Acute Periprosthetic Infection Research Articles

Update on the Treatment of Acute Infections in Knee Prostheses: Is it possible to retain the components? An in-depth look at the DAIR procedure.

Periprosthetic knee infections are serious complications after knee arthroplasty, affecting 1 to 2% of patients with primary surgery and up to 20% of revisions. The DAIR strategy (debridement, antibiotics, and implant retention) has emerged as a treatment for acute infections, allowing component retention in certain cases, with a high success rate. This review discusses its application, success factors, techniques such as the "double DAIR" and postoperative management, highlighting the importance of correct patient selection and the combination of a thorough and meticulous surgical technique with appropriate antibiotic therapy to optimize results. An exhaustive updated literature search was conducted regarding the use of DAIR in acute periprosthetic infections, highlighting the step-by-step procedure and some surgical tips that are helpful when performing it. Based on this, recommendations were made for physicians interested in the subject. A series of recommendations are made based on current literature, which are a useful guide when dealing with patients with acute infections in the context of knee prostheses, with a success rate greater than 70% in most cases where the patient is well selected. DAIR is a useful and effective tool in the eradication and treatment of acute periprosthetic infections, with a good success rate. It is a cheap, technically simple and reproducible procedure, so as a group, we suggest it be adopted globally by orthopedic surgeons.

Postoperative decrease in serum albumin as predictor of early acute periprosthetic infection after total knee arthroplasty

PurposePatients with hypoalbuminemia, (serum albumin (SA) < 3.5 g/dL) are at greater risk for complications after surgery, including increased postoperative infection rates after total knee arthroplasty (TKA). This study aimed to analyze both preoperative and postoperative SA in patients who experienced acute periprosthetic infection within the first 4 weeks after surgery.MethodsWe retrospectively analyzed data from 490 consecutive TKAs (314 patients). Five patients developed early acute infection requiring surgical treatment. SA data were collected preoperatively (SA0) and 1 week postoperatively (SA1W) to evaluate SA dynamics. Multiple patient and operative parameters that could influence SA were also analyzed.ResultsNo statistical differences were found in parameters expected to influence SA values between the surgically treated (STG) and non-treated groups (non-STG). None of the patients in STG had SA0 and SA1W below 3.5 g/dL. However, the amount and rate of SA reduction before and after surgery were significantly greater in STG than in non-STG.ConclusionSA dynamics revealed a greater reduction in both the amount and rate in STG before and after surgery than in non-STG. No correlation was found between early acute periprosthetic infection after TKA and each SA0 and SA1W time point. Further evaluation of the SA value of 3.5 g/dL as a threshold for acute early acute infection is warranted.

Diagnosis and Treatment of Acute Periprosthetic Infections with the BioFire® System within a Time-Dependent and Bacterium-Dependent Protocol: Review and Prosthesis-Saving Protocol.

Despite ongoing efforts to enhance diagnostic and treatment processes, the success rate for eradicating infections, particularly prosthetic joint infections (PJIs), currently stands at around 50%. For acute infections occurring shortly after arthroplasty, guidelines recommend a treatment known as DAIR (debridement, antibiotics, and implant retention). This approach is suggested for infections within 30 days post-arthroplasty or with less than 3 weeks of symptoms, provided that there is a stable implant and adequate soft-tissue mass. Several authors have suggested extending the use of DAIR beyond the initial 3-week period in specific cases. This extension practice seems increasingly feasible due to the rapid diagnostic capabilities offered by BioFire®. This technology allows for quick pathogen identification, aiding in the exclusion of cases that do not fit the criteria for the DAIR/DAPRI (debridement, antibiotic pearls and retention of the implant) protocol based on pathogen identification. The aim of this review is to re-examine the current literature on acute infections and present our proposed "prosthesis-saving" protocol, which integrates the BioFire® molecular diagnostic system. Continued research and assessment of the efficacy and safety of these protocols, especially regarding extended treatment timelines, are crucial for advancing the management of acute infections and enhancing outcomes for PJI patients.

Effects of Vancomycin/Tobramycin-Doped Ceramic Composite (Polyvinyl Alcohol Composite–Vancomycin/Tobramycin–Polymeric Dicalcium Phosphate Dihydrate) in a Rat Femur Model Implanted With Contaminated Porous Titanium Cylinders

BackgroundPeriprosthetic joint infection (PJI) remains common and problematic. We hypothesized that using a bioceramic that provided rapid release of the antibiotics (vancomycin [VAN] or VAN and tobramycin [VAN and TOB]) from a polyvinyl-alcohol-composite (PVA) combined with a delayed and sustained antibiotic release from polymeric-dicalcium-phosphate-dihydrate (PDCPD) ceramic would inhibit S. aureus-associated implant infections. MethodsA total of 50 male Sprague Dawley rats were randomly divided into 5 groups—I: negative control; II: bacteria only; III: bacteria + saline wash; IV: bacteria + PVA-VAN-PDCPD, and V: bacteria + PVA-VAN-TOB-PDCPD. A porous titanium (Ti) implant was press-fit into the rat knee. S. aureus-containing broth was added into the joint space creating a PJI. After 1 week, the joints from groups III to V were washed with saline and the fluid collected for bacterial quantification. This was followed by saline irrigation treatment (groups III to V) and application of the antibiotic-loaded PVA-PDCPD bioceramic (groups IV and V). On day 21, joint fluid was collected, and the implants harvested for bacterial quantification. ResultsNo bacteria were isolated from the negative control (group I). The positive control (group II) was positive on both days 7 and 21. Bacteria were still present on day 21 in the fluid and implant in group III. Groups (IV and V) showed a decrease in the bacterial burden in the fluid and implant on day 21. There were significant differences in bacteria levels in the collected wash fluid and on the implant at day 21 between the saline wash (group III) and treatment groups (IV and V). ConclusionsIn this animal model of acute periprosthetic infection, treatment with PVA-VAN-PDCPD and PVA-VAN/TOB-PDCPD reduced bacterial load in the infected joint and the infected Ti implant. Application of PVA-VAN-PDCPD and/or PVA-VAN/TOB-PDCPD after saline irrigation could be used as an addition to the treatment of PJI.

Management of acute periprosthetic knee infection: a comparison of arthroscopic and open debridement

IntroductionIn acute periprosthetic knee infections, debridement and implant retention (DAIR) is the preferred treatment prior to one- and two-stage revisions. The aim of this study is to compare the outcomes of arthroscopic and open debridement of infected primary total knee arthroplasties (TKA).Material and methodsWe analyzed clinical, laboratory, and antibiotic treatment data, collected in patients with periprosthetic knee infection treated with DAIR at a Swiss Level 1 orthopedic and trauma center over a 10-year period between January 2005 and May 2015. Inclusion criteria were primary total knee arthroplasty and early postoperative or acute hematogenous periprosthetic joint infection (PJI). The primary endpoint was the need for further revision surgery due to persistent infection. The secondary endpoint was the prosthesis salvage in further infection surgeries.ResultsForty-two patients with 44 acute or hematogenous periprosthetic knee infections were included. We recorded 20 recurrent infections (45%) in our study population: 10 (77%) out of 13 in the arthroscopic DAIR group and 10 (32%) out of 31 in the open DAIR group. Two-stage revision, meaning complete removal of the TKA, insertion of a spacer and replantation at a second stage, had to be performed in three patients treated initially arthroscopically (23%) and in six patients treated initially with an open surgical procedure (21%).ConclusionsOpen debridement for acute periprosthetic knee infection shows clear benefits in terms of infection eradication and prosthesis salvage compared to arthroscopic DAIR.

Clinical and Radiologic Outcomes of the 3-Component Salto Total Ankle Arthroplasty for End-Stage Ankle Osteoarthritis

Category: Ankle Arthritis; Ankle Introduction/Purpose: As the popularity of total ankle arthroplasty (TAA) increases and indications expand, surgeons require a better understanding of which factors are associated with the outcome. In this study, we evaluate the early clinical and radiologic outcomes of the Salto mobile bearing 3-component total ankle prosthesis. Methods: TAA was performed in 119 consecutive ankles (117 patients) by a single surgeon using 3-component Salto total ankle implant from June 2014 to May 2020. A prospectively collected database was used to identify all patients who underwent primary TAA with a minimum 1-year follow-up. All patients were followed up at two weeks, six weeks, three months, six months, at one year and yearly thereafter. Clinical outcome scoring was done pre-operatively and post-operatively. American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot functional score, pain VAS, satisfaction score and clinical range of motion (ROM) were collected along with weight-bearing radiographs of the ankle. Post-operative coronal, sagittal alignment of the component were evaluated with radiographs. Results: The average follow-up was 22.1 months (range, 12-79). Mean VAS pain score decreased from 6.7 (range, 3-10) pre- operatively to 1.7 (range, 0-8) at last follow-up (p &lt; 0.05). AOFAS score increased from 49.3 (range 8-85) to 85.1 (range 31-100) at last follow-up (p &lt; 0.05). Eighty eight percent of the patients was satisfied with the surgical results at the last follow-up. There were 9 cases (7%) with complication. 1 case had low grade infection, 6 cases had wound marginal necrosis, and 2 cases had acute periprosthetic infection that was managed by irrigation and debridement without replacing the implants. Post-operative radiographic angles checked serially and significantly changed from preoperative status (p &lt; 0.05). Conclusion: The TAA series using single Salto 3-componenet implant showed favorable radiologic and clinical outcomes. Also, the radiologic parameters showed statistically significant improvement.

The role of antibiotic calcium sulfate beads in acute periprosthetic knee infection: a retrospective cohort study

BackgroundThe study aimed to compare debridement, antibiotics, and implant retention (DAIR) vs. debridement antibiotic bead and retention of the implant (DABRI) in terms of infection-free success rate and treatment cost for acute periprosthetic joint infections after total knee arthroplasty (TKA).MethodBetween 2017 and 2020, 32 patients with acute periprosthetic joint infection who were treated by total knee arthroplasty were retrospectively reviewed. The patients were divided into a DAIR group (n=15) and a DABRI group (n=17). During the DABRI, additional calcium ulphate antibiotic beads were used. Patient age, the Musculoskeletal Infection Society score, microorganisms involved, and success rate were assessed. ResultsThe mean age of DAIR group (n=15) was 69 years, with 7 being male, and 8 female. The mean follow-up period lasted 30 months. The success rate was 80% (12/15). The mean age of DABRI group (n=17) was 64 years, with 10 patients being male and 7 female. The mean follow-up period was 16 months. The success rate was 88% (15/17). There were no significant differences in patient age (P>0.05), the Musculoskeletal Infection Society score (P>0.05), and success rate (P>0.05). A significant difference was found in the follow-up period between the two groups (P<0.05).ConclusionBoth DAIR and DABRI could be used to treat acute periprosthetic joint infections and the outcomes and treatment costs of the two procedures were comparable. Additional use of calcium sulfate beads was safe, but might not improve the treatment result. Randomized controlled studies are warranted for the routine use.

Total hip arthroplasty for unstable intertrochanteric fractures with necrosis of the femoral head:a 7-year follow-up

To discuss the result and long time follow-up of unstable intertrochanteric fracture combined with avascular necrosis of femoral head treated by total hip arthroplasty. From March 2008 to October 2014, 23 cases were enrolled and treated by total hip arthroplasty, including 10 males and 13 females, aged 59 to 82 years old with an average of(68.4±10.4) years old. There were 8 cases of type Ⅱa fractures, 6 cases of type Ⅱb fractures, 9 cases of type Ⅲ fractures according to Evans Classification. There were 3 cases of type Ⅱa, 3 cases of type Ⅱb, 9 cases of type Ⅲ, 8 cases type Ⅳaccording to Ficat Classification. The complications were recorded, the joint function was evaluated by Harris score and prosthesis survival rate was analysed. Postoperative complications occurred in 2 cases, one patient had acute periprosthetic infection 3 months after operation, and one patient had hip dislocation 3 months after operation. All 23 patients were followed up for 61 to 110 months with an agerage of (85.1±22.9) months. The Harris score at the final follow-up was 83 to 92 months with an average of(89.8±5.2) months, which was significantly different from that before operation (P<0.05). Imaging showed that all patients had bone healing of intertrochanteric fractures. The 7-year survival rate of prosthesis in 23 patients was 95.7%. The symptoms of unstable intertrochanteric fracture combined with avascular necrosis of femoral head could be solved by total hip arthroplasty, and the long time result was satisfied.

Evaluation of the serum level of CRP for diagnosing acute periprosthetic infection after TKA*

Objective: To determine the serum level of C-reactive protein (CRP) with greater accuracy for diagnosing acute periprosthetic infection after total knee arthroplasty (TKA). Method: Case-control study evaluating serum levels of CRP after TKA in infected and uninfected groups. The serum levels of CRP were assessed in patients submitted to TKA who had been readmitted in the acute phase for surgical debridement with implant retention and had their diagnosis of periprosthetic infection confirmed. These values were compared with a control group, which did not present infectious complications. Results: Between March 2014 and March 2016, 1,373 TKAs were performed in the institution, and 28 patients (0.49%) were readmitted in the acute phase with a diagnosis of periprosthetic infection. Sixteen patients met the inclusion criteria. Gender, skin color, age, and body mass index (BMI) were similar between the groups. The patients in the acute periprosthetic infection group had significantly higher mean serum levels of CRP than the control group (p&lt;0.001). For CRP levels = 30.615, the test's highest sensitivity (75%) and specificity (77%) were achieved, with an accuracy of 77.3% for the diagnosis of infection. The area under the 0.762 Receiver Operating Characteristics (ROC) curve showed satisfactory performance of the proposed test. Conclusion: Serum levels of CRP greater than 30.615 mg/L in the third week after TKA associated with clinical signs are highly suggestive of acute periprosthetic infection.Keywords: Knee; Osteoarthritis; Arthroplasty; Infection; CRP.*Study performed at the Centro de Cirurgia do Joelho, Instituto Nacional de Traumatologia e Ortopedia (INTO), Rio de Janeiro, RJ, Brazil.

Predicting the Exception-CRP and Primary Hip Arthroplasty.

Background: While primary hip arthroplasty is the most common operative procedure in orthopedic surgery, a periprosthetic joint infection is its most severe complication. Early detection and prediction are crucial. In this study, we aimed to determine the value of postoperative C-reactive protein (CRP) and develop a formula to predict this rare, but devastating complication. Methods: We retrospectively evaluated 708 patients with primary hip arthroplasty. CRP, white blood cell count (WBC), and several patient characteristics were assessed for 20 days following the operative procedure. Results: Eight patients suffered an early acute periprosthetic infection. The maximum CRP predicted an infection with a sensitivity and specificity of 75% and 56.9%, respectively, while a binary logistic regression reached values of 75% and 80%. A multinominal logistic regression, however, was able to predict an early infection with a sensitivity and specificity of 87.5% and 78.9%. With a one-phase decay, 71.6% of the postoperative CRP-variance could be predicted. Conclusion: To predict early acute periprosthetic joint infection after primary hip arthroplasty, a multinominal logistic regression is the most promising approach. Including five parameters, an early infection can be predicted on day 5 after the operative procedure with 87.5% sensitivity, while it can be excluded with 78.9% specificity.

Analysis of pathogen distribution and drug resistance of acute,delayed and chronic periprosthetic joint infection

Objective: To analyze the pathogen distribution and drug resistance in acute,delayed and chronic periprosthetic joint infection (PJI). Methods: The clinical data of 316 patients with periprosthetic infection after primary hip and knee arthroplasty admitted to the Department of Arthroplasty,the First Affiliated Hospital,Xinjiang Medical University from August 2010 to August 2020 were retrospectively analyzed.There were 146 males and 170 females,aged (62.3±14.2) years (range:22 to 89 years).One hundred and sixty one patients underwent total hip arthroplasty and 155 patients underwent total knee arthroplasty.According to the time of postoperative infection,the patients were divided into acute PJI group (65 cases),delayed PJI group (83 cases) and chronic PJI group (168 cases).The results of pathogen species,composition ratio and drug susceptibility tests were collected,and the independent sample t test,Chi-square test or Fisher's exact probability test were used for comparison. Results: Gram-positive bacteria were the main pathogens of PJI (49.7%,157/316),and the positive rates of culture in patients with acute PJI,delayed PJI and chronic PJI were 33.8% (22/65),55.4% (46/83) and 53.0% (89/168),and the difference was statistically significant(χ²=8.343,P=0.015).The common bacteria were coagulase-negative Staphylococcus (54.8%,86/157) and Staphylococcus aureus (30.6%,48/157),The drug-sensitivity to linezolid,vancomycin and tigacycline was 100%.The gram-negative bacteria were mainly Escherichia coli and Enterobacter cloacae,and the drug resistance rate to carbapenems was low,ranging from 0 to 9.09%.The drug resistance rates of acute PJI patients to rifampicin,ciprofloxacin and erythromycin were significantly higher than those of late onset and chronic PJI patients,the difference was statistically significant(rifampicin:χ²=14.332,P=0.001;ciprofloxacin:χ²=12.086,P=0.002;erythromycin:χ²=9.096,P=0.010);The drug resistance rate of acute PJI patients to levofloxacin,clindamycin and tetracycline was higher than that of chronic PJI patients,and the difference was statistically significant(levofloxacin:χ²=10.500,P=0.002; clindamycin: χ²=7.103,P=0.007; tetracycline: χ²=6.909,P =0.012).The resistance rate of ampicillin/sulbactam in acute PJI (60.0%) was significantly higher than that in chronic PJI (16.7%),and the difference was statistically significant(χ²= 5.853,P=0.040). Conclusion: Gram-positive bacteria are the main pathogens of PJI,and the resistance rate of pathogens of acute PJI is higher than that of late onset and chronic PJI.

Risk Scores and Machine Learning to Identify Patients With Acute Periprosthetic Joints Infections That Will Likely Fail Classical Irrigation and Debridement.

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.

Primary total knee arthroplasty in tibial plateau fractures: Literature review and our institutional experience

BackgroundDisplaced proximal tibia fractures in the elderly may be very difficult to manage. If osteosynthesis represents the standard of care in the younger patients, in the aged population this solution is controversial because a significant failure rate has been reported after internal fixation. Moreover, osteoarthritis progression following tibial plateau fractures is common, often requiring a subsequent total knee arthroplasty (TKA). In recent years, in order to overcome the fracture healing problems and to allow immediate full weight bearing, primary TKA after tibial plateau fractures in elderly patients has gained popularity. Material and methodsfrom 2015 to 2019, 11 tibial plateau fractures in elderly patients with pre-existing osteoarthritis were treated with a primary TKA. Age, gender, mechanism of trauma, pre-operative autonomy level, fractures classification, degree of osteoarthritis and intraoperative data (ligamentous stability and type of implant) were collected. After a mean follow-up of 28 months, Knee Society Score (KSS), post-operative autonomy level and Forgotten Joint Score (FJS) were evaluated. The radiological assessment (signs of loosening, limb axis and patellar height indices) and complications were also recorded. Resultsaccording to fracture type and ligamentous competence, 6 cases of posterior-stabilized (PS) design and 5 cases of semi-constrained TKA were implanted. At the final follow up, mean KSS knee score was 83±16 and mean KSS functional score was 74±15. Mean pre-operative autonomy level assessed with the Parker scale, was significantly higher than the post-operative one (7.5±1.4 vs 5.6 ± 1.3). Mean FJS was 66 ± 14. No lines of radiolucency or limb malalignment were found at the final radiological follow-up. One major complication was recorded: one acute periprosthetic infection. One patient reported a periprosthetic femoral fracture after 26 months. ConclusionBased on our and results and those reported on literature, primary TKA is a suitable option in case of tibial plateau fractures in elderly patients with pre-existing osteoarthritis and poor bone quality, in which osteosynthesis outcome may be poor. Unlike ORIF, primary TKA may allow immediate weightbearing and a faster recovery. Nevertheless, it is a demanding surgery with a significant complications rate and should be reserved for selected patients and experienced surgeons.

How reliable is the next generation of multiplex-PCR for diagnosing prosthetic joint infection compared to the MSIS criteria? Still missing the ideal test

Identification of the pathogen in case of a periprosthetic joint infection (PJI) remains 1 of the greatest challenges in septic surgery. Rapid germ identification enables timely, specific, antimicrobial therapy. The first multiplex PCR (polymerase chain reaction) generation (Unyvero-i60) enables germ detection within 5 hours with a sensitivity of 78.8% and a specificity of 100%. The aim of this study is to investigate the performance of the new generation of cartridges (Unyvero-ITI) of multiplex PCR in the case of a PJI. In a prospective study, intraoperatively aspirated synovial fluid from 97 patients with aseptic or septic hip or knee revision surgery (49 aseptic, 48 septic) was examined with the multiplex PCR system (Unyvero-ITI) and the results were compared with the MSIS criteria. In addition, the time until the microbiological result was obtained in the event of a germ detection was documented. The multiplex PCR showed a germ detection with a sensitivity of 85.1% and a specificity of 98.0%. In 7 cases a false negative result was found and in one patient a false positive result was found. The general accuracy of this test procedure was 91.8%. The detection of germs was carried out within 5 hours with the multiplex PCR compared to 4.9 days in conventional microbiological diagnostics. The new generation of multiplex-PCR was able to improve germ detection. The possibility of prompt detection of germs offers the option of faster, targeted antimicrobial therapy. This diagnostic tool offers significant advantages, particularly in the context of an acute periprosthetic infection.

Bacteria drug resistance profile affects knee and hip periprosthetic joint infection outcome with debridement, antibiotics and implant retention

BackgroundEvaluate the effect of bacteria drug resistance profile on the success rates of debridement, antibiotics and implant retention.MethodsAll early acute periprosthetic infections in hip and knee arthroplasties treated with DAIR at our institution over the period from 2011 to 2015 were retrospectively analyzed. The success rate was evaluated according to the type of organism identified in culture: multidrug-sensitive (MSB), methicillin-resistant Staphylococcus aureus (MRSA), multidrug-resistant Gram-negative bacteria (MRB) and according to other risk factors for treatment failure. The data were analyzed using univariate and multivariate statistics.ResultsFifty-seven patients were analyzed; there were 37 in the multidrug-sensitive bacteria (MSB) group, 11 in the methicillin-resistant Staphylococcus aureus (MRSA) group and 9 in the other multidrug-resistant Gram-negative bacteria (MRB) group. There was a statistically significant difference (p < 0.05) in the treatment failure rate among the three groups: 8.3% for the MSB group, 18.2% for the MRSA group and 55.6% for the MRB group (p = 0.005). Among the other risk factors for treatment failure, the presence of inflammatory arthritis presented a failure rate of 45.1 (p < 0.05).ConclusionDAIR showed a good success rate in cases of early acute infection by multidrug-sensitive bacteria. In the presence of infection by multidrug-resistant bacteria or association with rheumatic diseases the treatment failure rate was higher and other surgical options should be considered in this specific population. The MRSA group showed intermediate results between MSB and MRB and should be carefully evaluated.

Infección periprotésica aguda de rodilla por fusobacterium nucleatum. Revisión de la literaturaa propósito de un caso.

Fusobacterium Nucleatum is an anaerobic commensal microorganism present in the oral cavity and some mucous membranes with great capacity to form biofilm. In the literature, only one case of acute periprosthetic infection of the knee by Fusobacterium Nucleatum has been reported, providing the second case. A 72-year-old man presented with an acute periprosthetic infection by fusobacterium nucleatum after a second time of a prosthetic knee replacement. Debridement and spacer changes were performed up to 4 times, associating parenteral antibiotic treatment. After ensuring the absence of infection, a modular revision knee prosthesis with stems was placed, with a satisfactory evolution after two years. Currently he has preserved ambulation, joint balance of 0º-50º and is free of infection. Fusobacterium Nucleatum infection is very rare, but aggressive and difficult to resolve, recommending two-stage replacement in acute infection and adequate antibiotic treatment to offer curative treatment.

Irrigation and Debridement, Modular Exchange, and Implant Retention for Acute Periprosthetic Infection After Total Knee Arthroplasty.

The role of irrigation and debridement, modular exchange, and implant retention for the treatment of periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) remains controversial. The proposed benefits of debridement, antibiotics, and implant retention, often referred to as DAIR, include reduced economic cost and morbidity of 2-stage reimplantation1. The primary disadvantage of this approach is a higher rate of failure and infection recurrence2,3. Furthermore, several authors have demonstrated inferior outcomes of 2-stage exchange revision arthroplasty after a failed attempt at limited debridement with implant retention4-6. Because of study heterogeneity, the outcomes of acute PJI treatment with irrigation and debridement and implant retention have been variable in the literature, with reported success rates ranging from 16% to 100%; overall, the success rate is around 50%3,7,8. Recently, studies evaluating outcomes of DAIR have indicated that host factors, organism type, the timing of intervention, and the duration of symptoms can influence the likelihood of success with this approach7,9-12. DAIR may be considered for all patients with early postoperative PJI or an acute hematogenous infection in the context of well-fixed implants and a healthy soft-tissue envelope. Chronic PJI should be considered an absolute contraindication to DAIR13. The patient's health status, comorbidities, and immune status also should be considered. Caution should be exercised when considering DAIR for a patient in whom preoperative cultures demonstrate a drug-resistant or highly virulent organism, because of a higher risk of failure1,9,14,15. With careful patient selection and meticulous surgical technique, it is possible to achieve success with this treatment strategy. The surgical procedure begins with a medial parapatellar approach and arthrotomy. A complete synovectomy is then performed, and remaining synovial tissue is aggressively debrided. Multiple culture samples should be obtained, and aseptic technique should be utilized to decrease contamination. The implant is interrogated to ensure stable fixation. Following adequate debridement, high-volume irrigation is performed; in cases involving irrigation and debridement with implant retention, we recommend incorporation of an antiseptic solution such as povidone-iodine. We recommend switching to a clean setup to facilitate sterile, uncontaminated closure of the wound, which is performed in a standard fashion. Meticulous attention should be paid to layered closure, and, if there is concern about delayed skin-healing, incisional negative-pressure wound therapy may be utilized.

Hip arthroplasty for osteonecrosis of the femoral head secondary to alcohol abuse.

Although the challenges of hip arthroplasty for avascular necrosis (AVN) are known, limited data exist to describe patient demographics and outcomes in the setting of AVN attributed to alcoholism. We retrospectively identified 43 patients (62 hips) who underwent primary hip arthroplasty between 1999 and 2016 for a diagnosis of AVN of the femoral head with a concomitant diagnosis of alcohol abuse and minimum follow-up of 2 years (mean, 8.6 years). The mean age was 51 years, predominantly male (88%), with a high rate of comorbidities. History of cigarette smoking was prevalent (65%). Mean length of stay was 5.3 days, which is prolonged due to a high prevalence of acute postoperative alcohol withdrawal (14.5% of cases). There were 5 early (≤2 years) reoperations (8% of hips) for instability, periprosthetic acetabular fracture and component loosening, heterotopic ossification, superficial infection, and acute periprosthetic infection. There were no additional radiographic failures. The mean postoperative Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement was 97.8 ± 7.8, indicative of excellent outcomes at final follow-up of 2 to 18 years. Early risks associated with hip replacement surgery must be communicated to the predominantly young male subgroup of patients with AVN attributed to alcoholism, but these patients may achieve excellent mid- to long-term outcomes.

Revision surgery in acute periprosthetic knee joint infections

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. Early infection of TKA (<4weeks postoperatively); acute hematogenous TKA infection (symptom duration <3weeks). Delayed (>4weeks postoperatively) or chronic TKA infection; TKA loosening; difficult-to-treat pathogens; critical soft tissue with draining sinus tract. 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 1tissue 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 (3-5l saline solution). Glove change of the surgical team and new operation coverage. Inserting new polyethylene. Layerwise wound closure. Removal of redon drain on postoperative day2. Physiotherapy and CPM. Removal of cutaneous suture about 2weeks postoperatively. Antibiotic treatment for 12weeks postoperatively (2weeks intravenous, 10weeks per oral). Checking of inflammatory markers. 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.

Irrigation and Debridement with Component Retention for Acute Infection After Hip Arthroplasty: Improved Results with Contemporary Management.

There are conflicting data on the results of irrigation and debridement with component retention in patients with acute periprosthetic hip infections. The goals of this study were to examine contemporary results of irrigation and debridement with component retention for acute infection after primary hip arthroplasty and to identify host, organism, antibiotic, or implant factors that predict success or failure. Ninety hips (57 total hip arthroplasties and 33 hemiarthroplasties) were diagnosed with acute periprosthetic hip infection (using strict criteria) and were treated with irrigation and debridement and component retention between 2000 and 2012. The mean follow-up was 6 years. Patients were stratified on the basis of McPherson criteria. Hips were managed with irrigation and debridement and retention of well-fixed implants with modular head and liner exchange (70%) or irrigation and debridement alone (30%). Seventy-seven percent of patients were treated with chronic antibiotic suppression. Failure was defined as failure to eradicate infection, characterized by a wound fistula, drainage, intolerable pain, or infection recurrence caused by the same organism strain; subsequent removal of any component for infection; unplanned second wound debridement for ongoing deep infection; and/or occurrence of periprosthetic joint infection-related mortality. Treatment failure occurred in 17% (15 of 90 hips), with component removal secondary to recurrent infection in 10% (9 of 90 hips). Treatment failure occurred in 15% (10 of 66 hips) after early postoperative infection and 21% (5 of 24 hips) after acute hematogenous infection (p = 0.7). Patients with McPherson host grade A had a treatment failure rate of 8%, compared with 16% (p = 0.04) in host grade B and 44% in host grade C (p = 0.006). Most treatment failures (12 of 15 failures) occurred within the initial 6 weeks of treatment; failures subsequent to 6 weeks occurred in 3% of those treated with chronic antibiotic suppression compared with 11% of those who were not treated with suppression (hazard ratio, 4.0; p = 0.3). The success rate was higher in this contemporary series than in many previous series. Systemic host grade A was predictive of treatment success. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.