2020 study reported high success rates for the aforementioned second DAIR procedure. Methods: We conducted a multicenter observational study reviewing data from patients with failed DAIR procedures between 2005 and 2021. Patients diagnosed with acute periprosthetic joint infection of the hip or knee were included, following ICM criteria. Failure was defined as uncontrolled infection leading to additional surgeries, prosthesis removal, infection-related mortality, or suppressive antibiotic therapy. Demographic, surgical, and microbiological variables were recorded. Results: Among 197 patients from 10 institutions with failed DAIR procedures were included: 88 (44.7%) received a second DAIR, 21 (10.7%) underwent one-stage revision, and 77 (39.1%) underwent two-stage revision. One-stage revision success rate was 76.2%, with no identified predictors of failure. Two-stage revision success rate was 79.3%; factors associated with failure included polymicrobial infections (p = 0.025) and revision procedures (p = 0.049). Second DAIR success rate was 54.5%; factors associated with failure included non-specialized surgical teams in the first DAIR (p = 0.034), non-exchange of mobile components (p = 0.0038), polymicrobial infections (p = 0.043), and antibiotic resistance (p = 0.035). Excluding patients with these risk factors increased the success rate to 83.3%. Conclusions: Second DAIR's overall success rate was 54.5%, significantly increasing to 83.3% when excluding patients with identified risk factors. These findings suggest considering second DAIR in carefully selected patients without these risk factors. Our study found success rates of 76.2% and 79.3% for one- and two-stage revisions, respectively, aligning closely with published data.
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Affiliation(s)
- Álvaro Auñón
- Department of Orthopedics, IIS-Fundación Jiménez Díaz, CIBERINFEC (CIBER de Enfermedades Infecciosas), Madrid, Spain
| | - Martí Bernaus
- Department of Orthopedics, Mutua Terrassa, Terrassa, Spain
| | | | - Lluis Font-Vizcarra
- Department of Orthopedics, Bone and Joint Infection Unit, Hospital Transversal Moises Broggi, Consorci Sanitari Integral, Sant Joan Despí, Spain
| | - Jaime Esteban
- Department of Microbiology, IIS-Fundación Jiménez Díaz, CIBERINFEC (CIBER de Enfermedades Infecciosas), Madrid, Spain
| | - Monica Mijangos
- Department of Orthopedics, Hospital de Cruces, Barakaldo, Spain
| | - Nerea Hernández
- Department of Orthopedics, Hospital de Cruces, Barakaldo, Spain
| | - Ainara Achaerandio
- Department of Orthopedics, Hospital Universitario de Albacete, Albacete, Spain
| | - José Baeza
- Department of Orthopedics, Hospital Universitario y Politécnico de La Fe, Valencia, Spain
| | - Francisco Argüelles
- Department of Orthopedics, Hospital Universitario y Politécnico de La Fe, Valencia, Spain
| | - Roger Rojas
- Department of Orthopedics, Hospital Parc Taulí, Sabadell, Spain
| | - Joel Sánchez
- Department of Orthopedics, Hospital Parc Taulí, Sabadell, Spain
| | | | | | - Javier Martínez
- Department of Orthopedics, Hospital Virgen de la Arrixaca, El Palmar, Spain
| | - Alejandro Corredor
- Department of Orthopedics, Hospital Virgen de la Arrixaca, El Palmar, Spain
| | | | - Juan Castellanos
- Department of Orthopedics, Parc Sanitari Sant Joan de Déu, Sant Boi, Spain
| | | | - Alfonso Alías
- Department of Orthopedics, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Laia Boadas
- Department of Orthopedics, Hospital Clinic de Barcelona, Barcelona, Spain
| | | | - Marta Sabater
- Department of Orthopedics, Hospital Clinic de Barcelona, Barcelona, Spain
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Durham SH, Covington EW, Roberts MZ, Chahine EB. Rifampin in device-related infections: Assessing the modern evidence. Am J Health Syst Pharm 2025; 82:184-202. [PMID: 39324584 DOI: 10.1093/ajhp/zxae263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Indexed: 09/27/2024] Open
Abstract
PURPOSE Rifampin is commonly used to treat device-related infections (DRIs) due to its activity against biofilms, despite a history of limited clinical evidence to support its use. Evidence published since 2011 regarding rifampin use for DRIs is reviewed to describe the contemporary findings and ongoing considerations for rifampin use in these infections. SUMMARY A literature review was performed by searching PubMed and Google Scholar to identify relevant studies evaluating systemic rifampin use for the treatment of DRIs published from 2011 to 2023. References of identified studies were also screened for additional pertinent studies. Sixty-eight studies were identified, and 48 met the inclusion criteria. Rifampin efficacy was evaluated as both a primary outcome for cardiac device infections (n = 3) and prosthetic joint infections (n = 21) and as a nonprimary outcome (n = 24). Overall, the studies were primarily retrospective (n = 36) and small, with sample sizes ranging from 14 to 842 patients, and varied greatly with respect to prosthesis site, surgical intervention, pathogen, infection time frame, and antibiotic combination and duration. Efficacy outcome results varied greatly, with statistically significant evidence for the efficacy of rifampin combination in DRIs limited to a single study of prosthetic vascular graft infections and 13 studies of prosthetic joint infections. CONCLUSION The modern literature provides conflicting results regarding the benefit and lack of benefit with rifampin combination therapy in DRIs. Additional, robust research is imperative to solidify the ongoing role of rifampin in DRIs.
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Affiliation(s)
- Spencer H Durham
- Auburn University Harrison College of Pharmacy, Huntsville, AL, USA
| | | | - Megan Z Roberts
- Auburn University Harrison College of Pharmacy, Huntsville, AL, USA
| | - Elias B Chahine
- Gregory School of Pharmacy, Palm Beach Atlantic University, West Palm Beach, FL, USA
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Sanders P, Scheper H, van der Wal R, van de Sande M, de Boer M, Sander Dijkstra PD, Bus M. Periprosthetic Joint Infection Surrounding Lower-Extremity Endoprostheses After Tumor Resection: Causative Microorganisms, Effectiveness of DAIR, and Risk Factors for Treatment Failure. JB JS Open Access 2025; 10:e23.00119. [PMID: 39991113 PMCID: PMC11841843 DOI: 10.2106/jbjs.oa.23.00119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2025] Open
Abstract
Background Periprosthetic joint infection (PJI) surrounding an endoprosthesis after reconstruction of a lower extremity following tumor resection is a common complication, and the treatment of these infections is challenging and often requires multiple surgical interventions or even implant removal. Because there has been limited evidence to support treatment strategies and understanding of the epidemiology of the causative microorganisms, we analyzed the effectiveness of debridement, antibiotics, and implant retention (DAIR), risk factors for the failure of DAIR, and causative microorganisms in patients with a PJI surrounding a lower-extremity endoprosthesis after tumor resection. Methods A retrospective cohort study was conducted in a tertiary referral center for orthopaedic oncology. All patients treated between 2000 and 2018 for PJI surrounding a lower-extremity endoprosthesis after tumor resection were included. Treatment outcomes and risk factors for failure were analyzed in patients primarily treated with DAIR. Causative microorganisms were recorded. The minimum follow-up period was 2 years. Results Of the 337 patients who underwent endoprosthetic reconstruction of a lower extremity after tumor resection, 67 patients (20%) developed a PJI surrounding the endoprosthesis. Of those patients, 55 were primarily treated with DAIR. The functional cure rate of DAIR was 65% (36 of 55). A median of 2 debridements per patient was needed. Chemotherapy (odds ratio [OR], 3.1 [95% confidence interval (CI), 1.0 to 9.3]) and an erythrocyte sedimentation rate of >50 mm/hr at diagnosis (OR, 4.5 [95% CI, 1.3 to 15.4]) were associated with treatment failure. Nineteen patients (28%) had a polymicrobial infection. Conclusions Although sequential procedures are often needed, DAIR has acceptable clinical outcomes and should be considered, dependent on expected survival and the risk factors for treatment failure noted in this study. Level of Evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Philip Sanders
- Department of Orthopedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Henk Scheper
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Robert van der Wal
- Department of Orthopedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Michiel van de Sande
- Department of Orthopedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Mark de Boer
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Michael Bus
- Department of Orthopedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
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Karlsen ØE, Snorrason F, Westberg M. A prospective multicentre study of 82 prosthetic joint infections treated with a standardised debridement and implant retention (DAIR) protocol followed by 6 weeks of antimicrobial therapy: favourable results. Hip Int 2025; 35:62-69. [PMID: 39562499 DOI: 10.1177/11207000241295604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2024]
Abstract
INTRODUCTION Prosthetic joint infection (PJI) is a much-feared complication in total joint arthroplasty. Debridement, antibiotics, irrigation and implant retention (DAIR) is often the preferred treatment in acute PJIs, but with varying results. The primary aim of this study was to evaluate the outcome of a high quality DAIR procedure performed according to a consistently applied surgical protocol in early postoperative and acute haematogenous PJIs in hip and knee, and secondary to study risk factors associated with failure. METHODS We performed a prospective multicentre study to evaluate the effect of a standardised protocol-based surgical management (DAIR) emphasising a thorough debridement, followed by 6 weeks of antimicrobial therapy. Empiric parenteral antimicrobial treatment was administered until the results of susceptibility tests were available. No suppressive antimicrobial therapy was given after the 6-week treatment-period. Primary outcome measure was infection control at the 2-year follow-up. RESULTS A total of 99 patients from 8 Norwegian hospitals were found eligible and included in the study, and 82 patients were finally analysed. 69 of 82 patients (84% [CI, 76-92%]) were successfully treated with this treatment protocol. We found a reduced success rate when patients were treated with a DAIR procedure following an infected revision arthroplasty compared with an infected primary arthroplasty (11/17 (65 %) versus 58/65 (89 %), respectively (p = 0.02). CONCLUSIONS The success rate of a standardised DAIR procedure with a 6-week antimicrobial treatment was good in PJI following primary arthroplasties. The success rate following PJI in revision arthroplasty was poor, and other treatment options should be considered.
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Affiliation(s)
| | - Finnur Snorrason
- Division of Orthopaedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
| | - Marianne Westberg
- Division of Orthopaedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
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Gachet B, Dechartres A, Senneville E, Robineau O. Systematic review on oral antibacterial relay therapy for acute staphylococcal prosthetic joint infections treated with debridement, antibiotics and implant retention (DAIR). J Antimicrob Chemother 2024; 79:3091-3099. [PMID: 39383095 DOI: 10.1093/jac/dkae347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 09/06/2024] [Indexed: 10/11/2024] Open
Abstract
BACKGROUND The management of acute prosthetic joint infections (PJIs) often involves a debridement, antibiotics and implant retention (DAIR) strategy. OBJECTIVE Our objective was to conduct a systematic review and a network meta-analysis (NMA) to assess the comparative effectiveness of available oral antimicrobial regimens for the treatment of acute staphylococcal PJIs treated with DAIR. METHODS We conducted a systematic review searching articles from databases creation until 31 December 2023. We included articles on acute staphylococcal PJIs managed with DAIR with an oral antibiotic regimen relaying the initial management. The primary outcome was the remission rate. RESULTS Out of the 2421 studies screened, six studies completed the systematic review criteria: one randomized controlled trial and five observational studies. There was heterogeneity in patients' populations, duration and posology of treatments, definition of outcome and length of follow-up. Studies revealed 10 antibiotic regimens and most data focusing on five combinations recommended by the IDSA's guidelines: rifampicin associated to fluoroquinolone, clindamycin, cycline, linezolid or trimethoprim-sulfamethoxazole. Treatment comparisons were often secondary, without adjustment for confounding factors, resulting in a high risk of bias. Owing to inconsistencies a complete analysis, including an NMA was not possible. CONCLUSION The available data highlight five companions to rifampicin, however, there is insufficient evidence to compare them. The literature does not provide a basis for rationalizing alternatives when rifampicin cannot be used.
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Affiliation(s)
- Benoit Gachet
- Department of Biostatistics, ULR 2694 METRICS Evaluation des technologies de santé et des pratiques médicales, Gustave Dron Hospital of Tourcoing, Lille University, Lille, France
| | - Agnès Dechartres
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié-Salpêtrière, Département de Santé Publique, 75013 Paris, France
| | - Eric Senneville
- Department of Biostatistics, ULR 2694 METRICS Evaluation des technologies de santé et des pratiques médicales, Gustave Dron Hospital of Tourcoing, Lille University, Lille, France
| | - Olivier Robineau
- Department of Biostatistics, ULR 2694 METRICS Evaluation des technologies de santé et des pratiques médicales, Gustave Dron Hospital of Tourcoing, Lille University, Lille, France
- INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, UMR-S 1136, AP-HP, Paris, France
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Matsumoto T, Kaneda K, Kobayashi S, Harato K, Kodama T. Elective Treatment Strategy for Knee Prosthetic Joint Infection. Cureus 2024; 16:e76171. [PMID: 39840220 PMCID: PMC11747851 DOI: 10.7759/cureus.76171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2024] [Indexed: 01/23/2025] Open
Abstract
INTRODUCTION Prosthetic joint infection (PJI) is a complication, rarely encountered in daily clinical practice, but its treatment is frequently unsuccessful. In this report, we describe the treatment strategy used at our hospital, which has provided stable therapeutic results. METHODS We conducted a retrospective analysis of infections following knee arthroplasty at our hospital between April 2005 and December 2022. RESULTS Post-total knee arthroplasty (TKA) infection occurred in 26 of 2132 patients (1.2%), and post-unicompartmental knee arthroplasty (UKA) infection occurred in six of 842 patients (0.7%); the difference was not significant (p=0.22). Infection occurred ≤3 months postoperatively in 13 patients with TKA and three with UKA, and ≥4 months postoperatively in 13 patients with TKA and three with UKA. Recurrent infection was observed in five patients with TKA and no patients with UKA. We did not conduct surgery for patients with PJI until causative bacteria were identified. We performed debridement, antibiotics, and implant retention (DAIR), with debridement of the synovium and insert replacement. Irrigation or drain placement was not conducted. The appropriate antibiotic was administered at a sufficient dose for a sufficiently long period, and the transfer of antibiotics into the bone marrow was not considered. Although some cases of recurrence were noted, treatment was successful in all cases, with no instances of obvious implant loosening or medullary lesions. CONCLUSIONS In the absence of implant loosening, the post-arthroplasty infection can be controlled by elective debridement surgery and selective administration of the optimal antibiotic.
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Affiliation(s)
| | - Kazuya Kaneda
- Orthopaedics, Keio University, School of Medicine, Tokyo, JPN
| | - Shu Kobayashi
- Orthopaedics, Keio University, School of Medicine, Tokyo, JPN
| | - Kengo Harato
- Orthopaedics, Keio University, School of Medicine, Tokyo, JPN
| | - Takao Kodama
- Orthopaedics, Saitama Medical Center, Saitama, JPN
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Gavaskar AS, Tummala NC, Srinivasan P, Ayyadurai P, Ganesh D, Reddy R. Modular component exchange has no advantage in Debridement, Antibiotics and Implant Retention (DAIR) for early onset hip and knee prosthetic joint infection. Arch Orthop Trauma Surg 2024; 144:5261-5266. [PMID: 39316104 DOI: 10.1007/s00402-024-05546-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 09/03/2024] [Indexed: 09/25/2024]
Abstract
INTRODUCTION Debridement, Antibiotics and Implant Retention (DAIR) has been the mainstay of treatment for early onset periprosthetic joint infection in spite of variable results. Modular component exchange is a widely recommended strategy to improve success rates with DAIR though very strong evidence to support its practice is still lacking. MATERIALS AND METHODS Eighty six patients underwent DAIR for early onset PJI following primary hip and knee arthroplasty were divided into two groups for this retrospective review. 45 patients (group 1) underwent DAIR with modular component exchange and 41 patients without exchange (group 2). We compared success rates based on infection eradication (primary outcome variable) and need for revision surgical procedures between these two groups. We also assessed differences in primary outcome based on type of arthroplasty, timing of DAIR and addition of local antibiotics. RESULTS The overall success rate after DAIR was 71%. The outcome was similar in both groups (69% vs 74%, P = 0.66). The need for revision surgical procedures was 27% which was similar in both groups (P = 0.98) with 23% needing revision of prosthetic components. Type of arthroplasty (hip or knee) and addition of local antibiotics had no bearing on infection eradication after DAIR with or without modular component exchange. DAIR with in 45 days of primary arthroplasty had significantly higher success rate compared to DAIR after 45 days in both groups. CONCLUSIONS We observed that modular component exchange did not improve infection eradication after DAIR for early onset PJI following hip and knee arthroplasty. Reasonable success rates can be expected after DAIR especially if the patient develops early clinical signs and the procedure is carried out as early as possible.
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Affiliation(s)
| | | | | | | | - Dheepak Ganesh
- Vijaya Institute of Trauma and Orthopedics, Chennai, India
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Fontalis A, Yasen AT, Giebaly DE, Luo TD, Magan A, Haddad FS. Optimizing debridement and implant retention in acute periprosthetic joint infections. Bone Joint J 2024; 106-B:1377-1384. [PMID: 39615530 DOI: 10.1302/0301-620x.106b12.bjj-2024-0282.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/03/2025]
Abstract
Periprosthetic joint infection (PJI) represents a complex challenge in orthopaedic surgery associated with substantial morbidity and healthcare expenditures. The debridement, antibiotics, and implant retention (DAIR) protocol is a viable treatment, offering several advantages over exchange arthroplasty. With the evolution of treatment strategies, considerable efforts have been directed towards enhancing the efficacy of DAIR, including the development of a phased debridement protocol for acute PJI management. This article provides an in-depth analysis of DAIR, presenting the outcomes of single-stage, two-stage, and repeated DAIR procedures. It delves into the challenges faced, including patient heterogeneity, pathogen identification, variability in surgical techniques, and antibiotics selection. Moreover, critical factors that influence the decision-making process between single- and two-stage DAIR protocols are addressed, including team composition, timing of the intervention, antibiotic regimens, and both anatomical and implant-related considerations. By providing a comprehensive overview of DAIR protocols and their clinical implications, this annotation aims to elucidate the advancements, challenges, and potential future directions in the application of DAIR for PJI management. It is intended to equip clinicians with the insights required to effectively navigate the complexities of implementing DAIR strategies, thereby facilitating informed decision-making for optimizing patient outcomes.
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Affiliation(s)
- Andreas Fontalis
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals NHS Foundation Trust, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Adam T Yasen
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Dia E Giebaly
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Tianyi D Luo
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals NHS Foundation Trust, London, UK
- Orthopaedics Northeast, Fort Wayne, Indiana, USA
| | - Ahmed Magan
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Fares S Haddad
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals NHS Foundation Trust, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
- The Princess Grace Hospital, London, UK
- The Bone & Joint Journal , London, UK
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De A, Chalmers BP, Springer BD, Browne JA, Lewallen DG, Stambough JB. What Is the Incidence of and Outcomes After Debridement, Antibiotics, and Implant Retention (DAIR) for the Treatment of Periprosthetic Joint Infections in the AJRR Population? Clin Orthop Relat Res 2024; 482:2042-2051. [PMID: 39246104 PMCID: PMC11469890 DOI: 10.1097/corr.0000000000003138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 05/07/2024] [Indexed: 09/10/2024]
Abstract
BACKGROUND Debridement, antibiotics, and implant retention (DAIR) is used to manage acute periprosthetic joint infections (PJIs) after total joint arthroplasty (TJA). Given the uncertain success of single or multiple DAIR attempts and possible long-term deleterious effects this treatment can create when trying to treat persistent infection, it is important to understand the frequency with which surgeons in the United States are attempting multiple debridements for PJI and whether those procedures are achieving the desired goal. QUESTION/PURPOSES In the context of the American Joint Replacement Registry (AJRR), we asked: (1) What proportion of patients who undergo DAIR have only one DAIR, and what percentage of those patients have more than one? (2) Of the patients who undergo one or more DAIR procedures, what is the proportion who progress to additional surgical procedures? (3) What is the cumulative incidence of medical or surgical endpoints related to infection on the affected leg (other than additional DAIR procedures)? METHODS DAIR procedures to treat PJI, defined by ICD-9/10 and CPT (Current Procedural Technology) codes, reported to the AJRR from 2012 to 2020 were merged with Centers for Medicare and Medicaid Services (CMS) data from 2012 to 2020 to determine the incidence of patients aged 65 and older who underwent additional PJI-related procedures on the same joint. Linking to CMS ensures no loss to follow-up or patient migration to a non-AJRR site. As of 2021, the AJRR captures roughly 35% of all arthroplasty procedures performed in the United States. Of the total 2.2 million procedures in the AJRR, only 0.2% of the procedures were eligible based on our inclusion criteria. Additionally, 61% of the total population is Medicare eligible, and thus, these patients are linked to CMS. Of the 5029 DAIR attempts after a TKA, 46% (2318) were performed in female patients. Similarly, there were a total of 798 DAIR attempts after a THA, and 50% (398) were performed in female patients. For the purposes of decreasing confounding factors, bilateral THAs and TKAs were excluded from the study population. When querying for eligible procedures from 2012 to 2020, the patient population was limited to those 65 years and older, and a subsequent reoperation for infection had to be reported after a primary TJA. This limited the patient population as most infections reported to AJRR resulted in a revision, and we were searching for DAIRs. Although 5827 TJAs were identified as a primary TJA with a subsequent infectious event, more than 65% (3788) of that population did not have a reported event. The following conditions were queried as secondary outcomes after the first DAIR: sepsis, cellulitis, postoperative infection, endocarditis, amputation, knee fusion, resection, drainage, arthrotomy, and debridement. To answer our first and second study questions, we used frequency testing from the available AJRR data. Because of competing risks and issues with incomplete data, we used the cumulative incidence function to evaluate the outcomes specific to study question 3. RESULTS Of the patients who underwent DAIR, 93% (5406 of 5827) had one DAIR and 8% (421 of 5827) had more than one. Among the DAIR population, at least 35% of TKAs and 38% of THAs were identified as having experienced an additional PJI-related event (an additional surgical procedure on the same joint, sustained an infectious endpoint in the linked CMS-AJRR dataset, or they had died). The cumulative incidence of developing a further medical or surgical condition related to the joint that had the initial DAIR were as follows: 48% (95% CI 42% to 54%) at 8 years after a DAIR following a TKA and 42% (95% CI 37% to 46%) at 4 years after a DAIR following a THA. The timepoints for TKA and THA are different because there are more longitudinal procedure data available for TKAs regarding DAIR procedures than for THAs. CONCLUSION In this study, we used data from the AJRR to assess the incidences of single and multiple DAIR attempts and additional surgical- and infection-related sequalae. Continued investigation is required to determine the fate of infected joints that undergo DAIR with regard to ultimate patient outcome. Future cross-sectional studies using large datasets are necessary to assess functional outcomes and determine the risk of persistent infection after DAIR more precisely. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Ayushmita De
- American Academy of Orthopaedic Surgeons, Rosemont, IL, USA
| | - Brian P. Chalmers
- Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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Lin Y, Chen W, Peng S, Chang C, Lee S, Lin S. Impact of unplanned second debridement, antibiotics and implant retention on long-term outcomes in knee exchange arthroplasty: Elevated risk of failure and reinfection. J Exp Orthop 2024; 11:e12024. [PMID: 38694767 PMCID: PMC11058667 DOI: 10.1002/jeo2.12024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 02/02/2024] [Accepted: 03/26/2024] [Indexed: 05/04/2024] Open
Abstract
Purpose This study investigates the outcomes of two-stage exchange arthroplasty (EA) for periprosthetic joint infection (PJI) following initial or unplanned repeat debridement antibiotics, and implant retention (DAIR). Methods We retrospectively reviewed cases of knee arthroplasty infection treated with two-stage EA after DAIR, spanning from January 1994 to December 2010. A total of 138 patients were included, comprising 112 with initial DAIR and 26 with an unplanned second DAIR. Data on demographics, comorbidities, infection characteristics and causative organisms were analyzed. The primary outcome was implant failure or reinfection, observed over a minimum follow-up of 10 years. Results The overall success rate for two-stage EA was 87% (119/138 patients). Factors identified for treatment failure included reinfection with the same pathogen for unplanned second DAIR (hazard ratio [HR] = 3.41; 95% confidence interval [CI] = 1.35-4.38; p = 0.004), higher reinfection rates in patients undergoing EA after an unplanned second DAIR, especially with a prior history of PJI within 2 years (HR = 4.23; 95% CI = 2.39-5.31; p = 0.002), pre-first DAIR C-reactive protein (CRP) levels over 100 mg/dL (HR = 2.52; 95% CI = 1.98-3.42; p = 0.003) and recurrence with the same pathogen (HR = 2.35; 95% CI = 1.32-4.24; p = 0.007). Additional factors such as male gender (HR = 3.92; 95% CI = 1.21-5.25; p = 0.007) and osteoporosis (T score < -2.5; HR = 3.27; 95% CI = 1.23-5.28; p = 0.005) were identified as risk factors for implant failure in all EA cases. Conclusions This study identifies key risk factors for worse knee EA outcomes following DAIR, including a pre-first DAIR CRP level over 100 mg/L, same pathogen recurrence, and PJI history within 2 years. It shows implant failure rates remain constant across EA cases, regardless of DAIR sequence, particularly with risk factors like male gender and severe osteoporosis (T score < -2.5). These results underscore the need for careful evaluation before an unplanned second DAIR, given its significant impact on EA success. Level of Evidence Level III.
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Affiliation(s)
- Yu‐Chih Lin
- Department of Orthopaedic SurgeryChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- Bone and Joint Research CenterChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- College of MedicineChang Gung University (CGU)KweishanTaoyuanTaiwan
| | - Wei‐Cheng Chen
- Department of Orthopaedic SurgeryChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- Bone and Joint Research CenterChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- College of MedicineChang Gung University (CGU)KweishanTaoyuanTaiwan
| | - Shih‐Hui Peng
- Department of Orthopaedic SurgeryChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- Bone and Joint Research CenterChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- College of MedicineChang Gung University (CGU)KweishanTaoyuanTaiwan
| | - Chih‐Hsiang Chang
- Department of Orthopaedic SurgeryChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- Bone and Joint Research CenterChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- College of MedicineChang Gung University (CGU)KweishanTaoyuanTaiwan
| | - Sheng‐Hsun Lee
- Department of Orthopaedic SurgeryChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- Bone and Joint Research CenterChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- College of MedicineChang Gung University (CGU)KweishanTaoyuanTaiwan
| | - Sheng‐Hsuan Lin
- Institute of StatisticsNational Yang Ming Chiao Tung UniversityHsinchuTaiwan
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Cortes-Penfield N, Krsak M, Damioli L, Henry M, Seidelman J, Hewlett A, Certain L. How We Approach Suppressive Antibiotic Therapy Following Debridement, Antibiotics, and Implant Retention for Prosthetic Joint Infection. Clin Infect Dis 2024; 78:188-198. [PMID: 37590953 DOI: 10.1093/cid/ciad484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/03/2023] [Accepted: 08/14/2023] [Indexed: 08/19/2023] Open
Abstract
The optimal treatment of prosthetic joint infection (PJI) remains uncertain. Patients undergoing debridement, antibiotics, and implant retention (DAIR) receive extended antimicrobial treatment, and some experts leave patients at perceived highest risk of relapse on suppressive antibiotic therapy (SAT). In this narrative review, we synthesize the literature concerning the role of SAT to prevent treatment failure following DAIR, attempting to answer 3 key questions: (1) What factors identify patients at highest risk for treatment failure after DAIR (ie, patients with the greatest potential to benefit from SAT), (2) Does SAT reduce the rate of treatment failure after DAIR, and (3) What are the rates of treatment failure and adverse events necessitating treatment discontinuation in patients receiving SAT? We conclude by proposing risk-benefit stratification criteria to guide use of SAT after DAIR for PJI, informed by the limited available literature.
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Affiliation(s)
- Nicolas Cortes-Penfield
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Martin Krsak
- Department of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Laura Damioli
- Department of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Michael Henry
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
- Department of Medicine, Division of Infectious Diseases, Hospital for Special Surgery, New York, New York, USA
| | - Jessica Seidelman
- Department of Medicine, Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Angela Hewlett
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Laura Certain
- Department of Orthopedic Surgery, University of Utah, Salt Lake City, Utah, USA
- Department of Internal Medicine, Division of Infectious Diseases, University of Utah, Salt Lake City, Utah, USA
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Yusuf E, Bramer W, Anas AA. Clinical outcomes of rifampicin combination therapy in implant-associated infections due to staphylococci and streptococci: A systematic review and meta-analysis. Int J Antimicrob Agents 2024; 63:107015. [PMID: 37875179 DOI: 10.1016/j.ijantimicag.2023.107015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 09/20/2023] [Accepted: 10/19/2023] [Indexed: 10/26/2023]
Abstract
OBJECTIVES Adjunctive rifampicin for implant-associated infections is controversial. This study investigated the clinical outcomes of rifampicin combination therapy compared with monotherapy in treating prosthetic joint infection (PJI) or prosthetic valve endocarditis (PVE) due to staphylococci and streptococci. METHODS A systematic search was performed from inception to 13 June 2022 in Embase, MEDLINE, Cochrane and Web of Science to investigate the clinical outcomes of rifampicin combination therapy compared with monotherapy in treating staphylococcal and streptococcal PJI or PVE. Randomised controlled trials (RCTs) and observational studies were included in the systematic review and meta-analysis. RESULTS Fourteen studies were included. A moderate quality of evidence was found in favour of rifampicin in patients with staphylococcal PJI who underwent a debridement, antibiotics and implant retention (DAIR) procedure [odds ratio = 2.49, 95% confidence interval (CI) 1.93-3.23]. Including the two RCTs only, adding rifampicin to the antibiotic regimen after DAIR was also in favour of rifampicin, but this was not statistically significant (risk ratio = 1.27, 95% CI 0.79-2.04; n = 126). Pooling data for patients with staphylococcal PJI who underwent a two-stage procedure showed that adding rifampicin was not associated with therapeutic success. Limited evidence was found for the use of rifampicin for PVE caused by staphylococci. CONCLUSIONS Adding rifampicin in the treatment of staphylococcal PJI treated by DAIR clearly increased the likelihood for therapeutic success. The clinical benefit of adjunctive rifampicin in the treatment of other staphylococci and streptococci implant-associated infections is still unclear.
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Affiliation(s)
- Erlangga Yusuf
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Wichor Bramer
- Medical Library, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Adam A Anas
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Internal Medicine, Section of Infectious Diseases, Erasmus University Medical Center, Rotterdam, the Netherlands.
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Scharf M, Schraag AD, Ehrnsperger M, Grifka J. [Structured approach for infected prosthesis]. Z Rheumatol 2023; 82:859-866. [PMID: 37851164 DOI: 10.1007/s00393-023-01421-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Endoprosthesis infections represent a major challenge for doctors and patients. Due to the increase in endoprosthesis implantation because of the increasing life expectancy, an increase in endoprosthesis infections is to be expected. In addition to infection prophylaxis, methods of infection control become highly relevant, especially in the group of geriatric and multimorbid patients. The aim is to reduce the high 1‑year mortality from prosthesis infections through a structured algorithm. ALGORITHM FOR PROSTHESIS INFECTIONS Prosthesis infections can basically be divided into early and late infections. According to the criteria of the International Consensus Meeting, a late infection is defined as the occurrence more than 30 days after implantation. With respect to the planned approach, the (p)TNM classification offers an orientation. In the early postoperative interval the clinical appearance is crucial as in this phase neither laboratory parameters nor an analysis of synovial fluid show a high sensitivity. It is fundamental that, apart from patients with sepsis, environment diagnostics should be initiated. If a late infection is suspected, in addition to radiological diagnostics (X-ray, skeletal scintigraphy and if necessary, computed tomography, CT), laboratory (C-reactive protein, CRP, leukocytes, blood sedimentation, and if necessary, interleukin‑6, procalcitonin) and microbiological diagnostics (arthrocentesis with synovial analysis and microbiology) are indicated; however, in addition to the arthrocentesis result, the clinical appearance is crucial in cases where an exclusion cannot be confirmed by laboratory parameters. If an infection is confirmed, the treatment depends on the spectrum of pathogens, the soft tissue situation and the comorbidities, including a multistage procedure with temporary explantation and, if necessary, implantation of an antibiotic-containing spacer is necessary. A prosthesis preservation using the debridement, antibiotics and implant retention (DAIR) regimen is only appropriate in an acute infection situation. Basically, radical surgical debridement should be carried out to reduce the pathogen load and treatment of a possible biofilm formation for both early and late infections. The subsequent antibiotic treatment (short or long interval) should be coordinated with the infectious disease specialists. CONCLUSION A structured approach for prosthesis infections oriented to an evidence-based algorithm provides a sufficient possibility of healing. An interdisciplinary approach involving cooperation between orthopedic and infectious disease specialists has proven to be beneficial. Surgical treatment with the aim of reducing the bacterial load by removing the biofilm with subsequent antibiotic treatment is of intrinsic importance.
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Affiliation(s)
- Markus Scharf
- Orthopädische Klinik für die Universität Regensburg im Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland.
| | - Amadeus Dominik Schraag
- Orthopädische Klinik für die Universität Regensburg im Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Marianne Ehrnsperger
- Orthopädische Klinik für die Universität Regensburg im Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Joachim Grifka
- Orthopädische Klinik für die Universität Regensburg im Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
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Akkaya M, Zanna L, Sangaletti R, Bokhari A, Gehrke T, Citak M. What Is the Most Reliable Concordance Rate of Preoperative Synovial Fluid Aspiration and Intraoperative Biopsy to Detect Periprosthetic Joint Infection in Knee, Hip and Shoulder Arthroplasty? Antibiotics (Basel) 2023; 12:1482. [PMID: 37887183 PMCID: PMC10604270 DOI: 10.3390/antibiotics12101482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 10/28/2023] Open
Abstract
The accuracy of preoperative synovial fluid microbe detection in periprosthetic joint infection (PJI) is widely reported. However, the reliability of this diagnostic modality amongst the different joints is not yet described. We aimed to compare the concordance rate between preoperative synovial fluid and intraoperative tissue cultures in shoulder, knee and hip PJIs. A total of 150 patients who met the 2018 International Consensus Meeting criteria for shoulder, hip and knee PJI were retrospectively reviewed. This cohort was divided into three groups based on the involved joint (should, hip or knee), with 50 patients in each group. Cultures were collected and held for culture for 14 days. The overall concordance rate was 56.7%. Concordance rates between preoperative and intraoperative cultures were 60%, 56% and 54% for the knee, shoulder and hip joints, respectively. The analysis of high- or low-virulence and difficult- or not-difficult-to-treat germs did not reveal any significant differences between preoperative and intraoperative cultures in any of the groups. However, even considering the higher concordance in knee PJI, the overall discordance between preoperative and intraoperative cultures should prompt surgeons not to rely solely on preoperative synovial fluid culture data in determining appropriate treatment and antibiotics.
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Affiliation(s)
| | | | | | | | | | - Mustafa Citak
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, 22767 Hamburg, Germany; (M.A.); (L.Z.); (R.S.); (A.B.)
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Hulleman CWJ, de Windt TS, Veerman K, Goosen JHM, Wagenaar FCBM, van Hellemondt GG. Debridement, Antibiotics and Implant Retention: A Systematic Review of Strategies for Treatment of Early Infections after Revision Total Knee Arthroplasty. J Clin Med 2023; 12:5026. [PMID: 37568428 PMCID: PMC10419891 DOI: 10.3390/jcm12155026] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
GOAL The purpose of this review is to provide a systematic and comprehensive overview of the available literature on the treatment of an early prosthetic joint infection (PJI) after revision total knee arthroplasty (TKA) and provide treatment guidelines. METHODS This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The search was conducted using the electronic databases of PubMed, Trip, Cochrane, Embase, LILACS and SciElo. After the inclusion of the relevant articles, we extracted the data and results to compose a treatment algorithm for early and acute PJI after revision TKA. RESULTS After applying the in- and exclusion criteria, seven articles were included in this systematic review focusing on debridement, antibiotics and implant retention (DAIR) for PJI following revision TKA, of which one was prospective and six were retrospective. All studies were qualified as level IV evidence. CONCLUSIONS The current literature suggests that DAIR is a valid treatment option for early infections after revision TKA with success rates of 50-70%. Repeat DAIR shows success rates of around 50%. Further research should be aimed at predicting successful (repeat/two-stage) DAIRs in larger study populations, antibiotic regimes and the cost effectiveness of a second DAIR after revision TKA.
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Affiliation(s)
- Caspar W. J. Hulleman
- Sint Maartenskliniek, Orthopedic Surgery, 6574 NA Nijmegen, The Netherlands; (C.W.J.H.)
| | - Tommy S. de Windt
- Orthopedisch Centrum Oost Nederland, Orthopedic Center, 7555 DL Hengelo, The Netherlands
| | - Karin Veerman
- Sint Maartenskliniek, Orthopedic Surgery, 6574 NA Nijmegen, The Netherlands; (C.W.J.H.)
| | - Jon H. M. Goosen
- Sint Maartenskliniek, Orthopedic Surgery, 6574 NA Nijmegen, The Netherlands; (C.W.J.H.)
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Wakabayashi H, Hasegawa M, Naito Y, Tone S, Sudo A. Outcome of Irrigation and Debridement with Topical Antibiotic Delivery Using Antibiotic-Impregnated Calcium Hydroxyapatite for the Management of Periprosthetic Hip Joint Infection. Antibiotics (Basel) 2023; 12:antibiotics12050938. [PMID: 37237841 DOI: 10.3390/antibiotics12050938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 05/03/2023] [Accepted: 05/19/2023] [Indexed: 05/28/2023] Open
Abstract
We assessed the clinical results of irrigation and debridement (I&D) with antibiotic-impregnated calcium hydroxyapatite (CHA) as a novel antibiotic delivery system for the treatment of prosthetic-joint-associated infection (PJI) after total hip arthroplasty (THA). Thirteen patients (14 hips) treated with I&D for PJI after THA at our institution between 1997 and 2017 were retrospectively evaluated. The study group included four men (five hips) and nine women, with an average age of 66.3 years. Four patients (five hips) had symptoms of infection within less than 3 weeks; however, nine patients had symptoms of infection over 3 weeks. All patients received I&D with antibiotic-impregnated CHA in the surrounding bone. In two hips (two cups and one stem), cup and/or stem revision were performed with re-implantation because of implant loosening. In ten patients (11 hips), vancomycin hydrochloride was impregnated in the CHA. The average duration of follow-up was 8.1 years. Four patients included in this study died of other causes, with an average follow-up of 6.7 years. Eleven of thirteen patients (12 of 14 hips) were successfully treated, and no signs of infection were observed at the latest follow-up. In two patients (two hips) for whom treatment failed, infection was successfully treated with two-stage re-implantation. Both patients had diabetes mellitus and symptoms of infection over 3 weeks. Eighty-six percent of patients were successfully treated. No complications were observed with this antibiotic-impregnated CHA. I&D treatment with antibiotic-impregnated CHA produced a higher rate of success in patients with PJI after THA.
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Affiliation(s)
- Hiroki Wakabayashi
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Masahiro Hasegawa
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Yohei Naito
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Shine Tone
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Akihiro Sudo
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
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Deckey DG, Christopher ZK, Bingham JS, Spangehl MJ. Principles of mechanical and chemical debridement with implant retention. ARTHROPLASTY 2023; 5:16. [PMID: 37020248 PMCID: PMC10077701 DOI: 10.1186/s42836-023-00170-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 01/17/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is one of the most common causes of early revision for total hip and knee arthroplasty. Mechanical and chemical debridement typically referred to as debridement, antibiotics, and implant retention (DAIR) can be a successful technique to eradicate PJI in acute postoperative or acute hematogenous infections. This review will focus specifically on the indications, techniques, and outcomes of DAIR. DISCUSSION The success of mechanical and chemical debridement, or a DAIR operation, is reliant on a combination of appropriate patient selection and meticulous technique. There are many technical considerations to take into consideration. One of the most important factors in the success of the DAIR procedure is the adequacy of mechanical debridement. Techniques are surgeon-specific and perhaps contribute to the large variability in the literature on the success of DAIR. Factors that have been shown to be associated with success include the exchange of modular components, performing the procedure within seven days or less of symptom onset, and possibly adjunctive rifampin or fluoroquinolone therapy, though this remains controversial. Factors that have been associated with failure include rheumatoid arthritis, age greater than 80 years, male sex, chronic renal failure, liver cirrhosis, and chronic obstructive pulmonary disease. CONCLUSIONS DAIR is an effective treatment option for the management of an acute postoperative or hematogenous PJI in the appropriately selected patient with well-fixed implants.
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Affiliation(s)
- David G Deckey
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, AZ, 85054, USA
| | | | - Joshua S Bingham
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Mark J Spangehl
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, AZ, 85054, USA.
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Sancho I, Otermin-Maya I, Gutiérrez-Dubois J, Aláez I, Librero J, Portillo ME, Hidalgo-Ovejero Á. Redo DAIR: The Game Is Seldom Worth the Candle. Antibiotics (Basel) 2022; 12:antibiotics12010018. [PMID: 36671219 PMCID: PMC9854634 DOI: 10.3390/antibiotics12010018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 12/08/2022] [Accepted: 12/21/2022] [Indexed: 12/24/2022] Open
Abstract
Debridement, antibiotics and implant retention (DAIR) remains a commonly utilized technique in the treatment of acute prosthetic joint infections despite its inconsistent outcomes. The performance of a second DAIR after a failed first debridement is controversial as outcomes are uncertain and the final prognosis in the event of failure may be unfavorable. This study analyzes 84 cases of acute prosthetic (hip & knee) joint infection treated with DAIR between 2011 and 2020 at the same institution. In 12 failed cases, a second DAIR was performed, whose success rate was significantly lower than that of the first procedure (8% [95% CI, 0-38] vs. 57% [46-68]). Moreover, the ultimate outcome of the second failed DAIRs was unfavorable with eradication of the infection being achieved in none of the patients. Due to the high likelihood of failure and the potentially grim final prognosis following a second debridement, removal of the components should be considered.
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Affiliation(s)
- Ignacio Sancho
- Department of Orthopaedics and Trauma Surgery, Hospital Reina Sofía, 31500 Tudela, Spain
- Department of Orthopaedics and Trauma Surgery, Hospital Universitario de Navarra, 31008 Pamplona, Spain
- Campus de Arrosadía, Universidad Pública de Navarra (UPNA), 31008 Pamplona, Spain
- Correspondence: (I.S.); (M.E.P.)
| | - Iñaki Otermin-Maya
- Department of Internal Medicine, Hospital Universitario de Navarra, 31008 Pamplona, Spain
| | - Jorge Gutiérrez-Dubois
- Department of Internal Medicine, Hospital Universitario de Navarra, 31008 Pamplona, Spain
| | - Ignacio Aláez
- Department of Internal Medicine, Hospital Universitario de Navarra, 31008 Pamplona, Spain
| | - Julián Librero
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
- Navarrabiomed, Complejo Hospitalario de Navarra—UPNA, 31008 Pamplona, Spain
| | - Maria Eugenia Portillo
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
- Department of Microbiology, Hospital Universitario de Navarra, 31008 Pamplona, Spain
- Correspondence: (I.S.); (M.E.P.)
| | - Ángel Hidalgo-Ovejero
- Department of Orthopaedics and Trauma Surgery, Hospital Universitario de Navarra, 31008 Pamplona, Spain
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20
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van Schaik T, de Jong L, van Meer M, Goosen J, Somford M. The concordance between preoperative synovial fluid culture and intraoperative tissue cultures in periprosthetic joint infection: a systematic review. J Bone Jt Infect 2022; 7:259-267. [PMID: 36644592 PMCID: PMC9832305 DOI: 10.5194/jbji-7-259-2022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/11/2022] [Indexed: 12/15/2022] Open
Abstract
Background: this systematic review aims to evaluate the concordance between preoperative synovial fluid culture and intraoperative tissue cultures in patients with periprosthetic joint infection (PJI) undergoing total hip (THA) or knee arthroplasty (TKA) revision surgery. Methods: this review was conducted in accordance with the preferred reporting items for a systematic review and meta-analysis of diagnostic test accuracy studies (PRISMA-DTA) statement. Cochrane, Embase, PubMed, and Web of Science databases were searched to identify studies involving patients who had THA or TKA revision surgery for PJI and for whom preoperative synovial fluid culture and intraoperative tissue cultures were performed. Studies were only included if the diagnosis of PJI was based on the EBJIS (the European Bone and Joint Infection Society) or MSIS (Musculoskeletal Infection Society) criteria. Risk of bias was assessed using an amended version of Joanna Briggs Institute's (JBI) critical appraisal checklist for case series. Results: seven studies were included in this review comprising 1677 patients. All studies had a retrospective study design and five studies explored patients undergoing revision surgery of THA or TKA. Concordance rates varied between 52 % and 79 %, but different authors defined and calculated concordance differently. Six studies were judged as having an unclear to high risk of bias and one study as having a low risk of bias. Conclusions: the included studies showed a wide range of concordance rates between preoperative synovial fluid culture and intraoperative tissue cultures and the majority of studies had a high risk of bias. Higher-quality studies are warranted to obtain a more accurate estimate of this concordance rate. We recommend continuing the use of a system such as the EBJIS definition or MSIS criteria when diagnosing PJI.
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Affiliation(s)
- Thomas J. A. van Schaik
- Department of Orthopedic Surgery, Rijnstate Ziekenhuis, Arnhem, the
Netherlands
- Department of Orthopedic Surgery, Radboudumc, Nijmegen, the
Netherlands
| | - Lex D. de Jong
- Department of Orthopedic Surgery, Rijnstate Ziekenhuis, Arnhem, the
Netherlands
| | - Maurits P. A. van Meer
- Department of Medical Microbiology and Immunology, Rijnstate
Ziekenhuis, Arnhem, the Netherlands
| | - Jon H. M. Goosen
- Department of Orthopedic Surgery, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Matthijs P. Somford
- Department of Orthopedic Surgery, Rijnstate Ziekenhuis, Arnhem, the
Netherlands
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21
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Bernaus M, Auñón-Rubio Á, Monfort-Mira M, Arteagoitia-Colino I, Martínez-Ros J, Castellanos J, Lamo-Espinosa JM, Argüelles F, Veloso M, Gómez García L, Crespo FA, Sánchez-Fernández J, Murias-Álvarez J, Martí-Garín D, Hernández-González N, Villarejo-Fernández B, Valero-Cifuentes G, Hernández-Torres A, Molina-González J, Coifman-Lucena I, Esteban-Moreno J, Demaria P, Esteve-Palau E, Del Pozo JL, Suárez Á, Carmona-Torre F, Darás Á, Baeza J, Font-Vizcarra L. Risk Factors of DAIR Failure and Validation of the KLIC Score: A Multicenter Study of Four Hundred Fifty-Five Patients. Surg Infect (Larchmt) 2022; 23:280-287. [PMID: 35172116 DOI: 10.1089/sur.2021.320] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Debridement, antibiotic agents, and implant retention (DAIR) is a currently accepted approach for the treatment of early prosthetic joint infections (PJI). The success of a DAIR procedure has shown variable results throughout the published literature. Scoring systems such as the Kidney, Liver, Index surgery, Cemented prosthesis, and C-reactive protein value (KLIC) score for the selection of patients that are likely to benefit from DAIR have proved to be helpful in decision making. Our study aims to further validate the KLIC score using a large external multicentric cohort and to evaluate other risk factors for failure. Patients and Methods: A retrospective analysis of patients with an early acute PJI who were treated with DAIR and recorded in a database of eight Spanish university hospitals was performed. According to pre-operative variables of the KLIC study, patients were categorized into five groups: group A, ≤2 points; group B, 2.5-3.5 points; group C, 4-5 points; group D, 5.5-6.5 points; and group E, ≥7 points. Failure rates were compared between groups at 60 days and after 60 days of DAIR. Further variables for risk of failure were also analyzed. Results: A total of 455 patients with early acute PJI were included in the analyses. At 60 days, patients presenting with pre-operative elevated C-reactive protein serum levels, Staphylococcus aureus, and polymicrobial infections were associated with failure. Failure rates recorded were 12% for group A (n = 210), 18% for group B (n = 83), 26% for group C (n = 89), 24% for group D (n = 66), and 0% for group E (n = 7). Univariable analysis between consecutive groups of the KLIC score showed no differences for failure before 60 days of the DAIR procedure. Scheduled surgery and having the procedure performed by a specialized unit were also identified as important factors for DAIR success. Conclusions: Our results suggest the KLIC score was not useful for predicting failure in our cohort. Furthermore, our results indicate a specialized unit should conduct DAIR procedures.
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Affiliation(s)
- Martí Bernaus
- Department of Orthopedics and Traumatology, Osteoarticular Infection Unit, Hospital Universitari Mutua Terrassa, Barcelona, Spain
| | - Álvaro Auñón-Rubio
- Department of Orthopedics and Traumatology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Montserrat Monfort-Mira
- Septic Unit, Orthopedic Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | | | - Javier Martínez-Ros
- Osteoarticular Infection Unit, Department of Orthopedics and Traumatology, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Juan Castellanos
- Department of Orthopedics and Traumatology, Hospital General del Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain
| | | | - Francisco Argüelles
- Department of Orthopedics and Traumatology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Margarita Veloso
- Department of Orthopedics and Traumatology, Osteoarticular Infection Unit, Hospital Universitari Mutua Terrassa, Barcelona, Spain
| | - Lucia Gómez García
- Department of Infectious Diseases, Osteoarticular Infection Unit, Hospital Universitari Mutua Terrassa, Barcelona, Spain
| | - Francesc Anglès Crespo
- Department of Orthopedics and Traumatology, Osteoarticular Infection Unit, Hospital Universitari Mutua Terrassa, Barcelona, Spain
- Department of Surgery, Universitat de Barcelona, Barcelona, Spain
| | - Joel Sánchez-Fernández
- Septic Unit, Orthopedic Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Juan Murias-Álvarez
- Septic Unit, Orthopedic Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - David Martí-Garín
- Septic Unit, Orthopedic Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | | | | | - Gregorio Valero-Cifuentes
- Osteoarticular Infection Unit, Department of Orthopedics and Traumatology, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Alícia Hernández-Torres
- Osteoarticular Infection Unit, Department of Infectious Diseases, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - José Molina-González
- Osteoarticular Infection Unit, Department of Orthopedics and Traumatology, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Ismael Coifman-Lucena
- Department of Orthopedics and Traumatology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Jaime Esteban-Moreno
- Department of Microbiology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Pablo Demaria
- Department of Orthopedics and Traumatology, Hospital General del Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain
| | - Erika Esteve-Palau
- Department of Infectious Diseases, Parc Sanitari Sant Joan de Deu, Sant Boi de Llobregat, Barcelona, Spain
| | - José Luis Del Pozo
- Department of Infectious Diseases, Clínica Universidad de Navarra, Pamplona, Spain
| | - Álvaro Suárez
- Department of Orthopedics and Traumatology, Clínica Universidad de Navarra, Pamplona, Spain
| | | | - Álvaro Darás
- Department of Orthopedics and Traumatology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - José Baeza
- Department of Orthopedics and Traumatology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Lluís Font-Vizcarra
- Department of Orthopedics and Traumatology, Osteoarticular Infection Unit, Hospital Universitari Mutua Terrassa, Barcelona, Spain
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22
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Reinisch K, Schläppi M, Meier C, Wahl P. Local antibiotic treatment with calcium sulfate as carrier material improves the outcome of debridement, antibiotics, and implant retention procedures for periprosthetic joint infections after hip arthroplasty – a retrospective study. J Bone Jt Infect 2022; 7:11-21. [PMID: 35111565 PMCID: PMC8795886 DOI: 10.5194/jbji-7-11-2022] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 12/14/2021] [Indexed: 11/11/2022] Open
Abstract
Abstract. Purpose: Debridement, antibiotics, and implant retention (DAIR) is an established treatment modality in periprosthetic joint infections (PJIs), but success rates vary. This study compared the success of DAIR for PJIs after a total hip arthroplasty (THA), with or without local antibiotic delivery with CaSO4 as the carrier material.
Methods: A retrospective review of DAIR for PJIs after THA performed between 2010 and 2018, including 41 patients is conducted. A total of 27 patients were treated by DAIR with local antibiotics with CaSO4 as the carrier material, and 14 patients were treated by a standard DAIR. The endpoints were treatment failure, defined as the need for a reoperation, either a second DAIR or a prosthesis removal or exchange due to persistent or recurrent infection, the initiation of a long-term suppressive antibiotic treatment, or death related to infection.
Results: Considering any reoperation as an outcome, 11 of 14 cases treated without AB-CaSO4 (79 %) and 4 of the 27 cases treated with
AB-CaSO4 failed (15 %). Considering revision as an outcome, 9 out of 14 cases treated without AB-CaSO4 (64 %) and 4 of the 27 cases treated with AB-CaSO4 (15 %) failed. A Kaplan–Meier survival analysis showed that local antibiotic delivery with CaSO4 as the carrier material led to a significantly longer infection-free survival, considering any surgical revision (p<0.0001; hazard ratio 8.9 (95 % CI 2.8–28.2)) or revision with component exchange (p=0.0015; hazard ratio 5.6 (95 % CI 1.7–18.2)) as the endpoint.
Conclusion: The addition of local antibiotics with CaSO4 as the carrier material to DAIR for PJIs after THA significantly increases success rates, such as infection-free survival, any reoperation, and revision with component exchange in particular.
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23
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Debridement, Antibiotics, and Implant Retention in Periprosthetic Joint Infection: What Predicts Success or Failure? J Arthroplasty 2021; 36:3562-3569. [PMID: 34116912 DOI: 10.1016/j.arth.2021.05.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 03/17/2021] [Accepted: 05/13/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Debridement, antibiotics and implant retention (DAIR) is the treatment of choice for acute postoperative and acute hematogenous periprosthetic joint infection (PJI). There is limited literature on predictive prognostic factors for DAIR. We aim to report the outcomes of DAIR and investigate the predictive prognostic factors. METHODS We retrospectively reviewed 106 DAIRs. Failure was defined as requiring removal of TKA implants. Predictive factors that may influence success of DAIR treatment such as age, gender, body mass index, ethnicity, American Society of Anesthesiologists score, comorbidities, preoperative erythrocyte sedimentation rate (ESR) and C-reactive protein, symptom duration, time between total knee arthroplasty and DAIR, cultures, rifampicin use, polyethylene liner change, and antibiotic duration were analyzed. RESULTS The success rate of DAIR was 69.8% (74/106 patients). For successes, mean time from DAIR-to-mortality was longer than failures (61.6 ± 42.7 vs 9.75 ± 9.60 months, P = .0150). Methicillin-susceptible Staphylococcus aureus PJI (odds ratio [OR] 3.64, confidence interval [CI] 1.30-10.2, P = .0140) was a significant predictor for failure of DAIR. Higher preoperative ESR correlated to failure (OR 1.02, CI 1.01-1.04, P = .008). In successes, mean ESR was 75.4 (66.1-84.6), whereas mean ESR in failures was 116 (88.3-143) (P = .011). An ESR > 107.5 predicted failure with a sensitivity of 51.5 and specificity of 85.2. ESR > 107.5 correlated to failure (OR 6.60, CI 2.29-19.0, P < .001). Repeat DAIRs were strongly correlated to failure (OR 5.27, CI 1.99-13.9, P < .01). CONCLUSION DAIR failure is associated with earlier time to mortality. Repeat DAIRs, elevated ESR > 107.5, and S aureus PJI are associated with treatment failure and 2-stage revision is recommended.
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24
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Lehnen A, Wyss R, Meier C, Kalberer F, Breitenstein S, Wahl P. A Coxoperitoneal Shunt as Salvage for a Recurrent Giant Seroma of the Hip After Periprosthetic Joint Infection: A Case Report. JBJS Case Connect 2021; 11:01709767-202109000-00036. [PMID: 34293775 DOI: 10.2106/jbjs.cc.20.00931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A giant seroma developed in the hip of a 44-year-old man after resection arthroplasty performed for recurrent periprosthetic joint infection (PJI). The seroma persisted despite joint reconstruction but was ultimately treated successfully by internal drainage through a coxoperitoneal shunt. CONCLUSION Resection arthroplasty of the hip is considered a salvage procedure for failed implant retention in the situation of persistent PJI. Nevertheless, functional results are poor and further soft-tissue complications may occur. A giant seroma of the hip may be drained into the peritoneal cavity, permitting healing without risking contamination from external, percutaneous drainage.
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Affiliation(s)
- Aude Lehnen
- Division of Orthopaedics and Traumatology, Cantonal Hospital Winterthur, Winterthur, Switzerland
- Department of Surgery, Hospital Centre Biel, Biel, Switzerland
| | - Roland Wyss
- Division of Digestive Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Christoph Meier
- Division of Orthopaedics and Traumatology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Fabian Kalberer
- Division of Orthopaedics and Traumatology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Stefan Breitenstein
- Division of Digestive Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Peter Wahl
- Division of Orthopaedics and Traumatology, Cantonal Hospital Winterthur, Winterthur, Switzerland
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25
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Scheper H, Gerritsen LM, Pijls BG, Van Asten SA, Visser LG, De Boer MGJ. Outcome of Debridement, Antibiotics, and Implant Retention for Staphylococcal Hip and Knee Prosthetic Joint Infections, Focused on Rifampicin Use: A Systematic Review and Meta-Analysis. Open Forum Infect Dis 2021; 8:ofab298. [PMID: 34258321 PMCID: PMC8271145 DOI: 10.1093/ofid/ofab298] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 06/02/2021] [Indexed: 11/13/2022] Open
Abstract
The treatment of staphylococcal prosthetic joint infection (PJI) with debridement, antibiotics, and retention of the implant (DAIR) often results in failure. An important evidence gap concerns the treatment with rifampicin for PJI. A systematic review and meta-analysis were conducted to assess the outcome of staphylococcal hip and/or knee PJI after DAIR, focused on the role of rifampicin. Studies published until September 2, 2020 were included. Success rates were stratified for type of joint and type of micro-organism. Sixty-four studies were included. The pooled risk ratio for rifampicin effectiveness was 1.10 (95% confidence interval, 1.00-1.22). The pooled success rate was 69% for Staphylococcus aureus hip PJI, 54% for S aureus knee PJI, 83% for coagulase-negative staphylococci (CNS) hip PJI, and 73% for CNS knee PJI. Success rates for MRSA PJI (58%) were similar to MSSA PJI (60%). The meta-analysis indicates that rifampicin may only prevent a small fraction of all treatment failures.
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Affiliation(s)
- H Scheper
- Department of Infectious Diseases, Leiden University Medical Centre, Leiden, The Netherlands
| | - L M Gerritsen
- Department of Infectious Diseases, Leiden University Medical Centre, Leiden, The Netherlands
| | - B G Pijls
- Department of Orthopaedic Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - S A Van Asten
- Department of Microbiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - L G Visser
- Department of Infectious Diseases, Leiden University Medical Centre, Leiden, The Netherlands
| | - M G J De Boer
- Department of Infectious Diseases, Leiden University Medical Centre, Leiden, The Netherlands
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26
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GMI, an Immunomodulatory Peptide from Ganoderma microsporum, Restrains Periprosthetic Joint Infections via Modulating the Functions of Myeloid-Derived Suppressor Cells and Effector T Cells. Int J Mol Sci 2021; 22:ijms22136854. [PMID: 34202218 PMCID: PMC8268560 DOI: 10.3390/ijms22136854] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/22/2021] [Accepted: 06/22/2021] [Indexed: 12/30/2022] Open
Abstract
Periprosthetic joint infections (PJIs) caused by Staphylococcus aureus infection are difficult to treat due to antibiotic resistance. It is known that the biofilms from methicillin-resistant S. aureus (MRSA) promote expansion of myeloid-derived suppressor cells (MDSCs) to suppress T-cell proliferation and benefit bacterial infections. This study finds that GMI, a fungal immunomodulatory peptide isolated from Ganoderma microsporum, suppresses MDSC expansion to promote the proliferation of cytotoxic T cells. The enhancement is likely attributed to increased expression of IL-6 and TNF-α and reduction in ROS expression. Similar beneficial effects of GMI on the suppression of MDSC expansion and IL-6 expression are also observed in the whole blood and reduces the accumulation of MDSCs in the infected bone region in a mouse PJI infection model. This study shows that GMI is potentially useful for treating S. aureus-induced PJIs.
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27
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Wouthuyzen-Bakker M, Shohat N, Parvizi J, Soriano A. Risk Scores and Machine Learning to Identify Patients With Acute Periprosthetic Joints Infections That Will Likely Fail Classical Irrigation and Debridement. Front Med (Lausanne) 2021; 8:550095. [PMID: 34012968 PMCID: PMC8126631 DOI: 10.3389/fmed.2021.550095] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 03/23/2021] [Indexed: 11/24/2022] Open
Abstract
The most preferred treatment for acute periprosthetic joint infection (PJI) is surgical debridement, antibiotics and retention of the implant (DAIR). The reported success of DAIR varies greatly and depends on a complex interplay of several host-related factors, duration of symptoms, the microorganism(s) causing the infection, its susceptibility to antibiotics and many others. Thus, there is a great clinical need to predict failure of the "classical" DAIR procedure so that this surgical option is offered to those most likely to succeed, but also to identify those patients who may benefit from more intensified antibiotic treatment regimens or new and innovative treatment strategies. In this review article, the current recommendations for DAIR will be discussed, a summary of independent risk factors for DAIR failure will be provided and the advantages and limitations of the clinical use of preoperative risk scores in early acute (post-surgical) and late acute (hematogenous) PJIs will be presented. In addition, the potential of implementing machine learning (artificial intelligence) in identifying patients who are at highest risk for failure of DAIR will be addressed. The ultimate goal is to maximally tailor and individualize treatment strategies and to avoid treatment generalization.
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Affiliation(s)
- Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Noam Shohat
- Department of Orthopaedic Surgery, Yitzhak Shamir Medical Center, Zriffin, Israel
- Department of Orthopaedic Surgery, Tel Aviv University, Tel Aviv, Israel
| | - Javad Parvizi
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Alex Soriano
- Service of Infectious Diseases, Hospital Clínic, University of Barcelona, Barcelona, Spain
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28
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Löwik CAM, Parvizi J, Jutte PC, Zijlstra WP, Knobben BAS, Xu C, Goswami K, Belden KA, Sousa R, Carvalho A, Martínez-Pastor JC, Soriano A, Wouthuyzen-Bakker M. Debridement, Antibiotics, and Implant Retention Is a Viable Treatment Option for Early Periprosthetic Joint Infection Presenting More Than 4 Weeks After Index Arthroplasty. Clin Infect Dis 2021; 71:630-636. [PMID: 31504331 DOI: 10.1093/cid/ciz867] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 08/30/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The success of debridement, antibiotics, and implant retention (DAIR) in early periprosthetic joint infection (PJI) largely depends on the presence of a mature biofilm. At what time point DAIR should be disrecommended is unknown. This multicenter study evaluated the outcome of DAIR in relation to the time after index arthroplasty. METHODS We retrospectively evaluated PJIs occurring within 90 days after surgery and treated with DAIR. Patients with bacteremia, arthroscopic debridements, and a follow-up <1 year were excluded. Treatment failure was defined as (1) any further surgical procedure related to infection; (2) PJI-related death; or (3) use of long-term suppressive antibiotics. RESULTS We included 769 patients. Treatment failure occurred in 294 patients (38%) and was similar between time intervals from index arthroplasty to DAIR: the failure rate for Week 1-2 was 42% (95/226), the rate for Week 3-4 was 38% (143/378), the rate for Week 5-6 was 29% (29/100), and the rate for Week 7-12 was 42% (27/65). An exchange of modular components was performed to a lesser extent in the early post-surgical course compared with the late course (41% vs 63%, respectively; P < .001). The causative microorganisms, comorbidities, and durations of symptoms were comparable between time intervals. CONCLUSIONS DAIR is a viable option in patients with early PJI presenting more than 4 weeks after index surgery, as long as DAIR is performed within at least 1 week after the onset of symptoms and modular components can be exchanged.
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Affiliation(s)
- Claudia A M Löwik
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Javad Parvizi
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Paul C Jutte
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Wierd P Zijlstra
- Department of Orthopaedic Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Bas A S Knobben
- Department of Orthopaedic Surgery, Martini Hospital, Groningen, The Netherlands
| | - Chi Xu
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Karan Goswami
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Katherine A Belden
- Department of Infectious Diseases, Sydney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ricardo Sousa
- Department of Orthopaedic Surgery, Centro Hospitalar do Porto, Porto, Portugal
| | - André Carvalho
- Department of Orthopaedic Surgery and Traumatology, University of Barcelona, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Juan Carlos Martínez-Pastor
- Department of Orthopaedic Surgery and Traumatology, University of Barcelona, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Alex Soriano
- Department of Infectious Diseases, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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29
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Tonnelier M, Bouras A, Joseph C, Samad YE, Brunschweiler B, Schmit JL, Mabille C, Lanoix JP. Impact of rifampicin dose in bone and joint prosthetic device infections due to Staphylococcus spp: a retrospective single-center study in France. BMC Infect Dis 2021; 21:174. [PMID: 33579208 PMCID: PMC7881571 DOI: 10.1186/s12879-021-05832-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 01/22/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Prosthetic joint infections (PJI) are a major cause of morbidity and mortality burden worldwide. While surgical management is well defined, rifampicin (RIF) dose remains controversial. The aim of our study was to determine whether Rifampicin dose impact infection outcomes in PJI due to Staphylococcus spp. METHODS single-center retrospective study including 411 patients with PJI due to Rifampicin-sensitive Staphylococcus spp. Rifampicine dose was categorized as follow: < 10 mg/kg/day, 10-20 mg/kg/day or > 20 mg/kg/day. The primary endpoint was patient recovery, defined as being free of infection during 12 months after the end of the initial antibiotic course. RESULTS 321 (78%) received RIF for the full antibiotic course. RIF dose didn't affect patients recovery rate with 67, 76 and 69% in the < 10, 10-20 and > 20 mg/kg/day groups, respectively (p = 0.083). In univariate analysis, recovery rate was significantly associated with gender (p = 0.012) but not to RIF dose, or Staphylococcus phenotype (aureus or coagulase-negative). In multivariate analysis, age (p = 0.01) and treatment duration (p < 0.01) were significantly associated with recovery rate. CONCLUSION These data suggest that lower doses of RIF are as efficient and safe as the recommended high-dose French regimen in the treatment of PJI.
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Affiliation(s)
- M Tonnelier
- Infectious diseases department, CHU Amiens Nord, 1 place Victor Pauchet, 80000, Amiens, France.
- Centre hospitalier Compiègne-Noyon - service MIPI, 8 avenue Henri Adnot, 60200, Compiègne, France.
| | - A Bouras
- Infectious diseases department, CHU Amiens Nord, 1 place Victor Pauchet, 80000, Amiens, France
| | - C Joseph
- Infectious diseases department, CHU Amiens Nord, 1 place Victor Pauchet, 80000, Amiens, France
- UR 4294 AGIR, Université Picardie Jules Verne, 1-3 rue des Louvels, 80000, Amiens, France
| | - Y El Samad
- Infectious diseases department, CHU Amiens Nord, 1 place Victor Pauchet, 80000, Amiens, France
| | - B Brunschweiler
- Orthopedic department, CHU Amiens Sud, 1 rue du Professeur Christian Cabrol, 80054, Amiens, France
| | - J-L Schmit
- Infectious diseases department, CHU Amiens Nord, 1 place Victor Pauchet, 80000, Amiens, France
- UR 4294 AGIR, Université Picardie Jules Verne, 1-3 rue des Louvels, 80000, Amiens, France
| | - C Mabille
- Pharmacy department, CHU Amiens Sud, 1 rue du Professeur Christian Cabrol, 80054, Amiens, France
| | - J-P Lanoix
- Infectious diseases department, CHU Amiens Nord, 1 place Victor Pauchet, 80000, Amiens, France
- UR 4294 AGIR, Université Picardie Jules Verne, 1-3 rue des Louvels, 80000, Amiens, France
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Xu Y, Wang L, Xu W. Risk factors affect success rate of debridement, antibiotics and implant retention (DAIR) in periprosthetic joint infection. ARTHROPLASTY 2020; 2:37. [PMID: 35236454 PMCID: PMC8796582 DOI: 10.1186/s42836-020-00056-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/27/2020] [Indexed: 12/23/2022] Open
Abstract
Background Periprosthetic joint infection (PJI) is the most devastating complication of joint replacement that seriously affects the quality of life and causes a heavy burden to the families and society. Due to shorter hospital stays, lower costs, improved joint function and less morbidity, a process of debridement, antibiotics and implant retention (DAIR) is recommended as the preferred treatment for acute periprosthetic joint infection. However, the factors that impact the success rate of DAIR remain controversial. This article evaluates the influential factors of DAIR and provides insights for orthopaedics surgeons to make optimal decisions to improve the success rate of DAIR. Conclusion The poor general condition of patients, high preoperative C-reactive protein (CRP) level, repeated joint surgeries, and Methicillin-resistant Staphylococcus aureus (MRSA) infections may be associated with lower DAIR success rate. To the contrary, early surgery, radical debridement, exchange of removable components, washing with iodine and vacuum sealing drainage (VSD) may improve the success rate of DAIR. A sinus tract may not be absolutely contraindicated, but surgeons should treat it with caution. As there is no consensus on many issues, more high-quality research is required.
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Elevated ESR/CRP Ratio Is Associated With Reinfection After Debridement, Antibiotics, and Implant Retention in Chronic Periprosthetic Joint Infections. J Arthroplasty 2020; 35:3254-3260. [PMID: 32631730 DOI: 10.1016/j.arth.2020.06.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 05/22/2020] [Accepted: 06/03/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Ratios of established inflammatory markers, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), have been used for diagnostic purposes in the surgical field; however, the ESR:CRP ratio (ECR) has not been evaluated as a marker for predicting infection resolution in patients with periprosthetic joint infections (PJIs). This study aimed to evaluate the diagnostic accuracy of ECR in predicting postoperative reinfection in patients who underwent debridement, antibiotics, and implant retention (DAIR). METHODS This is a retrospective review of 179 consecutive patients who underwent DAIR revision total joint arthroplasty for PJI. Patients were stratified by acuity of their infection: acute PJI, acute hematogenous PJI, and chronic PJI. The area under the receiver operating characteristic curve was calculated to evaluate ECR as diagnostic marker for predicting postoperative reinfection in patients who underwent DAIR. RESULTS Statistically significant differences in ECR were found in patients who underwent DAIR revision total joint arthroplasty for chronic infection (1.23 vs 2.33; P = .04). There was no significant difference in ECR in patients who underwent DAIR for acute infection (P = .70) and acute hematogenous infection (P = .56). In patients who underwent DAIR for chronic PJI, ECR demonstrated a sensitivity and specificity of 75% and 84%, respectively, for the prediction of postoperative reinfection, which was significantly higher than that of ESR (sensitivity, 67%; specificity, 47%; P < .001) and CRP (sensitivity, 50%; specificity, 26%; P < .001). CONCLUSION Elevated ECR was associated with an increased reinfection risk in patients who underwent DAIR for chronic PJI, suggesting that preoperative ECR may be a useful predictor to identify patients at increased risk of reinfection after DAIR for chronic PJIs.
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Leta TH, Lygre SHL, Schrama JC, Hallan G, Gjertsen JE, Dale H, Furnes O. Outcome of Revision Surgery for Infection After Total Knee Arthroplasty: Results of 3 Surgical Strategies. JBJS Rev 2020; 7:e4. [PMID: 31188156 DOI: 10.2106/jbjs.rvw.18.00084] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Periprosthetic joint infection (PJI) after knee arthroplasty surgery remains a serious complication, yet there is no international consensus regarding the surgical treatment of PJI. This study aimed to assess prosthesis survival rates, risk of revision, and mortality rate following different surgical strategies (1-stage versus 2-stage implant revision and irrigation and debridement with implant retention) that are used to treat PJI. METHODS The study was based on 644 total knee arthroplasties (TKAs) that were revised because of a deep infection (i.e., surgically treated PJI) and reported to the Norwegian Arthroplasty Register (NAR) from 1994 to 2016. Kaplan-Meier and multiple Cox regression analyses were performed to assess implant survival rate and risk of revision. We also studied mortality rates at 90 days and 1 year after revision for PJI. RESULTS During the follow-up period, 19% of the irrigation and debridement cases, 14% of the 1-stage revision cases, and 12% of the 2-stage revision cases underwent a subsequent revision because of a PJI. The 5-year Kaplan-Meier survival rate with revision for infection as the end point was 79% after irrigation and debridement, 87% after 1-stage revision, and 87% after 2-stage revision. There were no significant differences between 1-stage and 2-stage revisions with subsequent revision for any reason as the end point (relative risk [RR], 1.7; 95% confidence interval [CI], 0.9 to 3.5) and no difference with revision because of infection as the end point (RR, 1.6; 95% CI, 0.7 to 3.7). In an age-stratified analysis, however, the risk of revision for any reason was 4 times greater after 1-stage revision than after 2-stage revision in patients over the age of 70 years (RR, 4.3; 95% CI, 1.3 to 14.8). Age had no significant effect on the risk of subsequent revision for knees that had been revised with the irrigation and debridement procedure. The 90-day and 1-year mortality rates after revision for PJI were 1.2% and 2.5%, respectively. CONCLUSIONS Irrigation and debridement yielded good results compared with previous published studies. Although the 1-stage revisions resulted in a fourfold increase in risk of subsequent revision compared with the 2-stage revisions in older patients, the overall outcomes after 1-stage and 2-stage revisions were similar. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Tesfaye H Leta
- Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway.,VID Specialized University, Bergen, Norway.,Haraldsplass Diaconal Hospital, Bergen, Norway
| | - Stein Håkon L Lygre
- Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Occupational Medicine, Haukeland University Hospital, Bergen, Norway
| | - Jan C Schrama
- Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Geir Hallan
- Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway.,Institute for Clinical Medicine, University of Bergen, Bergen, Norway
| | - Jan-Erik Gjertsen
- Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway.,Institute for Clinical Medicine, University of Bergen, Bergen, Norway
| | - Håvard Dale
- Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Ove Furnes
- Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway.,Institute for Clinical Medicine, University of Bergen, Bergen, Norway
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Boyle KK, Kapadia M, Landy DC, Henry MW, Miller AO, Westrich GH. Utilization of Debridement, Antibiotics, and Implant Retention for Infection After Total Joint Arthroplasty Over a Decade in the United States. J Arthroplasty 2020; 35:2210-2216. [PMID: 32279946 DOI: 10.1016/j.arth.2020.03.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 02/28/2020] [Accepted: 03/15/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Reported clinical outcomes have varied for debridement, antibiotics, and implant retention (DAIR) and little is known regarding trends in utilization. We sought to evaluate the rate of DAIR utilization for total knee arthroplasty (TKA) and total hip arthroplasty (THA) periprosthetic joint infection (PJI) over a decade and clinical factors associated with these trends. METHODS A retrospective study of primary TKAs and THAs was performed using Medicare data from 2005 to 2014 using the PearlDiver database platform. Current Procedural Technology and International Classification of Diseases Ninth Edition codes identified patients who underwent a surgical revision for PJI, whether revision was a DAIR, as well as associated clinical factors including timing from index arthroplasty. RESULTS The proportion of revision TKAs and THAs performed using DAIR was 27% and 12% across all years, respectively. This proportion varied by year for TKAs and THAs with a linear trend toward increasing relative use of DAIR estimated at 1.4% and 0.9% per year (P < .001; P < .001). DAIR for TKA and THA performed within 90 days increased at a faster rate, 3.4% and 2.1% per year (P < .001; P < .001). Trends over time in TKA DAIRs showed an association with Elixhauser Comorbidity Index (ECI), 0-5 group increasing at 2.0% per year (P = .03) and patients >85 years (P = .04). CONCLUSION The proportion of revision arthroplasty cases for PJI managed with DAIR has been increasing over time in the United States, with the most substantial increase seen <90 days from index arthroplasty. Age, gender, and ECI had a minimal association with this trend, except in the TKA population >85 years and in those with a very low ECI score.
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Affiliation(s)
- K Keely Boyle
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
| | - Milan Kapadia
- Department of Medicine, Division of Infectious Disease, Hospital for Special Surgery, New York, NY
| | - David C Landy
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
| | - Michael W Henry
- Department of Medicine, Division of Infectious Disease, Hospital for Special Surgery, New York, NY
| | - Andy O Miller
- Department of Medicine, Division of Infectious Disease, Hospital for Special Surgery, New York, NY
| | - Geoffrey H Westrich
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
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Wouthuyzen-Bakker M, Löwik CAM, Ploegmakers JJW, Knobben BAS, Dijkstra B, de Vries AJ, Mithoe G, Kampinga G, Zijlstra WP, Jutte PC. A Second Surgical Debridement for Acute Periprosthetic Joint Infections Should Not Be Discarded. J Arthroplasty 2020; 35:2204-2209. [PMID: 32192835 DOI: 10.1016/j.arth.2020.02.043] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 02/13/2020] [Accepted: 02/20/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In acute periprosthetic joint infections (PJIs), a second surgical debridement (debridement, antibiotics, and implant retention [DAIR]) is generally not recommended after a failed first one. We identified the failure rate of a second DAIR and aimed to identify patients in whom an additional debridement might still be beneficial. METHODS Patients with acute PJI of the hip or knee and treated with DAIR between 2006 and 2016 were retrospectively evaluated. A second DAIR was routinely performed provided that the soft tissue was intact. Failure of a second DAIR was described as (1) the need for additional surgical intervention to achieve infection control, (2) the need for antibiotic suppressive therapy due to persistent clinical and/or biochemical signs of infection, or (3) PJI related death. RESULTS From the 455 cases treated with DAIR, 144 cases underwent a second debridement (34.6%). Thirty-seven cases failed (37/144, 25.7%). The implant needed to be removed in 23 cases (23/144, 16%). Positive cultures during the second DAIR (odds ratio 3.16, 95% confidence interval 1.29-7.74) and chronic renal insufficiency (odds ratio 13.6, 95% confidence interval 2.03-91.33) were independent predictors for failure in the multivariate analysis. No difference in failure was observed between persistent infection with the same microorganism and reinfection with a new microorganism (failure rate 31.6% vs 34.6%, P = .83). CONCLUSION A second DAIR had a low failure rate in our cohort of patients and the implant could be retained in the majority of them. Therefore, a second DAIR should not be discarded in acute PJIs.
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Affiliation(s)
- Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Claudia A M Löwik
- Department of Orthopaedic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Joris J W Ploegmakers
- Department of Orthopaedic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Bas A S Knobben
- Department of Orthopaedic Surgery, Martini Hospital, Groningen, the Netherlands
| | - Baukje Dijkstra
- Department of Orthopaedic Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Astrid J de Vries
- Department of Orthopaedic Surgery, Martini Hospital, Groningen, the Netherlands
| | - Glen Mithoe
- Department of Medical Microbiology, Certe, Groningen, the Netherlands
| | - Greetje Kampinga
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Wierd P Zijlstra
- Department of Orthopaedic Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Paul C Jutte
- Department of Orthopaedic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Bongers J, Jacobs AME, Smulders K, van Hellemondt GG, Goosen JHM. Reinfection and re-revision rates of 113 two-stage revisions in infected TKA. J Bone Jt Infect 2020; 5:137-144. [PMID: 32566453 PMCID: PMC7295641 DOI: 10.7150/jbji.43705] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/07/2020] [Indexed: 02/01/2023] Open
Abstract
Introduction: Two-stage revision is the most frequently performed revision procedure of a (suspected) periprosthetic joint infection (PJI) after total knee arthroplasty (TKA). The reported results of this treatment show large variability between studies, ranging between 0 - 40 percent failure. The purposes of this study were to determine long term (1) reinfection rate, (2) re-revision rates for any reason, and (3) the reinfection rate of patients with positive cultures at reimplantation. Methods: We prospectively followed and retrospectively reviewed 113 consecutive two-stage revision TKAs, performed between 2003 and 2013 in our clinic with a minimum follow-up of 2 years. Diagnosis of PJI was based on the major Musculoskeletal Infection Society criteria for PJI. Results: After a mean follow-up of 94 months (range 24-172 months), infection recurred in 23 cases (23%). Of these, nine cases (9%) were defined as relapse (same micro-organism as index revision) and in 14 cases another causative was found (14%). In 11 patients debridement, antibiotics and retention of the prosthesis successfully eradicated the reinfection. After overall follow-up 17 patients (17%) underwent re-revision surgery, 11 patients (11%) due to an infection and 6 patients (6%) for aseptic reasons. Conclusions: Treatment of a (suspected) infection of a TKA by a two-stage revision had acceptable results based on re-revision and re-infection rates in the long term (>5 years), resembling the short-term results (<2 years). Focussing on the cultures at the index two-stage revision, episodes of relapse and new infections during follow-up were almost equally divided. Reinfection rates were higher in cases with positive cultures at reimplantation. Patients should be counselled appropriately in this particular situation.
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Affiliation(s)
- Joris Bongers
- Department of Orthopaedic Surgery, Prosthetic Joint Infection Unit, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Anouk M E Jacobs
- Department of Orthopaedic Surgery, Prosthetic Joint Infection Unit, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Katrijn Smulders
- Sint Maartenskliniek Research, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Gijs G van Hellemondt
- Department of Orthopaedic Surgery, Prosthetic Joint Infection Unit, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Jon H M Goosen
- Department of Orthopaedic Surgery, Prosthetic Joint Infection Unit, Sint Maartenskliniek, Nijmegen, the Netherlands
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Wouthuyzen-Bakker M, Löwik CAM, Knobben BAS, Zijlstra WP, Ploegmakers JJW, Mithoe G, Al Moujahid A, Kampinga GA, Jutte PC. Use of gentamicin-impregnated beads or sponges in the treatment of early acute periprosthetic joint infection: a propensity score analysis. J Antimicrob Chemother 2019; 73:3454-3459. [PMID: 30189006 DOI: 10.1093/jac/dky354] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 08/07/2018] [Indexed: 01/15/2023] Open
Abstract
Objectives Early acute periprosthetic joint infections (PJIs) treated with debridement, antibiotics and implant retention (DAIR) have failure rates ranging from 10% to 60%. We determined the efficacy of applying local gentamicin-impregnated beads and/or sponges during debridement in early PJI. Methods Patients with early acute PJI, defined as less than 21 days of symptoms and treated with DAIR within 90 days after index surgery, were retrospectively evaluated. Early failure was defined as PJI-related death, the need for implant removal or a second DAIR or antibiotic suppressive therapy owing to persistent signs of infection, all within 60 days after initial debridement. Overall failure was defined as implant removal at any timepoint during follow-up. A 1:1 propensity score matching was performed to correct for confounding factors. Results A total of 386 patients were included. Local gentamicin was applied in 293 patients (75.9%) and was withheld in 93 patients (24.1%). Multivariate analysis demonstrated that the use of local gentamicin was independently associated with early failure (OR = 1.97, 95% CI = 1.12-3.48). After propensity matching, early failure was 40.3% in the gentamicin group versus 26.0% in the control group (P = 0.06) and overall failure was 5.2% in the gentamicin group versus 2.6% in the control group (P = 0.40). These numbers remained when solely analysing the application of gentamicin-impregnated sponges. Conclusions Even after propensity score matching, failure rates remained higher if local gentamicin-impregnated beads and/or sponges were administered in early acute PJI. Based on these results, their use should be discouraged.
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Affiliation(s)
- Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Claudia A M Löwik
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Bas A S Knobben
- Department of Orthopaedic Surgery, Martini Ziekenhuis, Groningen, The Netherlands
| | - Wierd P Zijlstra
- Department of Orthopaedic Surgery, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - Joris J W Ploegmakers
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Glen Mithoe
- Department of Medical Microbiology, Certe Medical Diagnostics & Advice, Groningen, The Netherlands
| | - Aziz Al Moujahid
- Center for Infectious Diseases Friesland, Izore, Leeuwarden, The Netherlands
| | - Greetje A Kampinga
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Paul C Jutte
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Vahedi H, Aali-Rezaie A, Shahi A, Conway JD. Irrigation, Débridement, and Implant Retention for Recurrence of Periprosthetic Joint Infection Following Two-Stage Revision Total Knee Arthroplasty: A Matched Cohort Study. J Arthroplasty 2019; 34:1772-1775. [PMID: 31060919 DOI: 10.1016/j.arth.2019.04.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 03/21/2019] [Accepted: 04/04/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND We investigated clinical/functional outcomes and implant survivorship in patients who underwent 2-stage revision total knee arthroplasty (TKA) after periprosthetic joint infection (PJI), experienced acute PJI recurrence, and underwent irrigation, débridement, and polyethylene exchange (IDPE) with retention of stable implant. METHODS Twenty-four patients (24 knees) were identified who underwent 2-stage revision TKA for PJI, experienced acute PJI recurrence, and then underwent IDPE between 2005 and 2016 (minimum 2-year follow-up). After IDPE, intravenous antibiotics (6 weeks) and oral suppression therapy (minimum 6 months) were administered. Data were compared with 1:2 matched control group that underwent 2-stage revision TKA for chronic PJI and did not receive IDPE. RESULTS Average IDPE group follow-up was 3.8 years (range, 2.4-7.2). Reinfection rate after IDPE was 29% (n = 7): 3 of 7 underwent second IDPE (2 of 3 had no infection recurrence) and 5 (one was patient who had recurrent infection after second IDPE) underwent another 2-stage revision TKA. Control group reinfection rate was 27% (n = 13) (P = .85). For IDPE group, mean time to reinfection after 2-stage revision TKA was 4.6 months (range, 1-8 months) (patients presented with acute symptoms less than 3 weeks duration). At latest follow-up, mean Knee Society Score was 70 (range, 35-85) in IDPE group and 75 (range, 30-85) in control group (P = .53). CONCLUSION IDPE for acute reinfection following 2-stage revision TKA with well-fixed implants had a 71% success rate. These patients had comparable functional outcome as patients with no IDPE after 2-stage revision TKA. IDPE followed by long-term suppression antibiotic therapy should be considered in patients with acute infection and stable components.
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Affiliation(s)
- Hamed Vahedi
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD
| | - Arash Aali-Rezaie
- Joint Reconstruction Division, Rothman Institute, Thomas Jefferson University, Philadelphia, PA; Orthopedic Surgery Department, Ahwaz Jondi Shapour University of Medical Sciences, Ahwaz, Khuzestan, Iran
| | - Alisina Shahi
- Cooper Bone and Joint Institute, Cooper University Hospital, Camden, NJ
| | - Janet D Conway
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD.
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Chung AS, Niesen MC, Graber TJ, Schwartz AJ, Beauchamp CP, Clarke HD, Spangehl MJ. Two-Stage Debridement With Prosthesis Retention for Acute Periprosthetic Joint Infections. J Arthroplasty 2019; 34:1207-1213. [PMID: 30872035 DOI: 10.1016/j.arth.2019.02.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 01/31/2019] [Accepted: 02/11/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Historically, infection control rates with debridement and component retention have been poor in the management of acute prosthetic joint infections. We previously described a 2-stage debridement with prosthesis retention protocol for acute periprosthetic joint infection and reported a 90% success rate in a sample of 20 patients. METHODS A retrospective review of 83 patients who underwent a 2-stage debridement with implant retention with a minimum 1-year follow-up was performed. Patient data were primarily analyzed to determine infection control rates. Infections were considered controlled when patients had not undergone a reoperation for infection, and demonstrated lack of any clinical signs or symptoms of infection (a well healed wound, diminishing swelling and warmth, absence of erythema, improvement in baseline pain symptoms) A secondary goal of this study was to examine the effects of symptom duration on infection control rate. RESULTS Average patient follow-up was 41.8 months (range 12-171) for all patients. The overall protocol success rate was 86.7% (72/83): 82.9% in hips and 89.6% in knees. Additionally, protocol success was observed in 45 of 48 primary joints (93.8%) and 27 of 35 (77.1%) revision joints (P = .046). Average time from onset of symptoms to surgery was 6.2 days for successfully treated patients (range 0-27 days) compared to 10.7 days for those who failed treatment (range 1-28 days, P = .070). CONCLUSION This 2-stage retention protocol resulted in a higher likelihood of infection control compared to prior reports of single stage debridement and modular part exchange.
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Affiliation(s)
- Andrew S Chung
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, AZ
| | | | | | | | | | - Henry D Clarke
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, AZ
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Shohat N, Goswami K, Tan TL, Fillingham Y, Parvizi J. Increased Failure After Irrigation and Debridement for Acute Hematogenous Periprosthetic Joint Infection. J Bone Joint Surg Am 2019; 101:696-703. [PMID: 30994587 DOI: 10.2106/jbjs.18.00381] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Acute periprosthetic joint infection (PJI) is difficult to treat. In this study, we investigated the failure rates of irrigation and debridement (I&D) among patients with acute post-surgical and acute hematogenous PJI, and explored various host and organism-related risk factors that may be associated with treatment failure. METHODS We retrospectively reviewed the cases of 199 total joint arthroplasty patients who underwent I&D for acute post-surgical PJI (<3 months postoperatively) and acute hematogenous PJI (≥3 months postoperatively, with abrupt symptoms lasting <3 weeks) at a single center during the period of 2005 to 2016. Only patients meeting the Musculoskeletal Infection Society (MSIS) criteria for PJI were included. Patient demographics, comorbidities, physical examination findings, laboratory results, and organism profile were identified. Treatment failure, as defined by the Delphi criteria, was determined for 1-year follow-up. Primary statistical analysis involved univariate and multivariate regression. RESULTS The failure rate was 37.7% (75 of 199) at 1 year. Among the patients with acute hematogenous infections, the rate of failure (56%, 29 of 52) was almost 2 times higher than that of patients with acute post-surgical infections (31%, 46 of 147) (adjusted odds ratio [OR], 2.36; 95% confidence interval [CI], 1.16 to 4.81; p = 0.018). Host predictors of failure included prior revision surgery (adjusted OR, 2.55; 95% CI, 1.22 to 5.32; p = 0.013) and a higher Charlson Comorbidity Index (adjusted OR, 1.22; 95% CI, 1.01 to 1.51; p = 0.048). Specific comorbidities associated with failure included chronic obstructive pulmonary disease (p = 0.026), diabetes (p = 0.004), and a history of malignancy (p = 0.005). Patients with polymicrobial infections (adjusted OR, 2.40; 95% CI, 1.10 to 5.20; p = 0.028) were also more likely to experience failure of treatment after I&D. The clinical and laboratory risk factors associated with failure were the presence of intraoperative purulence (p = 0.05), elevated systolic blood pressure (p = 0.05), tachycardia (p = 0.06), and higher serum C-reactive protein level (p = 0.003). CONCLUSIONS This study revealed that I&D is associated with a high rate of failure for patients with an acute hematogenous PJI. The study also identified a number of risk factors for failure. The findings of this study may allow better decision-making by surgeons regarding the surgical management of patients with acute PJI. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Noam Shohat
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Karan Goswami
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Timothy L Tan
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Yale Fillingham
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Song X, Li X, Song J, Xu C, Li R, Li H, Chen J. [Clinical research of debridement with prosthesis retention for periprosthetic joint infection after arthroplasty]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 32:685-693. [PMID: 29905045 DOI: 10.7507/1002-1892.201711105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To investigate the mid-term effectiveness of debridement with prosthesis retention for periprosthetic joint infection (PJI) after total hip arthroplasty (THA) and total knee arthroplasty (TKA), and analyze the influence factors that affected the effectiveness. Methods A clinical data of 45 cases with PJI after THA (16 cases) and TKA (29 cases) that were treated with debridement with prosthesis retention between January 2011 and January 2015 were collected and analyzed. There were 19 males and 26 females with a mean age of 58.4 years (range, 23-78 years). PJI occurred after primary joint arthroplasty in 40 cases and after revision in 5 cases. The mean time interval between the performance of infection symptoms and the arthroplasty or revision was 15.5 months (range, 0.5-72.0 months). The time interval between the performance of infection symptoms and debridment was 35 days (range, 3-270 days). There were early postoperative infections in 13 cases, acute hematogenous infections in 24 cases, and late chronic infections in 8 cases. X-ray films showed that the location of prosthesis was good. The results of bacilli culture showed that 28 cases were positive and 17 were negative. Twelve cases had sinuses. Length of stay, Hospital for Special Surgery (HSS) score, and Harris score were recorded to evaluate risk factors by using a multivariate logistic regression. Results The mean length of stay was 22.6 days (range, 5-79 days). All patients were followed up 24-74 months (mean, 52 months). There were 33 cases that retained the prosthesis without further evidence of infection with the success rate was 73.3%. There were significant differences in Harris score and HSS score between pre- and post-operation ( P<0.05). The univariate analysis results showed that the failure of debridement with prosthesis retention had a significant correlation with sinus developing and duration of infection symptoms more than 14 days ( P<0.05). Multivariate logistic regression analysis results showed that sinus developing was an independent risk factor of failure ( P<0.05). Conclusion Debridement with prosthesis retention plays an important role in treating PJI after THA and TKA. These patients with sinus performing and duration of infection symptoms more than 14 days have higher risk to develop infection again.
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Affiliation(s)
| | - Xin Li
- Department of Orthopaedics, General Hospital of Chinese PLA, Beijing, 100853, P.R.China
| | - Junlei Song
- Department of Orthopaedics, General Hospital of Chinese PLA, Beijing, 100853, P.R.China
| | - Chi Xu
- Department of Orthopaedics, General Hospital of Chinese PLA, Beijing, 100853, P.R.China
| | - Rui Li
- Department of Orthopaedics, General Hospital of Chinese PLA, Beijing, 100853, P.R.China
| | - Heng Li
- Department of Orthopaedics, General Hospital of Chinese PLA, Beijing, 100853, P.R.China
| | - Jiying Chen
- Department of Orthopaedics, General Hospital of Chinese PLA, Beijing, 100853,
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Hirsiger S, Betz M, Stafylakis D, Götschi T, Lew D, Uçkay I. The Benefice of Mobile Parts' Exchange in the Management of Infected Total Joint Arthroplasties with Prosthesis Retention (DAIR Procedure). J Clin Med 2019; 8:E226. [PMID: 30744128 PMCID: PMC6407118 DOI: 10.3390/jcm8020226] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 01/28/2019] [Accepted: 02/05/2019] [Indexed: 12/25/2022] Open
Abstract
Background: The management of prosthetic joint infections (PJI) with debridement and retention of the implant (DAIR) has its rules. Some authors claim that lacking the exchange of mobile prosthetic parts is doomed to failure, while others regard it as optional. Methods: Single-center retrospective cohort in PJIs treated with DAIR. Results: We included 112 PJIs (69 total hip arthroplasties, 9 medullary hip prostheses, 41 total knee arthroplasties, and 1 total shoulder arthroplasty) in 112 patients (median age 75 years, 52 females (46%), 31 (28%) immune-suppressed) and performed a DAIR procedure in all cases-48 (43%) with exchange of mobile parts and 64 without. After a median follow-up of 3.3 years, 94 patients (84%) remained in remission. In multivariate Cox regression analysis, remission was unrelated to PJI localization, pathogens, number of surgical lavages, duration of total antibiotic treatment or intravenous therapy, choice of antibiotic agents, immune-suppression, or age. In contrast, the exchange of mobile parts was protective (hazard ratio 1.9; 95% confidence interval 1.2⁻2.9). Conclusions: In our retrospective single-center cohort, changing mobile parts of PJI during the DAIR approach almost doubled the probability for long-term remission.
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Affiliation(s)
- Stefanie Hirsiger
- Orthopaedic Surgery Service, University of Geneva, Geneva 1211, Switzerland.
- Balgrist University Hospital, Zurich 8008, Switzerland.
| | - Michael Betz
- Orthopaedic Surgery Service, University of Geneva, Geneva 1211, Switzerland.
- Balgrist University Hospital, Zurich 8008, Switzerland.
| | | | | | - Daniel Lew
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva 1211, Switzerland.
| | - Ilker Uçkay
- Orthopaedic Surgery Service, University of Geneva, Geneva 1211, Switzerland.
- Balgrist University Hospital, Zurich 8008, Switzerland.
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva 1211, Switzerland.
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Argenson JN, Arndt M, Babis G, Battenberg A, Budhiparama N, Catani F, Chen F, de Beaubien B, Ebied A, Esposito S, Ferry C, Flores H, Giorgini A, Hansen E, Hernugrahanto KD, Hyonmin C, Kim TK, Koh IJ, Komnos G, Lausmann C, Loloi J, Lora-Tamayo J, Lumban-Gaol I, Mahyudin F, Mancheno-Losa M, Marculescu C, Marei S, Martin KE, Meshram P, Paprosky WG, Poultsides L, Saxena A, Schwechter E, Shah J, Shohat N, Sierra RJ, Soriano A, Stefánsdóttir A, Suleiman LI, Taylor A, Triantafyllopoulos GK, Utomo DN, Warren D, Whiteside L, Wouthuyzen-Bakker M, Yombi J, Zmistowski B. Hip and Knee Section, Treatment, Debridement and Retention of Implant: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S399-S419. [PMID: 30348550 DOI: 10.1016/j.arth.2018.09.025] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Key Words
- acute periprosthetic joint infection (PJI)
- antibiotic combination
- antibiotic duration
- antibiotic therapy
- antibiotic treatment
- biofilm
- chronic obstructive pulmonary disease (COPD)), and C-reactive protein (CRP) >115 mg/L (C), rheumatoid arthritis (R), indication prosthesis (I), male (M), exchange of mobile components (E), age > 80 years (80) (CRIME80) scores
- chronic renal failure (K), liver cirrhosis (L), index surgery (I), cemented prosthesis (C), and C-reactive protein (CRP) >115 mg/L (KLIC) score
- contraindications
- debridement antibiotics and retention of the prosthesis
- debridement, antibiotics, implant retention (DAIR)
- emergency management
- exchange of modular components
- failed debridement, antibiotics, implant retention (DAIR) management
- fluoroquinolone
- gram-negative acute periprosthetic joint infection (PJI)
- indications
- infection recurrence
- intra-articular antibiotic infusion
- irrigation
- irrigation and debridement
- irrigation solution
- length of antibiotics
- megaprosthesis
- methicillin-resistant Staphylococcus aureus (MRSA)
- pathogen identification
- patient optimization
- periprosthetic joint infection (PJI) recurrence
- povidone-iodine
- rifampicin
- risk stratification
- surgical factors
- surgical intervention
- surgical outcome
- surgical outcomes
- surgical site infection (SSI) recurrence
- surgical timing
- treatment failure
- treatment success
- two-stage exchange arthroplasty
- unicompartmental knee arthroplasty debridement, antibiotics, implant retention (DAIR)
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Abblitt WP, Ascione T, Bini S, Bori G, Brekke AC, Chen AF, Courtney PM, Della Valle CJ, Diaz-Ledezma C, Ebied A, Fillingham YJ, Gehrke T, Goswami K, Grammatopoulos G, Marei S, Oliashirazi A, Parvizi J, Polkowski G, Saeed K, Schwartz AJ, Segreti J, Shohat N, Springer BD, Suleiman LI, Swiderek LK, Tan TL, Yan CH, Zeng YR. Hip and Knee Section, Outcomes: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S487-S495. [PMID: 30348557 DOI: 10.1016/j.arth.2018.09.035] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Role of Rifampin against Staphylococcal Biofilm Infections In Vitro, in Animal Models, and in Orthopedic-Device-Related Infections. Antimicrob Agents Chemother 2019; 63:AAC.01746-18. [PMID: 30455229 DOI: 10.1128/aac.01746-18] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Rifampin has been used as an agent in combination therapy in orthopedic device-related infections (ODRI) for almost three decades. The aim of this review is to provide data regarding the role of rifampin against biofilm infection in vitro, in animal models, and in clinical ODRI. Available data are gathered in order to present the rational use of rifampin combinations in patients with periprosthetic joint infection (PJI). The role of rifampin is well defined in patients with PJI and is indicated in those who fulfill the Infectious Diseases Society of America criteria for debridement and implant retention or one-stage exchange. It should be used with care because of the danger of rapid emergence of resistance. Potential drug interactions should be considered.
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Peng KT, Chiang YC, Huang TY, Chen PC, Chang PJ, Lee CW. Curcumin nanoparticles are a promising anti-bacterial and anti-inflammatory agent for treating periprosthetic joint infections. Int J Nanomedicine 2019; 14:469-481. [PMID: 30666108 PMCID: PMC6333393 DOI: 10.2147/ijn.s191504] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Periprosthetic joint infections (PJIs) have a high incidence of recurrence after total joint replacement and are difficult to treat by debridement or antibiotic treatment. Curcumin is a natural product with anti-inflammatory and anti-bacterial properties. The low bioactivity of curcumin in water restricts its clinical application. Curcumin nanoparticles (CURN) were developed to overcome this limitation. Methods In this study, the therapeutic effects of CURN and their anti-inflammatory functions were investigated in a Staphylococcus aureus biofilm-induced PJIs model. Results CURN first attenuated the biofilm-induced expansion of myeloid-derived suppressor cells (MDSCs) and then regulated M1- and M2-phenotypic MDSC expression. Down-regulation of cytokines and reactive oxygen species was considered as the mechanism of CURN in reversing the suppression of T cell proliferation. The recovery of bone permeative destruction demonstrated that CURN enhanced therapeutic potency of vancomycin in vivo. Conclusion This is the first study to demonstrate that CURN may be useful for treating PJIs.
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Affiliation(s)
- Kuo-Ti Peng
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Puzi City, Chiayi County 61363, Taiwan, .,College of Medicine, Chang Gung University, Guishan District, Taoyuan City 33303, Taiwan,
| | - Yao-Chang Chiang
- Department of Nursing, Chang Gung University of Science and Technology, Puzi City, Chiayi County 61363, Taiwan, .,Division of Basic Medical Sciences, and Chronic Diseases and Health Promotion Research Center, Chang Gung University of Science and Technology, Puzi City, Chiayi County 61363, Taiwan,
| | - Tsung-Yu Huang
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Pei-Chun Chen
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Puzi City, Chiayi County 61363, Taiwan,
| | - Pey-Jium Chang
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang-Gung University, Taoyuan, Taiwan.,Department of Nephrology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Chiang-Wen Lee
- Department of Nursing, Chang Gung University of Science and Technology, Puzi City, Chiayi County 61363, Taiwan, .,Division of Basic Medical Sciences, and Chronic Diseases and Health Promotion Research Center, Chang Gung University of Science and Technology, Puzi City, Chiayi County 61363, Taiwan, .,Research Center for Industry of Human Ecology and Research Center for Chinese Herbal Medicine, Chang Gung University of Science and Technology, Guishan District, Taoyuan City 33303, Taiwan, .,Department of Rehabilitation, Chang Gung Memorial Hospital, Puzi City, Chiayi County 61363, Taiwan,
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Wouthuyzen-Bakker M, Sebillotte M, Lomas J, Taylor A, Palomares EB, Murillo O, Parvizi J, Shohat N, Reinoso JC, Sánchez RE, Fernandez-Sampedro M, Senneville E, Huotari K, Barbero JM, Garcia-Cañete J, Lora-Tamayo J, Ferrari MC, Vaznaisiene D, Yusuf E, Aboltins C, Trebse R, Salles MJ, Benito N, Vila A, Toro MDD, Kramer TS, Petersdorf S, Diaz-Brito V, Tufan ZK, Sanchez M, Arvieux C, Soriano A. Clinical outcome and risk factors for failure in late acute prosthetic joint infections treated with debridement and implant retention. J Infect 2019; 78:40-47. [PMID: 30092305 DOI: 10.1016/j.jinf.2018.07.014] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 07/05/2018] [Accepted: 07/19/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Debridement, antibiotics and implant retention (DAIR) is the recommended treatment for all acute prosthetic joint infections (PJI), but its efficacy in patients with late acute (LA) PJI is not well described. METHODS Patients diagnosed with LA PJI between 2005 and 2015 were retrospectively evaluated. LA PJI was defined as the development of acute symptoms (≤ 3 weeks) occurring ≥ 3 months after arthroplasty. Failure was defined as: (i) the need for implant removal, (ii) infection related death, (iii) the need for suppressive antibiotic therapy and/or (iv) relapse or reinfection during follow-up. RESULTS 340 patients from 27 centers were included. The overall failure rate was 45.0% (153/340). Failure was dominated by Staphylococcus aureus PJI (54.7%, 76/139). Significant independent preoperative risk factors for failure according to the multivariate analysis were: fracture as indication for the prosthesis (odds ratio (OR) 5.4), rheumatoid arthritis (OR 5.1), age above 80 years (OR 2.6), male gender (OR 2.0) and C-reactive protein > 150 mg/L (OR 2.0). Exchanging the mobile components during DAIR was the strongest predictor for treatment success (OR 0.35). CONCLUSION LA PJIs have a high failure rate. Treatment strategies should be individualized according to patients' age, comorbidity, clinical presentation and microorganism causing the infection.
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Affiliation(s)
- Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
| | - Marine Sebillotte
- Department of Infectious Diseases and IntensiveCare Medicine, Rennes University Hospital, Rennes, France
| | - Jose Lomas
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Adrian Taylor
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | | | - Oscar Murillo
- Infectious Disease Service, IDIBELL-Hospital Universitari Bellvitge, Barcelona, Spain
| | - Javad Parvizi
- Rothman Institute at Thomas Jefferson University Hospital, Philidelphia, United States
| | - Noam Shohat
- Rothman Institute at Thomas Jefferson University Hospital, Philidelphia, United States; Department of Orthopaedic Surgery, Tel Aviv University, Tel Aviv, Israel
| | - Javier Cobo Reinoso
- Servicio de Enfermedades Infecciosas, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Rosa Escudero Sánchez
- Servicio de Enfermedades Infecciosas, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Marta Fernandez-Sampedro
- Infectious Diseases Unit, Department of Medicine, Hospital Universitario Marques de Valdecilla-IDIVAL, Cantabria, Spain
| | - Eric Senneville
- Department of Infectious Diseases, University Hospital Gustave Dron Hospital, Tourcoing, France
| | - Kaisa Huotari
- Inflammation center, Infectious Diseases, Peijas Hospital, Helsinki University Hospital and University of Helsinki, Finland
| | - José Maria Barbero
- Department of Internal Medicine, Hospital Universitario Principe de Asturias, Madrid, Spain
| | - Joaquín Garcia-Cañete
- Department of Internal Medicine-Emergency, IIS-Fundación Jiménez Díaz, UAM, Av. Reyes Católicos 2, 28040 Madrid, Spain
| | - Jaime Lora-Tamayo
- Department of Internal Medicine. Hospital Universitario 12 de Octubre. Instituto de Investigación i+12, Madrid, Spain
| | - Matteo Carlo Ferrari
- Department of Prosthetic Joint Replacement and Rehabilitation Center, Humanitas Research Hospital and Humanitas University, Milan, Italy
| | - Danguole Vaznaisiene
- Department of Infectious Diseases, Medical Academy, Lithuanian University of Health Sciences, Kaunas Clinical Hospital, Kaunas, Lithuania
| | - Erlangga Yusuf
- Department of Microbiology, Antwerp University Hospital (UZA), University of Antwerp, Edegem, Belgium
| | - Craig Aboltins
- The Department of Infectious Diseases, Northern Health, Melbourne, Australia; The University of Melbourne, Northern Clinical School, Melbourne, Australia
| | - Rihard Trebse
- Service for Bone Infections, Valdoltra Orthopaedic Hospital, Ankaran, Slovenia
| | - Mauro José Salles
- Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brasil
| | - Natividad Benito
- Infectious Diseases Unit, Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Andrea Vila
- Servicio de Infectología, Hospital Italiano de Mendoza, Mendoza, Argentina
| | - Maria Dolores Del Toro
- Unidad Clínica de Enfermedades Infecciosa y Microbiología, Universidad de Sevilla, Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain
| | - Tobias Siegfried Kramer
- Nationales Referenzzentrum für Surveillance von nosokomialen Infektionen am Institut für Hygiene und Umweltmedizin Charité-Universitätsmedizin, Berlin, Germany; LADR, GmbH MVZ, Neuruppin, Germany
| | - Sabine Petersdorf
- Institute of Medical Microbiology and Hospital Hygiene University Hospital, Heinrich-Heine-University. Düsseldorf, Germany
| | - Vicens Diaz-Brito
- Infectious Diseases Unit, Parc Sanitari Sant Joan de Deu, Sant Boi, Barcelona, Spain
| | - Zeliha Kocak Tufan
- Infectious Diseases and Clinical Microbiology Department, Ankara Yildirim Beyazit University, Ataturk Training & Research Hospital, Ankara, Turkey
| | - Marisa Sanchez
- Infectious Diseases Section, Internal Medicine Service, Hospital Italiano de Buenos Aires, Argentina
| | - Cédric Arvieux
- Department of Infectious Diseases and IntensiveCare Medicine, Rennes University Hospital, Rennes, France; Great West Reference centers for Complex Bone and Joint Infections (CRIOGO), France
| | - Alex Soriano
- Service of Infectious Diseases, Hospital Clínic, University of Barcelona, Barcelona, Spain
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Outcome of Irrigation and Debridement after Failed Two-Stage Reimplantation for Periprosthetic Joint Infection. BIOMED RESEARCH INTERNATIONAL 2018; 2018:2875018. [PMID: 30406131 PMCID: PMC6201492 DOI: 10.1155/2018/2875018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 07/14/2018] [Accepted: 09/05/2018] [Indexed: 01/04/2023]
Abstract
Introduction Two-stage revision is the gold standard for the treatment of deep implant infection after knee or hip arthroplasty. Irrigation and debridement may be a treatment option for failed 2-stage revisions in cases where a reinfection occurs within 30 days or the symptoms exist not longer than 3 weeks and is appealing because of its low morbidity. We determined the incidence of recurrent infections following irrigation and debridement for failed two-stage revision hip and knee arthroplasty. Methods We performed a single center retrospective review of periprosthetic hip and knee infections treated with a two-stage procedure from 2002 to 2010. All patients that subsequently underwent irrigation and debridement for a subsequent infection were selected for the current study. Results 440 two-stage revisions were performed between 2002 and 2010. Fifty-one two-stage revisions failed (11.6%). Nineteen failed two-stage revisions were treated with irrigation and debridement; 12 (63.2%) patients remained free of infection at follow-up (mean follow-up: 39 months; range, 24-90 months), infection persisted in 6 patients (31.6%), and 1 patient died (5.3%). Conclusions Success rates of irrigation and debridement for failed two-stage procedures are similar to the success rates of irrigation and debridement in primary implant infections. According to the current paper, irrigation and debridement are an acceptable treatment for acute reinfections after failed two-stage revision if performed within the first 30 postoperative days after failed two-stage procedure or if symptoms are present for less than 3 weeks in the presence of a susceptible organism.
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Matar HE, Stritch P, Emms N. Assessment and management of infected total knee replacements. Br J Hosp Med (Lond) 2018; 79:524-529. [PMID: 30188200 DOI: 10.12968/hmed.2018.79.9.524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Infection following total knee replacement surgery is a challenging and devastating complication. Clinical assessment including history, examination, radiographs, blood tests and knee aspirations helps to establish the diagnosis. Revision surgery is typically required to eradicate infection and restore function. This has traditionally been performed through two-stage revision surgery, although single-stage revision surgery is gaining popularity with comparable results in carefully selected patients. This article reviews the clinical assessment and principles of surgical management of infected total knee replacements.
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Affiliation(s)
- Hosam E Matar
- Specialty Registrar in Trauma and Orthopaedics, Department of Trauma and Orthopaedics Whiston Hospital, Prescot, Liverpool L35 5DR
| | - Paula Stritch
- Surgical Care Practitioner, Department of Trauma and Orthopaedics, Whiston Hospital, Prescot, Liverpool
| | - Nicholas Emms
- Consultant Primary and Revision Arthroplasty Surgeon, Department of Trauma and Orthopaedics, Whiston Hospital, Prescot, Liverpool
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Fagotti L, Tatka J, Salles MJC, Queiroz MC. Risk Factors and Treatment Options for Failure of a Two-Stage Exchange. Curr Rev Musculoskelet Med 2018; 11:420-427. [PMID: 29934884 PMCID: PMC6105486 DOI: 10.1007/s12178-018-9504-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Although a two-stage exchange revision is reported to have a high success rate, this strategy may fail as a treatment for prosthetic joint infection (PJI). When it does, resection arthroplasty, arthrodesis, amputation, and chronic antibiotic suppression may play a role. The purpose of this review is to determine which are the main risk factors for a two-stage exchange failure and to analyze the indications and results of resection arthroplasty, arthrodesis, amputation, and antibiotic chronic suppression for PJI. RECENT FINDINGS Recent literature demonstrates that the main risk factors for a two-stage exchange failure are as follows: hemodialysis, obesity, multiple previous procedures, diabetes mellitus, corticosteroid therapy, hypoalbuminemia, immunosuppression, rheumatological conditions, coagulation disorders, and infection due to multidrug-resistant (MDR) bacteria or fungal species. Regarding microorganisms, besides Staphylococcus aureus, Streptococcus spp., Enterobacteriaceae species such as Klebsiella pneumoniae and Enterobacter sp., Pseudomonas aeruginosa, or Acinetobacter baumannii, and fungus including Candida sp. are also considered risk factors for a two-stage exchange failure. Resection arthroplasty, arthrodesis, and amputation have a limited role. Chronic suppression is an option for high-risk patients or unfeasible reconstruction. In summary, we report the main risk factors for a two-stage exchange failure and alternative procedures when it occurs. Future research on patient-specific risk factors for a two-stage exchange may aid surgical decision-making and optimization of outcomes.
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Affiliation(s)
| | - Jakub Tatka
- Steadman Philippon Research Institute, Vail, CO, USA
| | - Mauro Jose Costa Salles
- Division of Infectious Diseases, Department of Internal Medicine, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Marcelo C Queiroz
- Department of Orthopaedic Surgery, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil.
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Horriat S, Ayyad S, Thakrar RR, Haddad FS. Debridement, antibiotics and implant retention in management of infected total knee arthroplasty: A systematic review. ACTA ACUST UNITED AC 2018. [DOI: 10.1053/j.sart.2019.01.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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