Irrigation and Debridement with Chronic Antibiotic Suppression Is as Effective as 2-Stage Exchange in Revision Total Knee Arthroplasty with Extensive Instrumentation

The Fate of the DAIR, Outcomes after 1 Year: A Large Database Study

Debridement with antibiotics and implant retention (DAIR) is commonly utilized for treatment of prosthetic joint infection (PJI) in total knee arthroplasty (TKA), particularly in cases of acute PJI. Reported success rates of DAIR have been highly variable, but the overall success rate of DAIR cohort studies is approximately 70 to 80%. However, no large database studies have investigated the success rate of DAIR. Therefore, we seek to provide a framework for large-database analysis of PJI interventions and their outcomes and to assess the success rate of DAIR. We queried the MarketScan Database for patients who underwent a DAIR (CPT 27310 and/or CPT 27486) procedure for indication of PJI (ICD-10 T84.53 OR T84.54) between January 1, 2017 and December 31, 2021. We identified reoperations (i.e., stage 1 revision, amputation, or arthrodesis) indicating failure of DAIR. Failure of DAIR treatment was defined by subsequent reoperation. We also identified prescriptions of suppression antibiotics more than 6 months after DAIR. We identified 1,018 patients who underwent a DAIR procedure for PJI. Of these patients, 195 (19.2%) underwent reoperation within 1 year and an additional 178 (17.5%) were prescribed suppressive antibiotics. For 780 patients with a minimum of 2 years of follow-up, 164 (21%) underwent reoperation and an additional 179 (22.9%) were prescribed suppressive antibiotics. Patients with obesity and patients younger than 60 years had significantly higher rates of having reoperation or suppressive antibiotics at 1 year following DAIR. DAIR is a viable option in the treatment of PJI, with an approximately 19% rate of reoperation at 2 years. Our findings are consistent with that of previously published literature.

The Application of artificial intelligence in periprosthetic joint infection

Periprosthetic joint infection (PJI) represents one of the most devastating complications following total joint arthroplasty, often necessitating additional surgeries and antimicrobial therapy, and potentially leading to disability. This significantly increases the burden on both patients and the healthcare system. Given the considerable suffering caused by PJI, its prevention and treatment have long been focal points of concern. However, challenges remain in accurately assessing individual risk, preventing the infection, improving diagnostic methods, and enhancing treatment outcomes. The development and application of artificial intelligence (AI) technologies have introduced new, more efficient possibilities for the management of many diseases. In this article, we review the applications of AI in the prevention, diagnosis, and treatment of PJI, and explore how AI methodologies might achieve individualized risk prediction, improve diagnostic algorithms through biomarkers and pathology, and enhance the efficacy of antimicrobial and surgical treatments. We hope that through multimodal AI applications, intelligent management of PJI can be realized in the future.

Efficacy of Adjunctive Antiseptic Lavage Solution in Managing Acute Hip/Knee Prosthetic Joint Infection: A Comparative Study in a Tertiary Revision Center

Background

Debridement, antibiotics and implant retention (DAIR) procedure is well-established as a management option for acute periprosthetic joint infection (PJI). We investigated the infection eradication rates of DAIR procedures at our center using Bactisure wound lavage.

Methods

A retrospective consecutive review of DAIR procedures for hip and knee PJI was conducted between 2018 and 2023 with a minimum 12-month follow-up at our tertiary revision arthroplasty center. Suitability for DAIR was determined at the multi-disciplinary team discussion. Revision procedures and patients with previous PJI were excluded. Patient, surgical, microbiological, and postoperative data (minimum 12 months) was reviewed. The use of Bactisure was in addition to routine surgical management.

Results

During the study period, 76 DAIR procedures were performed (55 knees and 21 hips). Bactisure was used in 26 cases (20 knees and 6 hips). Overall, 6 of 26 Bactisure DAIRs failed (23%), while 14 of 50 non-Bactisure DAIRs failed (28%), which did not demonstrate statistical significance (P = .644). Subgroup analysis demonstrated no difference in knee DAIRs (P = .761) but a trend toward significance in hip DAIRs (P = .262). No adverse effects of Bactisure use were noted intraoperatively or postoperatively. DAIR failed in 50% of diabetic patients compared to 20% of nondiabetic patients (P = .015). Age, body mass index, and organism identification did not influence outcome.

Conclusions

The addition of Bactisure to DAIR procedures did not demonstrate statistically significant improvement of successful eradication of infection, but a potential trend toward significance was noted in hip DAIRs. Diabetic patients failed DAIR in 50% of cases. The in-vivo outcomes of Bactisure use during DAIR procedures remain inconclusive.

The Efficacy of Antibiotic-Loaded Calcium Sulfate Beads (Stimulan) in Patients with Hip Arthroplasty Infections

Background: Given the increasing rate of infections following hip arthroplasty, one of the current options is the application of a biocomposite at the site of the infection. One of the products used is Stimulan, a completely resorbable calcium sulfate, designed to treat acute and chronic infections. This biocomposite has a controlled purity, is easy to mix with liquid, powder, and antibiotics, and can be applied directly to the site of infection, or it can be injected. Methods: We analyzed data from 76 patients, who were admitted to the County Clinical Hospital of Emergency "St. Apostol Andrei" in Galati during January 2017-September 2023, with a diagnosis of infection associated with hip arthroplasty. Results: In 69.73% of cases (52 patients), we decided to keep the implant in place. In this subgroup, Stimulan was applied in 26 cases (57.78%). Of these, 100% were cured-compared to the subgroup in which Stimulan was not applied, where this percentage was lower. All patients underwent chemical and mechanical toileting, and for 24 patients (20.27%), it was necessary to ablate the implant with or without the application of Stimulan, then reimplantation of the prosthesis. Conclusions: The patients with Stimulan had a longer average length of hospitalization, almost half of them required intervention in two periods, and a quarter required the implantation of spacers. However, the cure rate was higher, only in three people could we not control the infection, and there was no death. This study confirms the effectiveness of the treatment when using a biocomposite in addition to the classical treatment for both acute and chronic cases.

Socioeconomic Disadvantage Predicts Decreased Likelihood of Maintaining a Functional Knee Arthroplasty Following Treatment for Prosthetic Joint Infection

BACKGROUND

Prosthetic joint infection (PJI) carries major morbidity and mortality as well as a complicated and lengthy treatment course. In patients who have high degrees of socioeconomic disadvantage, this may be a particularly devastating complication. Our study sought to evaluate the impact of socioeconomic deprivation on outcomes following treatment for PJI of the knee.

METHODS

We conducted a retrospective review of revision total knee arthroplasty (TKA) procedures performed for the treatment of initial PJI between 2008 and 2020 at a single tertiary care center in the United States. The Area Deprivation Index (ADI) was used to quantify socioeconomic deprivation. The primary outcome measure was presence of a functional knee joint at the time of most recent follow-up defined as TKA components or an articulating spacer. A total of 96 patients were included for analysis. The median follow-up duration was 26.5 months.

RESULTS

There was no significant difference in the rate of treatment failure (P = .63). However, the proportion of patients who had a functional knee arthroplasty (in contrast to having undergone arthrodesis, amputation, or retention of a static spacer) declined significantly with increasing ADI index (81.8% for the least disadvantaged group, 58.7% for the middle group, 42.9% for the most disadvantaged group, P = .021).

CONCLUSIONS

Patients who have a higher socioeconomic disadvantage as measured by ADI are less likely to maintain a functional knee arthroplasty following treatment for TKA PJI. These findings support continued efforts to improve access to care and optimize treatment plans for patients who have socioeconomic disadvantage.

Risk factors for early septic failure after two-stage exchange total knee arthroplasty for treatment of periprosthetic joint infection

BACKGROUND

The cause of early septic failure after two-stage exchange revision total knee arthroplasty (TKA) for chronic periprosthetic joint infection (PJI) and the factors affecting it are not well known. The purpose of this study was to determine the surgical outcomes and the risk factors for early septic failure after two-stage revision TKA for chronic PJI.

METHODS

We identified a total of 246 adult patients who met the Musculoskeletal Infection Society (MSIS) diagnostic criteria for chronic PJI at two academic tertiary hospitals from March 2012 to December 2018. Finally, 151 patients who consecutively received two-stage exchange revision TKA for chronic PJI and who had a minimum 3-year follow-up were enrolled and retrospectively reviewed. Successful surgical treatment was evaluated for two-stage revision TKA and risk factors for early septic failure were identified.

RESULTS

Early septic failures occurred within 3 years after reimplantation in 48 patients (31.8%). After accounting for potentially confounding variables, we found that male patient [odds ratio (OR): 2.753, 95% confidence interval (CI) 1.099-6.893, p = 0.031], fungus or mycobacterial infection (OR: 5.224, 95% CI 1.481-18.433, p = 0.01), and positive culture at reimplantation (OR: 4.407, 95% CI 1.255-15.480, p = 0.021) were independently associated with early septic failure after two-stage exchange revision TKA.

CONCLUSION

Male patients, fungus or mycobacterial infection, and positive culture at reimplantation were independently associated with an increased risk of early septic failure after two-stage exchange revision TKA despite normal C-reactive protein values prior to reimplantation. Further prospective and high-quality studies are needed to determine the risk factors of two-stage exchange revision TKA for chronic PJI.

LEVEL OF EVIDENCE

level IV; retrospective comparison; treatment study.

Outcomes After Successful Debridement, Antibiotic, and Implant Retention Therapy for Periprosthetic Joint Infection in Total Knee Arthroplasty

BACKGROUND

Controversy surrounds debridement, antibiotic and implant retention (DAIR) for treatment of acute periprosthetic joint infection (PJI). Data regarding DAIR's rate of infection resolution is variable with little investigation of functional outcomes.

METHODS

We identified 191 DAIR cases at a single institution from 2008 to 2020. Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) and Patient Reported Outcome Measurement Information System-10 (PROMIS) scores were collected. Patient Reported Outcome Scores were obtained from 60 cases. Median follow-up (IQR) was 4.5 (2.1 to 7.6) versus 3.0 (1.2 to 5.3) years for the control group. Mean scores were compared to a cohort of uncomplicated total knee arthroplasties matched by age, body mass index, and sex using generalized linear models adjusted for follow-up duration. Kaplan-Meier survivorship curves for PJI were constructed.

RESULTS

Mean Patient Reported Outcome Scores for the DAIR cohort were 57.2 ± 19.7 for KOOS-JR, 41.6 ± 7.1 for PROMIS physical health (PH), and 46.6 ± 8.7 for PROMIS mental health (MH). Mean control group values were 65.8 ± 21.0 for KOOS-JR, 44.6 ± 8.4 for PROMIS PH, and 49.2 ± 9.2 for PROMIS MH. No difference was observed in KOOS-JR (P = .83) or PROMIS MH (P = .11). PROMIS PH was lower in the DAIR cohort compared to the control group (P = .048). Median follow-up (years) for all 191 cases was 5.9 (range, 0.5 to 13.1). Survivorship (years) without subsequent operation for infection was 84% at 1, 82% at 2, and 79% at 5.

CONCLUSION

Knee and MH outcomes in successful DAIR procedures were similar to uncomplicated total knee arthroplasty. DAIR's success rate was 79% in treating acute PJI at 5 years.

LEVEL OF EVIDENCE

Level III.

Irrigation and Debridement With Chronic Antibiotic Suppression for the Management of Acutely Infected Aseptic Revision Total Joint Arthroplasties

BACKGROUND

Most data on irrigation and debridement with component retention (IDCR) as a treatment for acute periprosthetic joint infections (PJIs) focuses on primary total joint arthroplasties (TJAs). However, the incidence of PJI is greater after revisions. We investigated the outcomes of IDCR with suppressive antibiotic therapy (SAT) following aseptic revision TJAs.

METHODS

Through our total joint registry, we identified 45 aseptic revision TJAs (33 hips, 12 knees) performed from 2000 to 2017 that were treated with IDCR for acute PJI. Acute hematogenous PJI was present in 56%. Sixty-four percent of PJIs involved Staphylococcus. All patients were treated with 4 to 6 weeks of intravenous antibiotics with the intention to treat with SAT (89% received SAT). The mean age was 71 years (range, 41 to 90), with 49% being women and a mean body mass index of 30 (range, 16 to 60). The mean follow-up was 7 years (range, 2 to 15).

RESULTS

The 5-year survivorships free from re-revision for infection and reoperation for infection were 80% and 70%, respectively. Of the 13 reoperations for infection, 46% involved the same species as the initial PJI. The 5-year survivorships free from any revision and any reoperation were 72% and 65%, respectively. The 5-year survivorship free from death was 65%.

CONCLUSION

At 5 years following IDCR, 80% of implants were free from re-revision for infection. As the penalty for implant removal is often high in revision TJAs, IDCR with SAT is a viable option for acute infection after revision TJAs in select patients.

LEVEL OF EVIDENCE

IV.

A comparison of outcomes for above-knee-amputation and arthrodesis for the chronically infected total knee arthroplasty: a systematic review

INTRODUCTION

Several strategies have been shown to have some efficacy in the chronically infected total knee arthroplasty (TKA): chronic antibiotic suppression, a second two-stage revision, arthrodesis, and above-the-knee amputation (AKA). We conducted a systematic review to determine the efficacy of these treatments in patients who had previously received a two-stage revision.

METHODS

A systematic review of the literature was performed which investigated PubMed, Embase, Scopus, and Web of Science Databases. Chronic infection was defined as a persistent infection of a TKA after a previous two-stage revision. Studies were independently evaluated by two reviewers. Quality appraisal was performed using MINORS Criteria.

RESULTS

14 studies were included for the final review. For chronically infected TKA, a second two-stage revision was often sufficient to control infection. If revision failed, the most common next procedure was either a repeat revision or AKA. AKA patients had less pain and higher quality of life scores compared to arthrodesis, but a higher five-year mortality rate.

DISCUSSION AND CONCLUSION

Chronic infection in TKA offers a multitude of challenges for orthopedic surgeons. We found that arthrodesis and AKA were not significantly different in rates of infection eradication or quality of life. We recommend clinicians to actively discuss options with patients to find a procedure most suitable for them.

Principles of mechanical and chemical debridement with implant retention

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.

Peri-Prosthetic Joint Infection in Patients Prescribed Suppressive Antibiotic Therapy Undergoing Primary Total Joint Arthroplasty: A 1:4 Case Control Matched Study

Background: Oral suppressive antibiotic therapy (SAT) has emerged as a potential means to increase rates of infection-free survival in many complex peri-prosthetic joint infection (PJI) cases after total joint arthroplasty (TJA). The purpose of the present study is to evaluate the risk of PJI of a new primary TJA in patients on oral SAT. Patients and Methods: A retrospective matched cohort study from five hospitals in a 20-year period within a large hospital network was performed. Inclusion criteria consisted of patients over age 18 undergoing primary TJA, with any order for oral long-term (>6 months duration) SAT, and minimum of one-year clinical follow-up. Patients were matched 1:4 on age, gender, body mass index (BMI), hip or knee surgery, diabetes mellitus, smoking status, and indication for primary TJA. Student t-test, Fisher exact, and χ² tests were utilized for group comparisons. Our study was powered to detect a 10.5% increase in PJI incidence compared with a 1% baseline rate of PJI. Results: We identified 45 TJA in 33 patients receiving SAT, which were matched to 180 control cases. There was no difference in the rate of development of PJI at any time point within follow-up between the SAT cohort and control group (2.22% vs. 1.11%; p = 0.561). Conclusions: We found a 2.22% rate of PJI in a cohort of patients receiving SAT identified over a 20-year period. As the clinical scenario of primary TJA while on SAT is rare but likely to become more prevalent, future large-scale studies can be performed to better clarify rates and risk of PJI in this population.

A desirability of outcome ranking (DOOR) for periprosthetic joint infection - a Delphi analysis

Background: Treatment outcomes in studies on prosthetic joint infection are generally assessed using a dichotomous outcome relating to treatment success or failure. These outcome measures neither include patient-centred outcome measures including joint function and quality of life, nor do they account for adverse effects of treatment. A desirability of outcome ranking (DOOR) measure can include these factors and has previously been proposed and validated for other serious infections. We aimed to develop a novel DOOR for prosthetic joint infections (PJIs). Methods: The Delphi method was used to develop a DOOR for PJI research. An international working group of 18 clinicians (orthopaedic surgeons and infectious disease specialists) completed the Delphi process. The final DOOR comprised the dimensions established to be most important by consensus with > 75  % of participant agreement. Results: The consensus DOOR comprised four main dimensions. The primary dimension was patient-reported joint function. The secondary dimensions were infection cure and mortality. The final dimension of quality of life was selected as a tie-breaker. Discussion: A desirability of outcome ranking for periprosthetic joint infection has been proposed. It focuses on patient-centric outcome measures of joint function, cure and quality of life. This DOOR provides a multidimensional assessment to comprehensively rank outcomes when comparing treatments for prosthetic joint infection.

A comparsion study between debridement, antibiotics, and implant retention and two-stage revision total knee arthroplasty for the management of periprosthetic joint infection occurring within 12 weeks from index total knee arthroplasty

BACKGROUND

Managing periprosthetic joint infections are variable in practices. Debridement, antibiotics, and implant retention (DAIR) is one of the favorable interventions. Given that the success rate of the two-stage revision total knee arthroplasty (rTKA) might be overestimated. The purpose of this study is to compare the success rate between DAIR and standard two-stage rTKA with a comparable intervention time.

METHODS

We retrospectively reviewed the consecutive knee periprosthetic joint infection cases which underwent DAIR or two-stage rTKA (all procedures were performed by the senior author) within 12 weeks since their primary TKA between July 2009 and October 2019. Average follow-up was 72.20 ± 40.70 months (range 29-148 months) in the DAIR group compared to 89.14 ± 43.06 months after spacer insertion (range 29-163 months) in the two-stage revision group (P = 0.156). According to different interventions, demographic data; timing of surgical intervention; hospital for special surgery knee score; and success rate were collected and compared between the DAIR group and two-stage revision group. Failure of treatment was based on the Delphi consensus and the fate of spacers. The pathogen types and failure cases were also recorded and analyzed.

RESULTS

Average follow-up was 72.20 ± 40.70 months (range 29-148 months) in the DAIR group compared to 89.14 ± 43.06 months after spacer insertion (range 29-163 months) in the two-stage revision group. Time from index surgery was 3.90 ± 2.92 weeks (range 0-12 weeks) in the DAIR group, and 5.11 ± 2.86 weeks (range 0-12 weeks) in the 2-stage exchange group, respectively. The success rate was 70.0% and 75.0% in the DAIR group and two-stage revision group, respectively. But no significant differences were observed between the two groups.

CONCLUSION

DAIR demonstrated comparable effectiveness with two-stage rTKA. We recommended DAIR as a choice for patients with current infection within 12 weeks after primary TKA. For methicillin-resistant staphylococcal infections and fungal infections, two-stage rTKA might be preferred.

Prosthetic Knee Infection With Coagulase-Negative Staphylococcus: A Harbinger of Poor Outcomes

BACKGROUND

Coagulase-negative staphylococci (CoNS) are biofilm-producing pathogens whose role in periprosthetic joint infection (PJI) is increasing. There is little data on the prognosis and treatment considerations in the setting of PJI. We sought to evaluate the clinical characteristics, outcomes, and complications in these patients.

METHODS

This is a retrospective cohort study of adult patients at a single tertiary medical center from 2009 to 2020 with culture-proven CoNS PJI after total knee arthroplasty, as diagnosed by Musculoskeletal Infection Society criteria. The primary outcome was treatment success, with failure defined as recurrent CoNS PJI, recurrent PJI with a new pathogen, and/or chronic oral antibiotic suppression at one year postoperatively.

RESULTS

We identified 55 patients with a CoNS total knee arthroplasty PJI with a mean follow-up of 29.8 months (SD: 16.3 months). The most commonly isolated organism was Staphylococcus epidermidis (n = 36, 65.5%). The overall prevalence of methicillin resistance was 63%. Surgical treatment included surgical debridement, antibiotics, and implant retention in 25 (45.5%) cases and two-stage revision (22 articulating and eight static antibiotic-impregnated spacers). At one-year follow-up, only 47% of patients had successful management of their infection. The surgical debridement, antibiotics, and implant retention cohort had the higher rate of treatment failure (60.0%) compared to two-stage revision (46.7%).

CONCLUSION

These results indicate a poor rate of success in treating CoNS PJI. This likely represents the interplay of inherent virulence through biofilm formation and decreased antibiotic efficacy.

The Use of Megaprostheses in Nononcologic Lower-Extremity Total Joint Arthroplasty: A Critical Analysis Review

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As the number of primary total joint arthroplasty (TJA) procedures continues to rise, megaprostheses have found an emerging role in more complex revision arthroplasty cases that require additional reconstruction, stability, and restoration of function.

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Megaprosthesis options have evolved: in addition to cemented prostheses, cementless and even hybrid fixation designs optimize longevity. Proximal femoral replacement (PFR), distal femoral replacement (DFR), proximal tibial replacement (PTR), and total femoral replacement (TFR) are all limb salvage options in the setting of substantial bone loss, poor bone quality, and soft-tissue compromise.

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Dislocation is one of the most common complications after PFR, likely due to the loss of soft-tissue integrity, most notably the hip abductor musculature from the greater trochanter. The utilization of dual-mobility constructs, larger femoral heads, elevated acetabular liners, and constrained acetabular liners may reduce the risk of instability and improve overall hip function.

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Patients with megaprostheses may be more prone to periprosthetic joint infection and surgical site infection given multiple variables, such as the lengthy nature of the surgical procedure, prolonged wound exposure, extensive soft-tissue dissection and resection, poor soft-tissue coverage, and poorer host status.

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Despite advances in technology, complication and revision rates remain high after megaprosthesis reconstruction. Therefore, thorough attention to patient-specific factors must be considered for appropriate use of these constructs.