Debridement, Antibiotics and Implant Retention for Early Periprosthetic Infections of the Hip: Outcomes and Influencing Factors

Success rate of single versus multiple debridement, antibiotics, and implant retention (DAIR) in hip and knee periprosthetic joint infection: a systematic review and meta-analysis

PURPOSE

This systematic review aimed to compare outcomes between multiple and single debridement, antibiotics, and implant retention (DAIR) procedures for early periprosthetic joint infection (PJI) in hip and knee arthroplasty.

METHODS

Four databases were searched from inception till January 2024 for original studies investigating the outcomes of multiple DAIR in hip and knee PJI. The primary outcome was the success rate in eradicating joint infection. This review was conducted per PRISMA guidelines.

RESULTS

A total of 9 observational studies with 1104 participants were included, with a mean age and BMI of 58.37 years (95%CI: 25.77-90.98) and 31.43 kg/m2 (95%CI: 28.89-34.98), respectively. The mean follow-up period was 58.37 months (95%CI: 25.77-90.98), and the average MINORS score assigned to the review was 17.6 ± 3.46, indicating a low overall risk of bias. An equivalent success rate between single and double DAIR was observed, at 67% (95%CI: 64-71%) and 70% (95%CI: 48-86%), respectively, with no statistically significant difference between the two treatment modalities (p = 0.740). Additionally, the success rate for triple DAIR ranged from 50 to 60%.

CONCLUSION

This study suggests that double DAIR is a valid treatment option for acute PJI after TKA and THA, with a success rate comparable to single DAIR (70% vs. 67%, p = 0.740). Triple DAIR achieved success rates ranging from 50 to 60%. However, caution is warranted when interpreting these results due to heterogeneity in host comorbidity factors, DAIR protocols, and antibiotic regimens.

LEVEL OF EVIDENCE

Therapeutic, Level III.

Debridement, Antibiotic Pearls, and Retention of the Implant (DAPRI) in the Treatment of Early Periprosthetic Joint Infections: A Consecutive Series

INTRODUCTION

Periprosthetic joint infections (PJI) represent a devastating consequence following total joint arthroplasty (TJA). In this study, the authors describe a modified surgical technique developed to enhance the classical irrigation and debridement procedure (DAIR) to improve the possibilities of retaining an acutely infected TJA.

MATERIALS AND METHODS

This technique, debridement antibiotic pearls and retention of the implant (DAPRI), aims to remove the intra-articular biofilm allowing a higher and prolonged local antibiotic concentration by using calcium sulphate antibiotic-added beads in a setting of acute (<4 weeks from symptoms onset) PJI with pathogen identification. The combination of three different surgical techniques (tumor-like synovectomy, argon beam/acetic acid application and chlorhexidine gluconate brushing) aims to remove the bacterial biofilm from the implant without explanting the original hardware.

RESULTS

In total, 62 patients met the acute infection criteria (<4 weeks of symptoms); there were 57 males and five females. The patients' average age at the time of treatment was 71 years (62-77) and the average BMI was 37 kg/m². The micro-organism, always identified through synovial fluid analysis (culture, multiplex PCR or Next Generation Sequencing), was an aerobic Gram + in 76% (S. Coag-Neg 41%; S. aureus 16%), Gram-in 10% (E. coli 4%) and anaerobic Gram + in 4%. The DAPRI treatment was performed at an average of 3 days from symptoms onset (1-7 days). All patients underwent a 12-week course of post-operative antibiotic therapy (6 weeks I.V. and 6 weeks oral). All patients were available at the 2-year minimum FU (24-84 months). A total of 48 (77.5%) patients were infection-free at the final FU, while 14 patients underwent 2-stage revision for PJI recurrence. In total, four patients (6.4%) had a prolonged drainage from the wound after placement of the calcium sulphate beads.

CONCLUSIONS

This study suggests that the DAPRI technique could represent a valid alternative to the classic DAIR procedure. The current authors do not recommend this procedure outside of the main inclusive criteria (acute scenario micro-organism identification).

The Impact of Sex on the Outcomes of Prosthetic Joint Infection Treatment with Debridement, Antibiotics and Implant Retention: A Systematic Review and Individual Patient Data Meta-analysis

BACKGROUND

The influence of sex on the failure of débridement antibiotics and implant retention (DAIR) for treating prosthetic joint infection (PJI) is important for decision-making, patient counseling, and equitable health care. However, very few studies in the orthopaedic literature conduct sex-specific analyses.

AIM

The primary aim was to determine whether sex influences treatment success after DAIR.

METHODS

A systematic review and individual patient data (IPD) meta-analysis was conducted. MEDLINE (Ovid), EMBASE (Ovid), Web of Science, and Google Scholar were searched, and IPD was requested via e-mail. Patients who underwent DAIR after developing PJI within 12 months of a primary total hip or knee arthroplasty were included in the analysis. Treatment failure was defined by the Delphi International Consensus criteria. Adjusted odds ratios for treatment failure were calculated using a mixed-effects logistic regression.

RESULTS

The study collected and analyzed IPD of 1,116 patients from 21 cohorts. The odds of treatment failure were 29% lower in women (odds ratio, 0.71; 95% CI 0.54 to 0.017; P = 0.017), after adjusting for duration of symptoms >7 days and Staphylococcus aureus infection (methicillin-susceptible Staphylococcus aureus or any infection with S aureus). None of the 64 studies included in the systematic review conducted a sex-specific analysis.

CONCLUSION

For patients who developed a PJI within 1 year postsurgery, females have lower odds of DAIR failure than males. Other factors also have varying effects on outcome for men and women. It is essential to implement sex-specific analysis in orthopaedic research.

A review of current practices in periprosthetic joint infection debridement and revision arthroplasty

BACKGROUND

Periprosthetic joint infection remains a significant challenge for arthroplasty surgeons globally. Over the last few decades, there has been much advancement in terms of treatment and diagnosis, however, the fight rages on. As management of periprosthetic joint infections continues to evolve, it is critical to reflect back on current debridement practices to establish common ground as well as identify areas for future research and improvement. BODY: In order to understand the debridement techniques of periprosthetic joint infections, one must also understand how to diagnose a periprosthetic joint infection. Multiple definitions have been elucidated over the years with no single consensus established but rather sets of criteria. Once a diagnosis has been established the decision of debridement method becomes whether to proceed with single vs two-stage revision based on the probability of infection as well as individual patient factors. After much study, two-stage revision has emerged as the gold standard in the management of periprosthetic infections but single-stage remains prominent with further and further research.

CONCLUSION

Despite decades of data, there is no single treatment algorithm for periprosthetic joint infections and subsequent debridement technique. Our review touches on the goals of debridement while providing a perspective as to diagnosis and the particulars of how intraoperative factors such as intraarticular irrigation can play pivotal roles in infection eradication. By providing a perspective on current debridement practices, we hope to encourage future study and debate on how to address periprosthetic joint infections best.

Exchange of Modular Components Improves Success of Debridement, Antibiotics, and Implant Retention: An Observational Study of 575 Patients with Infection After Primary Total Hip Arthroplasty

Debridement, antibiotics, and implant retention (DAIR) is a surgical treatment for periprosthetic joint infection (PJI). DAIR is a desirable treatment option from an economic and patient perspective, if successful. The aim of this observational study was to compare the rates of success, defined as no additional reoperations due to PJI, between DAIR with exchange of modular components and DAIR without exchange in patients who had first-time PJI after primary total hip arthroplasty (THA).

METHODS

Patients with PJI at the site of a primary THA who were treated with DAIR in Sweden between January 1, 2009, and December 31, 2016, were identified in the Swedish Hip Arthroplasty Register. Supplementary questionnaires were sent to orthopaedic departments for additional variables of interest related to PJI. The primary end point was another reoperation due to PJI within 2 years after the first-time DAIR. DAIR with exchange was compared with DAIR without exchange using Kaplan-Meier survival analysis and Cox regression analysis.

RESULTS

A total of 575 patients treated with DAIR for a first-time PJI at the site of a primary THA were analyzed; 364 underwent component exchange and 211 did not. The exchange of components was associated with a lower rate of reoperations due to PJI after DAIR (28.0%) compared with non-exchange (44.1%). The Kaplan-Meier implant survival estimate for exchange was 71.4% (95% confidence interval [CI] = 66.9% to 76.3%) compared with 55.5% (95% CI = 49.1% to 62.7%) for non-exchange. With the analysis adjusted for confounders, DAIR with exchange was associated with a significantly decreased risk of another reoperation due to PJI compared with non-exchange (hazard ratio [HR] = 0.51 [95% CI = 0.38 to 0.68]).

CONCLUSIONS

In patients with a first-time PJI at the site of a primary THA, DAIR with exchange of modular components was superior to non-exchange DAIR. Surgeons should strive to exchange components when they perform DAIR, but there is a need to further identify how DAIR best should be practiced and which patients benefit from it.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Use of Calcium Sulphate beads in Periprosthetic Joint Infection, a systematic review

Purpose: To assess the use of calcium sulphate (CS) beads in the management of knee and hip periprosthetic joint infections (PJI) in terms of outcomes, complications and re-infection rates.

Methods: A search of NICE healthcare database advanced search (HDAS) was conducted from its year of inception to October 2019 with the keywords: “Calcium Sulphate Beads” or “Calcium Sulfate Beads” or “Antibiotics beads” or “Stimulan” and “Arthroplasty” or “Hip Replacement” or “Knee Replacement” and “Periprothetic joint infection” or “Debridement, Antibiotics and implant retention” or “Revision”. A quality assessment was performed using the NIH study Quality Assessment Tool for case series.

Results: Out of relevant 74 articles, 5 articles met the inclusion criteria. Variable outcomes and success rates have been reported in most of the patients. A small number of wound discharges and heterotrophic ossification (HO) were reported, which are occasionally symptomatic. Hypercalcemia is identified as a potential risk with the use of CS beads especially with doses over 40 cc per operation. The influence of CS beads on reinfection rate is reported in 4 out of 5 articles. Due to the case-mix and heterogenicity of the patients involved and the causative microorganism reported as well as varied procedures are undertaken including one and two stages revision and Debridement, Antibiotics and implant retention (DAIR), the influence of CS beads varied from high success to poor outcome. The poor outcome is higher if the primary procedure for the management of hip and knee PJI is DAIR rather than full revision.

Conclusions: The use of CS beads in the treatment of PJI is a useful technique in delivering high doses of antibiotics locally. A favourable outcome is reported when antibiotics loaded CS is used as an adjuvant to revision procedure for PJI in hip and knee arthroplasty compared to its use as an adjuvant to DAIR procedure. There has been an increase in complications when higher volumes of beads are used, especially in subcutaneous structures and in high-risk patients. Another possible theoretical and unreported complication of CS beads is accelerating the wear rate in the artificial joint due to the possibility of causing abrasion to the bearing surfaces. The current evidence is not enough to indicate the superiority of antibiotic-loaded CS beads as an adjuvant for the treatment of PJI in Hip and Knee arthroplasty.