Good quality of life outcomes after treatment of prosthetic joint infection with debridement and prosthesis retention

Debridement, antibiotics, and implant retention (DAIR) for the early prosthetic joint infection of total knee and hip arthroplasties: a systematic review

PURPOSE

Early periprosthetic joint infection (PJI) represents one of the most fearsome complications of joint replacement. No international consensus has been reached regarding the best approach for early prosthetic knee and hip infections. The aim of this updated systematic review is to assess whether debridement, antibiotics, and implant retention (DAIR) is an effective choice of treatment in early postoperative and acute hematogenous PJI.

METHODS

This systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The diagnostic criteria defining a PJI, the most present pathogen, and the days between the index procedure and the onset of the PJI were extracted from the selected articles. Additionally, the mean follow-up, antibiotic regimen, and success rate of the treatment were also reported.

RESULTS

The articles included provided a cohort of 970 patients. Ten studies specified the joint of their cohort in PJIs regarding either hip prostheses or knee prostheses, resulting in 454 total knees and 460 total hips. The age of the patients ranged from 18 to 92 years old. Success rates for the DAIR treatments in the following cohort ranged from 55.5% up to a maximum of 90% (mean value of 71%).

CONCLUSION

Even though the DAIR procedure is quite limited, it is still considered an effective option for patients developing an early post-operative or acute hematogenous PJI. However, there is a lack of studies, in particular randomized control trials (RCTs), comparing DAIR with one-stage and two-stage revision protocols in the setting of early PJIs, reflecting the necessity to conduct further high-quality studies to face the burden of early PJI.

Risk Factors and Management of Prosthetic Joint Infections in Megaprostheses-A Review of the Literature

Prosthetic joint infection (PJI) is the most common mode of failure of megaprostheses, yet the literature on the topic is scarce, and studies report conflicting data regarding the optimal treatment strategy. Patients with megaprostheses PJI are often immunosuppressed, and surgeons must balance the trade-off between treatment efficacy and morbidity associated with the surgery aiming for infection eradication. Our review on megaprostheses PJI focuses on two axes: (1) risk factors and preventative strategies; and (2) surgical strategies to manage this condition. Risk factors were classified as either unmodifiable or modifiable. Attempts to decrease the risk of PJI should target the latter group. Strategies to prevent PJI include the use of silver-coated implants, timely discontinuation of perioperative antibiotic prophylaxis, and adequate soft tissue coverage to diminish the amount of dead space. Regarding surgical treatment, main strategies include debridement, antibiotics, implant retention (DAIR), DAIR with modular component exchange, stem retention (DAIR plus), one-stage, and two-stage revision. Two-stage revision is the "gold standard" for PJI in conventional implants; however, its success hinges on adequate soft tissue coverage and willingness of patients to tolerate a spacer for a minimum of 6 weeks. DAIR plus and one-stage revisions may be appropriate for a select group of patients who cannot endure the morbidity of two surgeries. Moreover, whenever DAIR is considered, exchange of the modular components should be performed (DAIR plus). Due to the low volume of megaprostheses implanted, studies assessing PJI should be conducted in a multi-institutional fashion. This would allow for more meaningful comparison of groups, with sufficient statistical power. Level of evidence: IV.

Incidence, associated disease burden and healthcare utilization due to Staphylococcus aureus prosthetic joint infection in European hospitals: the COMBACTE-NET ARTHR-IS multi-centre study

BACKGROUND

The aim of this study was to estimate the incidence, associated disease burden and healthcare utilization due to Staphylococcus aureus prosthetic joint infections (SA-PJI) after primary hip and knee arthroplasty in European centres.

METHODS

This study was conducted in patients who underwent primary hip and knee arthroplasty in 19 European hospitals between 2014 and 2016. The global incidence of PJI and SA-PJI was calculated. The associated disease burden was measured indirectly as infection-related mortality plus loss of function. For healthcare utilization, number and duration of hospitalizations, number and type of surgical procedures, duration of antibiotic treatments, and number of outpatient visits were collected. Subgroup and regression analyses were used to evaluate the impact of SA-PJI on healthcare utilization, controlling for confounding variables.

RESULTS

The incidence of PJI caused by any micro-organism was 1.41%, and 0.40% for SA-PJI. Among SA-PJI, 20.7% were due to MRSA with substantial regional differences, and were more frequent in partial hip arthroplasty (PHA). Related deaths and loss of function occurred in 7.0% and 10.2% of SA-PJI cases, respectively, and were higher in patients with PHA. Compared with patients without PJI, patients with SA-PJI had a mean of 1.4 more readmissions, 25.1 more days of hospitalization, underwent 1.8 more surgical procedures, and had 5.4 more outpatient visits, controlling for confounding variables. Healthcare utilization was higher in patients who failed surgical treatment of SA-PJI.

CONCLUSIONS

This study confirmed that the SA-PJI burden is high, especially in PHA, and provided a solid basis for planning interventions to prevent SA-PJI.

The Effect of Prosthetic Joint Infection on Work Status and Quality of Life: A Multicenter, International Study

BACKGROUND

Periprosthetic joint infection (PJI) and subsequent revision surgeries may affect patients' social and physical health, ability to complete daily activities, and disability status. This study sought to determine how PJI affects patients' quality of life through patient-reported outcome measures with minimum 1-year follow-up.

METHODS

Patients who suffered PJI following primary total joint arthroplasty (TJA) from 2012 to 2021 were retrospectively reviewed. Patients met Musculoskeletal Infection Society criteria for acute or chronic PJI, underwent revision TJA surgery, and had at least 1 year of follow-up. Patients were surveyed regarding how PJI affected their work and disability status, as well as their mental and physical health. Outcome measures were compared between acute and chronic PJIs. In total, 318 patients (48.4% total knee arthroplasty and 51.6% total hip arthroplasty) met inclusion criteria.

RESULTS

Following surgical treatment for knee and hip PJI, a substantial proportion of patients reported that they were unable to negotiate stairs (20.5%), had worse physical health (39.6%), and suffered worse mental health (25.2%). A high proportion of patients reported worse quality of life (38.5%) and social satisfaction (35.3%) following PJI. Worse reported patient-reported outcome measures including patients' ability to complete daily physical activities were found among patients undergoing treatment for chronic PJI, and also, 23% of patients regretted their initial decision to pursue primary TJA.

CONCLUSIONS

A PJI negatively affects patients' ability to carry out everyday activities. This patient population is prone to report challenges overcoming disability and returning to work. Patients should be adequately educated regarding the risk of PJI to decrease later potential regrets.

LEVEL OF EVIDENCE

Case series (IV).

A Pilot Study Using a Standardized Method of Measuring Distress Demonstrates Higher Levels in Septic Revisions

Background

Combined Orthopaedic Infectious Disease Clinics facilitate care for prosthetic joint infection (PJI) patients similar to multidisciplinary care in cancer centers. The National Comprehensive Cancer Network developed a standardized distress thermometer (DT) to measure distress in cancer patients. We propose using this tool to assess distress in PJI patients.

Methods

In this pilot study, a retrospective review of patients treated in our combined clinic over 2 years was conducted. In addition to providing information surrounding their treatment, patients completed a questionnaire and DT, adapted with permission from the National Comprehensive Cancer Network. DT scores were compared to a chronologically collected matched aseptic control group.

Results

There were 122 patients in the septic group and 40 patients in the aseptic group. On a scale of 0-10 (10, the highest level of distress), the septic group reported a mean DT score of 6.18 (±3.2), which was significantly higher than the aseptic mean score of 3.33 (±2.06) [P < .0001]. Over 75% of patients in the septic group reported a DT score ≥4, the cutoff used in most cancer centers to warrant additional support. Twenty-one percent of the septic group (26/122) reported extreme distress (defined as a score ≥10) compared to 0/40 of aseptic patients.

Conclusions

Patients treated for PJI experience significantly higher levels of distress compared to aseptic revision patients. More attention is needed to measure and clinically address distress. Improved screening for distress would allow us to provide more comprehensive care and possibly improve compliance, outcomes, and resources available for the treatment of PJI patients.

Implantable biomedical materials for treatment of bone infection

The treatment of bone infections has always been difficult. The emergence of drug-resistant bacteria has led to a steady decline in the effectiveness of antibiotics. It is also especially important to fight bacterial infections while repairing bone defects and cleaning up dead bacteria to prevent biofilm formation. The development of biomedical materials has provided us with a research direction to address this issue. We aimed to review the current literature, and have summarized multifunctional antimicrobial materials that have long-lasting antimicrobial capabilities that promote angiogenesis, bone production, or "killing and releasing." This review provides a comprehensive summary of the use of biomedical materials in the treatment of bone infections and a reference thereof, as well as encouragement to perform further research in this field.

Quality of Life After Orthopedic Procedures at Buraydah Central Hospital and King Fahad Specialist Hospital in Qassim Region, Saudi Arabia

Aim

Patients' perspectives on their condition and treatment, their sense of need for healthcare, and their preferences for care and outcomes are all addressed by quality of life metrics. Therefore, it is important to all health professionals and patients involved in orthopedic surgery. This study aimed to evaluate the quality of life after orthopedic procedures and how its results could potentially be used for future improvement.

Methods

This is a cross-sectional study conducted among patients who underwent orthopedic procedures at Buraydah Central Hospital (BCH) and King Fahad Specialist Hospital (KFSH). A self-administered questionnaire was distributed among the patients using a paper questionnaire. The questionnaire was composed of socio-demographic data (e.g. age, gender, education, etc.) and the 36-Item Short Form Survey (SF-36) to measure patients’ quality of life.

Results

In this study, 215 patients were able to complete the survey (male 82.3% vs female 17.7%). The most common age group was 18 to 30 years old (30.2%) and the most common surgery performed on patients was thigh surgery (19.5%) and hand surgery (13%). The overall mean physical health score after the surgery was 51.1 (SD 11.8) higher than the mental health score (mean 47.7; SD 11.2). Poor quality of life was significantly more common among patients with chronic disease while poor physical functioning and general health subdomains were more associated among patients who underwent hand surgery.

Conclusion

Patients suffering from chronic diseases tend to exhibit a low quality of life as compared to other patients. The quality of life after the surgery is an important indicator of patient satisfaction which may have a direct impact on the future outlook of a patient. More research is needed to determine the overall quality of life in patients who underwent a surgical procedure in our region.

Management strategies for prosthetic joint infection: long-term infection control rates, overall survival rates, functional and quality of life outcomes

DAIR (debridement, antibiotics, and implant retention), one-stage and two-stage revision surgery are the most common management strategies for prosthetic joint infection (PJI) management. Our knowledge concerning their efficacy is based on short to medium-term low-quality studies.

Most studies report infection recurrence rates or infection-free time intervals. However, long-term survival rates of the infection-free joints, functional and quality of life outcome data are of paramount importance.

DAIR, one-stage and two-stage revision strategies are not unique surgical techniques, presenting several variables. Infection control rates for the above strategies vary from 75% to 90%, but comparisons are difficult because different indications and patient selection criteria are used in each strategy.

Recent outcome data show that DAIR and one-stage revision in selected patients (based on host, bacteriological, soft tissue and type of infection criteria) may present improved functional and quality of life outcomes and reduced costs for health systems as compared to those of two-stage revision.

It is expected that health system administrators and providers will apply pressure on surgeons and departments towards the wider use of DAIR and one-stage revision strategies. It is the orthopaedic surgeon’s responsibility to conduct quality studies in order to fully clarify the indications and outcomes of the different revision strategies.

Cite this article: EFORT Open Rev 2021;6:727-734. DOI: 10.1302/2058-5241.6.210008

Comparison of the success rate after debridement, antibiotics and implant retention (DAIR) for periprosthetic joint infection among patients with or without a sinus tract

BACKGROUND

The relevance between the presence of a sinus tract and the failure risk after debridement, antibiotics and implant retention (DAIR) for periprosthetic joint infection (PJI) after hip or knee arthroplasty is still unclear. This study aimed to compare the success rate of DAIR between patients with or without a sinus tract and to explore the possible risk factors for failure after DAIR in patients with a sinus tract.

METHODS

Consecutive DAIR cases for PJI after hip or knee arthroplasty between January 2009 and June 2019 with a minimum 1-year follow-up in two tertiary joint arthroplasty centers were included. Patients were classified into the sinus tract group and the non-sinus tract group according to the presence of a sinus tract. The success rate after DAIR were compared using Kaplan-Meier survival analysis. Potential risk factors for failure in the sinus group were also explored.

RESULTS

One hundred seven patients were included. At a median 4.4 years of follow-up, 19 of 52 (36.5%) cases failed in the sinus tract group, while 15 of 55 (27.3%) cases failed in the non-sinus tract group. The 1-year and 5-year cumulative success rates were 71.2% (95% confidence interval (CI): 59.8-84.6%) and 56.8% (95% CI: 42.6-75.7%) in the sinus tract group, respectively, which were similar to the counterparts in the non-sinus tract group (P = 0.214). Among patients with a sinus tract, DAIR with the exchange of modular components showed a higher success rate (75.8% versus 47.4%, P = 0.038).

CONCLUSIONS

The presence of a sinus tract does not affect the success rate of DAIR. Modular component exchange in DAIR was proposed for patients with a sinus tract for an improved infection control rate.

Effect of a multidisciplinary team on the treatment of hip and knee prosthetic joint infections: a single-centre study of 154 infections

BACKGROUND

A multidisciplinary team responsible for the management plan of prosthetic joint infections (PJI) was founded in January 2008. The aim of this study was to investigate whether a decrease in the number of surgeries and length of stay (LOS) was seen in the management of PJI with the aid of the multidisciplinary team.

METHODS

This retrospective cohort study consisted of a total of 154 postoperative PJIs from three time periods: 21 PJIs from 2005 to 2007 (Group 1), 65 PJIs from 2011 to 2013 (Group 2), and 68 PJIs from 2015 to 2016 (Group 3). Successful outcome was classified as the retention of the original implant or revised implant and no infection-related death.

RESULTS

The median number of operations decreased from 2.0 operations (Group 1) to 1.0 operation (Group 3) (p = .023), and the median LOS was shortened from 49.0 days (Group 1) to 17.0 days (Group 3) (p = .000). The number of PJIs treated with two-stage exchange decreased from 52.4% (11/21, Group 1) to 16.2% (11/68, Group 3) (p = .004). Simultaneously, debridement, antibiotics, and implant retention (DAIR) as primary surgical treatment increased from 42.9% (9/21, Group 1) to 89.7% (61/68, Group 3) (p = .000). The successful outcome of DAIR improved from 55.6% (5/9, Group 1) to 85.2% (52/61, Group 3) (p = .077).

CONCLUSIONS

Treatment of PJI in a specialized centre with the aid of a multidisciplinary team lead to fewer surgeries and reduced LOS. Successful outcome of DAIR improved over time.

Long-Term Patient-Related Quality of Life after Knee Periprosthetic Joint Infection

BACKGROUND

We aimed to evaluate the impact of knee periprosthetic joint infection (PJI) by assessing the patients' long-term quality of life and explicitly their psychological wellbeing after successful treatment.

METHODS

Thirty-six patients with achieved eradication of infection after knee PJI were included. Quality of life was evaluated with the EQ-5D and SF-36 outcome instruments as well as with an ICD-10 based symptom rating (ISR) and compared to normative data.

RESULTS

At a follow-up of 4.9 ± 3.5 years the mean SF-36 score was 24.82 ± 10.0 regarding the physical health component and 46.16 ± 13.3 regarding the mental health component compared to German normative values of 48.36 ± 9.4 (p < 0.001) and 50.87 ± 8.8 (p = 0.003). The mean EQ-5D index reached 0.55 ± 0.33 with an EQ-5D VAS rating of 52.14 ± 19.9 compared to reference scores of 0.891 (p < 0.001) and 68.6 ± 1.1 (p < 0.001). Mean scores of the ISR revealed the psychological symptom burden on the depression scale.

CONCLUSION

PJI patients still suffer from significantly lower quality of life compared to normative data, even years after surgically successful treatment. Future clinical studies should focus on patient-related outcome measures. Newly emerging treatment strategies, prevention methods, and interdisciplinary approaches should be implemented to improve the quality of life of PJI patients.

Methods and probability of success after early revision of prosthetic joint infections with debridement, antibiotics and implant retention

Prosthetic joint infection (PJI) is a rare-and dreaded-complication of arthroplasty requiring multidisciplinary care. Given the dual goal of treating the infection and maintaining satisfactory function, it is preferable to determine how and when the implanted components can be retained. Bacteria and fungi organize themselves into biofilms that shield them from antibiotics and the immune system. This biofilm is in place after 15 days of active infection. Some antibiotics have a better activity on biofilms. The following factors have a negative impact on the probability of a successful debridement, antibiotics and implant retention (DAIR) intervention: fracture or revision, use of cement, bacteremia, kidney and/or liver failure, immunosuppression and elevated CRP. Hematogenous infections have a worse prognosis than early postoperative infections. Using a decision algorithm increases the chances of DAIR being successful. The KLIC score applies to early postoperative infections (<4 weeks postoperative and<3 weeks from the first signs) while the CRIME-80 score applies to hematogenous infections (<3 weeks from the first signs). Arthroscopic treatments have no role here, whereas DAIR through an arthrotomy is well standardized. Wide spectrum antibiotic therapy, secondarily adapted to the causative microorganism, is indicated for a total of 3 months. The results against the infection are mixed, although following a decision algorithm resolves the infection in about 75% of cases. The functional outcomes and quality of life are close to those of patients who have undergone primary joint replacement. It is not recommended to carry out a second DAIR if the first one fails. It is logical to apply the principles set out for the hip and knee to other joint replacements, and to use the same algorithm. For the upper limb, and especially for reverse shoulder arthroplasty, one must be careful about Cutibacterium acnes infections as they are hard to diagnose. Surgeons should not hesitate to contact a referral center for any PJI, although it is preferable that early infections be treated at the facility that performed the implantation.

No differences in short-term outcomes between patients with anaerobic and aerobic culture positive prosthetic joint infection

BACKGROUND

Prosthetic joint infection (PJI) is a devastation complication of total joint arthroplasty that can result in poor patient outcomes. Anaerobic organisms make up a small proportion of PJI cases and are much less studied. Studies comparing patient outcomes in anaerobic PJI to outcomes in aerobic PJI are sparse. The purpose of this study was to compare the clinical presentation, duration of antibiotics, type of treatment provided, and final outcome between PJI patients with anaerobic infection and those with aerobic infection.

METHODS

This was a retrospective study of 26 patients who underwent treatment for PJI at a tertiary referral center. Eight patients with anaerobic PJI were compared to 18 patients with aerobic PJI in terms of clinical presentation, laboratory values, treatment duration, and functional outcome. Statistical analysis was performed on continuous variables of interest.

RESULTS

The results of our study showed that there are no differences in short term clinical outcomes between PJI patients with cultures positive for anaerobic vs aerobic organisms (38.9% vs 50% successfully treated). Inflammatory markers were higher in the aerobic group and patients in the anaerobic group tended to have fewer medical comorbidities.

CONCLUSION

PJI caused by anaerobic organisms results in poor patient outcomes similar to infection caused by aerobic organisms. There are some differences in clinical presentation between the two groups that can be explained by the fact that anaerobic organisms are of low virulence and result in indolent infections causing longstanding symptoms.

Early Debridement, antibiotics and implant retention (DAIR) in patients with suspected acute infection after hip or knee arthroplasty - safe, effective and without negative functional impact

Introduction: Debridement, antibiotics and implant retention (DAIR) is known to be effective in treating acute periprosthetic joint infection (PJI). However, deciding to perform additional surgery in the early postoperative period may be challenging as there is the concern of adding morbidity and clinical presentation is often subtle. We mean to assess the impact of early DAIR on final functional outcome. Methods: A case-control comparison was performed between patients that underwent DAIR for suspected PJI between 2010-2016 and controls randomly selected (1:2 ratio) from a list of primary joint replacements. Patients were matched for anatomic site, age, gender, American Society of Anesthesiologists (ASA) classification, body mass index and follow-up time. The outcome of surgical treatment and complications were assessed and Hip disability and Osteoarthritis Outcome Score (HOOS) or Knee injury and Osteoarthritis Outcome Score (KOOS) were performed. Results: Thirty-eight cases were included at a mean follow-up of 42 months. Infection was not confirmed in one patient. There was one infection related-death and three other cases of treatment failure that required a two-stage revision. Overall success rate was 89.2%. There were no significant patient reported differences regarding final functional outcome between both groups: pain 91±6 vs. 87±13; other symptoms 90±8 vs. 90±9; activities of day living 86±8 vs. 85±14; sport 63±13 vs. 57±16; quality of life 78±17 vs. 76±16. Discussion: These findings support that DAIR for suspected acute PJI is safe, effective and causes no impact on final functional results. Thus, a low threshold for assuming infection and subsequent DAIR may safely be adopted in the early postoperative period.

Evaluation One Year after DAIR Treatment in 91 Suspected Early Prosthetic Joint Infections in Primary Knee and Hip Arthroplasty

INTRODUCTION

Early recognition and appropriate initial treatment with debridement, antibiotics and implant retention (DAIR) if a suspicion of an early prosthetic joint infection (PJI) is present can eradicate infection on first attempt and prevent implant failure. We evaluated the outcome after 1 year of patients treated with DAIR after primary total knee arthroplasty (TKA) or total hip arthroplasty (THA). Furthermore, we determined preoperative, microbiology, and treatment factors related to failure after DAIR.

METHODS

A retrospective cohort study was assembled with 91 patients undergoing DAIR with a high suspicion of an early PJI. Records were reviewed for demographics, preoperative laboratory results, microbiological data, given treatment and postoperative follow-up. The primary outcome was infection-free implant survival at 1 year. Repeated DAIR was not considered as treatment failure.

RESULTS

The rate of infection-free implant survival following DAIR in a suspected early PJI was 85% (95% confidence intervals (CI) 78-91). Cultures remained negative in 20 patients, with no occurrence of infection during follow-up. A higher failure rate was seen in early PJI caused by Enterococcus faecalis (p=0.04). Multivariate analysis showed a statistically significant association between treatment failure and high C-reactive protein level (CRP >100) (odds ratio 10.0, 95% CI [1.5-70]) and multiple DAIR procedures (≥2) (odds ratio 5.0, 95%CI [1.1-23]).

CONCLUSION

If an early PJI is suspected DAIR is the appointed treatment with up to 2 debridement procedures. Since culture-negative DAIRs were not related to any complications during follow-up, overtreatment of suspected PJI seems to do no significant harm with respect to implant failure.

Iatrogenic wounds: a common but often overlooked problem

Iatrogenic wounds are a common but often overlooked concept. They can lead to increases in hospital stays, therapy costs, repeat surgeries, and implant removal. If not handled properly, these wounds have a very poor prognosis and will cause serious physical and psychological harm to patients, which may result in medicolegal disputes. In recent years, the incidence of iatrogenic wounds has increased because of (1) an increase in the population of older people owing to increased life expectancy, (2) the continued expansion of surgical indications, (3) an increase in difficult surgeries, and (4) the constant emergence and application of new implantable biomaterials and other therapies. Thus, there is a pressing clinical need to improve the therapy of iatrogenic wounds. However, the difficulty in treating these wounds is considerable due to the emergence of drug-resistant bacteria, the high number of patients with metabolic diseases, and complex complications in patients. In particular, iatrogenic wounds caused by surgical site infections due to implantable biomaterials could lead to material leakage and conflicts regarding whether to retain or remove the implants. This review provides a definition of iatrogenic wounds, describes their characteristics, classifies them, and provides information about the importance of analyzing iatrogenic wounds. We hope that this review will provide useful information for the diagnosis and treatment of iatrogenic wounds and help to reduce their incidence in the future.

Studying Biofilm and Clinical Issues in Orthopedics

The association between biofilm-forming microorganisms and prosthetic joint infection influences all aspect of management including approaches to diagnosis, management and prevention. This article will provide an overview of new anti-biofilm strategies for management of prosthetic joint infection.

Septic complication following porous hydroxyapatite cranioplasty: prosthesis retention management

After failing of autologous cranioplasty or when the bone flap is unavailable, the alloplastic (heterologous) materials are the choice for cranial reconstruction. No agreement has been reported about the material with a significant lower risk of septic complications. This is due to extremely heterogeneous prognostic factors related not only to the material used but also to the surgical procedures and/or to the timing of the procedure. More attention should be focused on the material whose characteristic could enable a delay in bacterial colonization, where an antibiotic therapy could be effective, without need of prosthesis removal. Four cases of severe septic complication following cranioplasty with porous hydroxyapatite (HA) prosthesis are presented. Patients were conservatively treated, without heterologous bone flap removal. All of our patients presented reasons for delaying HA cranioplasty removal: patients #1, 3, and 4 had an associated shunted hydrocephalus and the need for not removing the prosthesis was related to the predictable recurrence of overshunting and/or sinking skin flap syndrome. In patient #4, the revision surgery would have also damaged the microvascular flap with latissimus dorsi muscle used by plastic surgeon for skin reconstruction. In patient #2, the patient refused revision surgery. In all cases, systemic and/or radiological signs of infection were observed. In patient #2 the infective process surrounded completely the HA prosthesis, while it was located in the epidural region in patients #1 and 4. In patient #3, a surgical curettage of the infected wound was performed over the HA prosthesis. Following prosthesis retention management with antibiotic therapy, all patients revealed systemic and/or radiological signs of sepsis resolution at follow-up. The possibility to avoid a prosthesis removal with effective antibiotic treatment is mainly due to the combination of three factors: targeted antibiotic therapy, good anatomical area revascularization (resulting of an "in situ" intake of antibiotics), and the biomimetism of HA prosthesis. Further investigations in a larger number of cases need to confirm these observations.