Late Acute Periprosthetic Joint Infections; When Should the Implant Be Removed?

Abstract

Background: Late acute (LA) periprosthetic joint infections (PJI) treated with surgical debridement and implant retention (DAIR) have a high failure rate. Therefore, we evaluated treatment outcome in LA PJIs treated with DAIR versus implant removal. Methods: In a large multicenter study, LA PJIs of the hip and knee were retrospectively evaluated. Failure was defined as: PJI related death, prosthesis removal or the need for suppressive antibiotic therapy. LA PJI was defined as acute symptoms <3 weeks and more than 3 months after the index surgery. Findings: A total of 445 patients were included, comprising 340 cases treated with DAIR and 105 cases treated with implant removal (19% one-stage revision (n=20), 74.3% two-stage revision (n=78) and 6.7% definitive implant removal (n=7). Overall treatment failure was 45.0% in the DAIR group versus 24.8% in the implant removal group (p < 0.001). This difference remained after 1:1 propensity-score matching. DAIR was an independent predictor for failure in the multivariate analysis (OR 2.7, p 0.006). A high preoperative risk score for DAIR failure defined by a CRIME80 score ≥3, demonstrated a failure rate of 68.7% (57/83) in the DAIR group and a 16.7% failure rate (4/24) in the implant removal group (p < 0.0001). No significant difference in failure was observed with a CRIME80 score <3 (35.7% versus 23.9%, respectively (p 0.07). Interpretation: Implant removal is associated with significantly better outcomes compared to DAIR in LA PJI with a high CRIME80 score and this should be taken into consideration when choosing the surgical strategy. Funding: No funding was obtained for this study. Declaration of Interest: The authors state no conflict of interest. Ethical Approval: Informed consent was retrieved when required by the ethics committee of the participating center.