Efficacy of Open Debridement and Polyethylene Exchange in Strictly Selected Patients with Infection after Total Knee Arthroplasty

Treatment experience with continuous local antibiotic perfusion for periprosthetic joint infection

BACKGROUND

Antibiotic concentrations 100-1000 times higher than the minimum inhibitory concentration are necessary for eradicating biofilms in periprosthetic joint infections (PJI). Achieving this with intravenous antibiotics is challenging, but continuous local antibiotic perfusion (CLAP) can increase the local concentration of antibiotics. Although there are several reports on CLAP therapy in the fracture-related infection, there are only few reports on its application in PJI. Here, we report our experience with CLAP therapy for PJI.

METHODS

Eight patients with PJI (two males and six females, with mean age of 73.5 years [±11.6]) were treated at our department, and their clinical characteristics were analyzed. The parameters considered were the classification of PJI, surgical procedure, duration of CLAP, duration of transvenous antibiotic administration, time of CRP-negative status, whether the infection resolved or recurred, and whether there were complications due to CLAP.

RESULTS

Initial surgery included total knee arthroplasty in five cases, unicompartmental knee arthroplasty in one case, and total hip arthroplasty in two cases. There were four cases of early postoperative infection, two of acute delayed infection, and two of chronic delayed infection. The surgical procedures performed were two-stage revision for two patients, and debridement, antibiotics, and implant retention (DAIR) for the other six. The mean durations of CLAP and transvenous antibiotic administration were 8.5 (±2.4) and 22.4 days (±13.7), respectively, and the mean time to CRP-negative status was 23.3 days (±10.7). All eight patients successfully resolved without additional irrigation or debridement, and no recurrence was observed at the last follow-up after discontinuation of oral antibiotics. No systemic side effects of gentamicin or other complications associated with CLAP were observed.

CONCLUSION

All patients achieved infection resolution with the combined use of CLAP. This suggests that CLAP is a useful treatment option for PJI.

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.

Debridement and implant retention in acute hematogenous periprosthetic joint infection after knee arthroplasty: a systematic review

Debridement, antibiotic, and implant retention (DAIR) can be used as a first surgical procedure for acute infections in patients who have well-fixed components. However, its use in hematogenous or late acute infections is still debated. This systematic review of literature aims to clarify the effectiveness of DAIR procedure in the treatment of hematogenous periprosthetic knee infections. DAIR is an effective way to treat acute hematogenous PJIs of the knee and reaches its best efficacy when performed within one week from the onset of symptoms, modular components are exchanged, and a pathogen-oriented antibiotic therapy can be set. It is safe, economic, and effective technique, but has to be performed in a very narrow temporal window.

Periprosthetic Knee Infection - Part 2: Treatment

Several treatment modalities are proposed for periprosthetic infections, with variable success rates. However, efficacy is related to the appropriate selection of cases for each type of treatment. Debridement with implant retention is indicated in acute infections with fixed implant, and its success depends on the type of infection, comorbidities of the host, and virulence of the etiological agent. One- or two-stage revision is required in cases in which biofilm is forming, or of implant loosening. The choice between performing the review in one or two stages depends on factors such as etiological agent identification, pathogen virulence, local and systemic host factors. Rescue procedures such as arthrodesis, amputation, resection arthroplasty or even antibiotic suppression are reserved for cases in which the infection has not been eradicated.

A novel open synovectomy technique using an arthroscopy shaver blade in revision surgery to treat infected total knee arthroplasty: a technical note

Background

This article introduces a novel open synovectomy technique using an arthroscopy shaver blade to effectively remove intra-articular synovitis during revision surgery for infected primary total knee arthroplasty.

Methods (techniques)

Open synovectomy is performed using a 4.2-mm arthroscopy shaver blade, and the handpiece is connected to suction drainage. Suction is supplied through the central cylinder of the shaver blade to bring the debrided fragments of soft tissue into the window. Grossly inflamed, reddened, diseased synovium is debrided to reveal yellowish, healthy synovium. The inflamed tissues of the knee joint (suprapatellar pouch, medial and lateral gutters, and peripatellar area) are debrided. Then, with maintaining full flexion of the knee joint, a shaver equipped with a longer bar can be used to easily access the medial and lateral posterior compartments, which are generally difficult to access.

Results

During a mean of 13.5-month follow-up, there was no recurrent infection in either group; however, patients who underwent the novel technique improved significantly faster in terms of acute serological markers during the first period.

Conclusions

This technique yielded favorable outcomes compared with the conventional technique. In particular, it may facilitate the approach to the posterior joint space, which is difficult to access.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03024-5.

Contemporary outcomes of debridement, antibiotics and implant retention in knee arthroplasty

Periprosthetic joint infection (PJI) is a major complication after knee arthroplasty, with approximately a quarter of knee arthroplasty revisions citing PJI as an indication. With the demand for knee arthroplasty predicted to increase, coupled with a lack of evidence for decreasing PJI risk, an appreciation of the burdens of PJI on both patients and health care systems is vital. Patients with PJI can experience a reduced quality of life as well as increased morbidity, whilst the management of PJI has significant economic implications. Surgical options include debridement, antibiotics and implant retention (DAIR), single-stage revision, two-stage revision and salvage procedures. DAIR involves the systematic debridement of all infected and unhealthy tissues coupled with directed antibiotic therapy, with definitive infection clearance the objective. In contrast to single- and two-stage revision procedures for PJI, DAIR does not involve the removal of fixed implants, with only modular components exchanged. Potential benefits of DAIR include reduced tissue destruction, reduced morbidity and reduced healthcare burdens, but with a higher reinfection risk compared to staged revision techniques, and utility largely restricted to acute bacterial PJI. A review of contemporary DAIR outcomes is of value given advances in the understanding of PJI biology; the development of consensus-based definitions for PJI diagnosis and treatment outcomes; and evolution of DAIR indications and technique. This review discusses outcomes of DAIR for knee PJI, published over the last two decades.

Direct-Contact Low-Frequency Ultrasound and Pulse Lavage Eradicates Biofilms on Implant Materials In Vitro

Pulse lavage (PL) debridement and ultrasound are both known to be the treatment of biofilm-related periprosthetic joint infection (PJI). However, the efficacy of these in combination is unknown in eradicating biofilm from the orthopaedic metal implant surface. This study was conducted to understand the efficacy of PL and ultrasound in combination in eradicating bacterial biofilms on titanium alloy in vitro. Biofilms of Staphylococcus aureus strains were grown on titanium alloy coupons for 24 h. Then, the coupons were taken to each treatment group: (i) debrided with PL, (ii) exposed to ultrasound, or (iii) exposed to both. An untreated biofilm was set as a control group. Viable plate count and confocal microscopy using live/dead staining was used to measure the amount of biofilm. Viable plate count showed an approximate two-log reduction in CFU/cm² in PL alone, from an initial cell count on the mental surface of approximately 10⁹ CFU/cm². The ultrasound caused an approximate seven-log reduction, and the combination group eradicated viable biofilm bacteria completely. Confocal imaging corroborated the CFU data. Our results indicate that PL and ultrasound both are remarkably in eradicating biofilm, and the combination of PL and ultrasound is more effective than alone in reducing biofilm.

A decision analysis of treatment strategies for acute periprosthetic joint infection: Early irrigation and debridement versus delayed treatment based on organism

OBJECTIVE

The purpose of this study was to investigate whether immediate or delayed tailored DAIR treatment based on microbial species is the optimal treatment for acute post-operative periprosthetic joint infection (PJI).

METHODS

A multicenter retrospective study was conducted to identify patients who underwent debridement, antibiotics, and implant retention (DAIR) for PJI. Decision analysis modeling was employed to determine the treatment strategy that yielded the greatest patient outcome.

RESULTS

316 patients who underwent DAIR for PJI were identified.

CONCLUSION

The decision analysis model determined that the optimal treatment strategy is to perform an immediate DAIR to achieve the greatest QALY outcomes in TKA and THA patients with acute PJI.

Carbon nanotube-based biomaterials for orthopaedic applications

Carbon nanotubes can enhance the functionality of orthopedic applications.

A retrospective comparative study of infection control rate and clinical outcome between open debridement using antibiotic-impregnated cement beads and a two-stage revision in acute periprosthetic knee joint infection

The aim of this study was to determine whether the infection control rate of a modified debridement, antibiotics, and implant retention (DAIR) protocol (DAIR with antibiotic-impregnated cement beads) is comparable to that of 2-stage revision for acute periprosthetic joint infection (PJI) after total knee arthroplasty (TKA). We also aimed to determine whether this modified DAIR technique produced better clinical results than those obtained using 2-stage revision in terms of functional outcome, range of motion (ROM), and patient satisfaction at 2 years after surgery.This retrospective comparative study included patients who underwent modified DAIR (7 patients, 9 knees) or 2-stage revision (8 patients, 9 knees) for acute PJI of the knee joint. Infection control rate, functional outcome measured using Western Ontario and McMaster Universities Arthritis Index (WOMAC) score, ROM and patient satisfaction were compared between the two groups.There was no difference in infection control rates between the modified DAIR and 2-stage revision groups (78% vs 78%, respectively). In contrast, surgical outcome in the modified DAIR group was tended to be better than 2-stage revision group, but it did not reach statistical significance. Median maximal range of flexion was 103° in the modified DAIR group and it was 90° in the 2-stage group (P = .191). In addition, the median WOMAC function score was 24 in the modified DAIR group and it was 30 in the 2-stage group (P = .076). Median patient satisfaction measured using visual analogue scale was 8 in the modified DAIR group and 5 in the 2-stage group (P = .069).The infection control rates of the modified DAIR protocol and 2-stage revision protocol were similar for the treatment of acute PJI of the knee joint. However, the modified DAIR protocol could not provide substantially increased functional outcomes and patient satisfaction compared to 2-stage revision. Therefore, the modified DAIR technique should be considered to be of limited use in patients with high surgical morbidity.

Debridement, antibiotics, and implant retention for periprosthetic knee infections: a pooling analysis of 1266 cases

Background

The debridement, antibiotics, and implant retention (DAIR) procedure is an established therapeutic option for periprosthetic knee infections (PKI). However, the efficacy and the indication for this procedure are still controversial.

Methods

All the relevant literatures were systematically reviewed and analyzed. The present study aimed to assess the success rate of DAIR in the management of PKI, identify the factors associated with prognosis of DAIR, and establish a simple algorithm for predicting a high success rate of DAIR.

Results

Totally, 33 studies with 1266 cases were included. The overall success rate following DAIR in the management of PKI was 57.11%. In the subgroup analyses, the factors of “the time from symptoms to debridement was < 3 weeks” and “the bacterial species other than methicillin-resistant Staphylococcus aureus” significantly improved the success rate of DAIR and thus were defined as the major criteria. The statistically insignificant factors of “the open debridement and liner exchange” and “the comorbidity of rheumatoid arthritis” were set as the minor criteria. The success rate of DAIR for PKI meeting all the major criteria and no less than one minor criterion was 80.98%, which was significantly higher than the overall success rate of DAIR (p < 0.05).

Conclusion

PKI cases meeting two major criteria and no less than one minor criterion may confer a high success rate of DAIR. This simple algorithm may contribute to identifying the appropriate PKI patient for DAIR treatment and predicting the prognosis of DAIR.

Haematogenous prosthetic knee infections: Prospective cohort study of 58 patients

BACKGROUND

Prosthetic joint infection (PJI) is a rare (incidence, 0.15% to 0.9%) but serious complication of knee arthroplasty. Haematogenous PJI of the knee (KhPJI) which accounts for 10% of cases, has been less studied than PJI due to other mechanisms. The primary objective of this study in patients with KhPJI of the knee was to determine the 2-year infection eradication failure rate after either exchange arthroplasty or arthrotomy/synovectomy/irrigation (ASI), combined with prolonged peri-operative antibiotic therapy, at a referral centre for complex osteo-articular infections.

HYPOTHESIS

ASI within 2 weeks after symptom onset and one-stage exchange arthroplasty produce similar 2-year success rates in patients with KhPJI of the knee.

MATERIAL AND METHODS

A prospective observational cohort study was performed in patients managed for PJI of the knee between 2003 and 2015. The primary outcome measure was the occurrence of a septic event or of KhPJI -related death during a minimum follow-up of 2 years.

RESULTS

Of 265 patients with PJI after total knee arthroplasty, 58 (22.1%) had KhPJI with onset more than 3 months after the last arthroplasty procedure and were included in the study. Among them, one-third had immune deficiencies. The most common causative organisms were streptococci (n=25, 43%) and Staphylococcusaureus (n=20, 34%). The primary focus of infection was identified in only 64% of patients and was most often cutaneous (n=19, 33%) or dental (n=11, 19%). A septic event or KhPJI-related death occurred in 5/34 (15%) patients after one-stage exchange arthroplasty and 6/19 (32%) patients after ASI within 15 days after symptom onset (p=0.03). Patient characteristics, type of prosthesis, and causative organism were not significantly associated with failure to eradicate the infection.

CONCLUSION

ASI carried a high failure rate despite being performed within 15 days after symptom onset. One-stage exchange arthroplasty seems to be the best surgical option, particularly as the exact time of symptom onset may be difficult to determine. Identifying and eradicating the primary focus of infection is crucial.

LEVEL OF EVIDENCE

II, low-powered prospective cohort study.

[Revision surgery in acute periprosthetic knee joint infections]

OBJECTIVE

Reduction of pathogens in the knee joint by removal of infected periprosthetic soft tissue, irrigation and modular implant exchange of the total knee arthroplasty (TKA) to eliminate the infection and long-term preservation of the TKA.

INDICATIONS

Early infection of TKA (<4 weeks postoperatively); acute hematogenous TKA infection (symptom duration <3 weeks).

CONTRAINDICATIONS

Delayed (>4 weeks postoperatively) or chronic TKA infection; TKA loosening; difficult-to-treat pathogens; critical soft tissue with draining sinus tract.

SURGICAL TECHNIQUE

Excision of the wound or old surgical scar (= primary approach to the knee joint). Preparation of subcutaneous tissue. Opening the joint capsule. Removal of the old suture in tissue layers. Five tissue samples taken for microbiological and 1 tissue sample for histopathological examination using an unused instrument from the knee joint. Debridement of the upper recesses with complete synovectomy. Partial resection of Hoffa's fat body. Eversion of the patella. Resection of peripatellar soft tissue and infection membranes from the medial and lateral part of the capsule. Removal of the polyethylene inlay. Débridement of the posterior joint capsule with protection of vessels and nerve. Systematic removal of avital and infected periprosthetic tissue. Checking for correct fit of the femoral and tibial part of TKA. Antiseptic rinsing of the joint cavity with mechanical cleaning of the TKA. Extensive irrigation of the joint cavity by jet lavage (3-5 l saline solution). Glove change of the surgical team and new operation coverage. Inserting new polyethylene. Layerwise wound closure.

POSTOPERATIVE MANAGEMENT

Removal of redon drain on postoperative day 2. Physiotherapy and CPM. Removal of cutaneous suture about 2 weeks postoperatively. Antibiotic treatment for 12 weeks postoperatively (2 weeks intravenous, 10 weeks per oral). Checking of inflammatory markers.

RESULTS

Using correct indications and therapy, up to 90% of patients with acute periprosthetic TKA infection can be successfully treated with infection elimination and TKA preservation.