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Indications and Guidelines for Debridement and Implant Retention for Periprosthetic Hip and Knee Infection

  • Prosthetic Joint Infection (S Nodzo and N Frisch, section editors)
  • Published:
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Abstract

Purpose of Review

Prosthetic joint infection is one the most common causes of revision surgery after hip or knee replacement. Debridement and implant retention (DAIR) is one method of treating these infections; however, significant controversy exists. The purpose of our review was to describe current knowledge about indications, intraoperative/postoperative patient management, and outcomes of DAIR.

Recent Findings

Patient selection affects the success of DAIR. Medical comorbidities, duration of symptoms, and nature of infectious organism all influence outcomes. Intraoperative techniques such as open arthrotomy, extensive debridement, copious irrigation, and exchange of modular parts remain current standards for DAIR. Postoperative administration of antibiotics tailored to operative cultures remains critical. Antibiotic suppression may increase the success of DAIR.

Summary

DAIR provides reasonable infection eradication between 50 and 80% with improved outcomes in appropriately selected patients. More research is needed on the use of adjuvant therapies intraoperatively and the role of postoperative antibiotic suppression.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Byren I, Bejon P, Atkins BL, Angus B, Masters S, McLardy-Smith P, et al. One hundred and twelve infected arthroplasties treated with 'DAIR' (debridement, antibiotics and implant retention): antibiotic duration and outcome. J Antimicrob Chemother. 2009;63(6):1264–71. https://doi.org/10.1093/jac/dkp107.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  2. Kuiper JW, Willink RT, Moojen DJ, van den Bekerom MP, Colen S. Treatment of acute periprosthetic infections with prosthesis retention: review of current concepts. World J Orthop. 2014;5(5):667–76. https://doi.org/10.5312/wjo.v5.i5.667.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckelberg JM, et al. Infectious Diseases Society of America. Executive summary: diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2013;56(1):1–10. https://doi.org/10.1093/cid/cis966.

    Article  PubMed  Google Scholar 

  4. Chen J, Cui Y, Li X, Miao X, Wen Z, Xue Y, et al. Risk factors for deep infection after total knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg. 2013;133(5):675–87. https://doi.org/10.1007/s00402-013-1723-8.

    Article  PubMed  Google Scholar 

  5. Choong PF, Dowsey MM, Carr D, Daffy J, Stanley P. Risk factors associated with acute hip prosthetic joint infections and outcome of treatment with a rifampin-based regimen. Acta Orthop. 2007;78(6):755–65. https://doi.org/10.1080/17453670710014527.

    Article  PubMed  Google Scholar 

  6. Everhart JS, Altneu E, Calhoun JH. Medical comorbidities are independent preoperative risk factors for surgical infection after total joint arthroplasty. Clin Orthop Relat Res. 2013;471(10):3112–9. https://doi.org/10.1007/s11999-013-2923-9.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Pulido L, Ghanem E, Joshi A, Purtill JJ, Parvizi J. Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res. 2008;466(7):1710–5. https://doi.org/10.1007/s11999-008-0209-4.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Buller LT, Sabry FY, Easton RW, Klika AK, Barsoum WK. The preoperative prediction of success following irrigation and debridement with polyethylene exchange for hip and knee prosthetic joint infections. J Arthroplast. 2012;27(6):857–864.e4. https://doi.org/10.1016/j.arth.2012.01.003.

    Article  Google Scholar 

  9. • Fink B, Schuster P, Schwenninger C, Frommelt L, Oremek DA. Standardized regimen for the treatment of acute postoperative infections and acute Hematogenous infections associated with hip and knee arthroplasties. J Arthroplast. 2017;32(4):1255–61. https://doi.org/10.1016/j.arth.2016.10.011. Employed a standardized regimen to treat patients with DAIR in acute postoperative and hematogenous PJI. This included open arthrotomy, extensive debridement, lavage with antiseptic and antibiotic therapy, and standardized antibiotic administration. Following their criteria, 72% overall success was found.

    Article  Google Scholar 

  10. • Sendi P, Lötscher PO, Kessler B, Graber P, Zimmerli W, Clauss M. Debridement and implant retention in the management of hip periprosthetic joint infection: outcomes following guided and rapid treatment at a single centre. Bone Joint J 2017 99-B(3):330–336. doi: https://doi.org/10.1302/0301-620X.99B3.BJJ-2016-0609.R1. Described institutional experience after DAIR in hip PJI using strict indication criteria: acute periprosthetic or hematological infection, stable implant, susceptible pathogen to biofilm active antimicrobial agents, no sinus tract or periprosthetic abscess. Overall success was 90% in this selected group.

  11. • Siqueira MB, Saleh A, Klika AK, O'Rourke C, Schmitt S, Higuera CA, et al. Chronic suppression of Periprosthetic joint infections with oral antibiotics increases infection free survivorship. J Bone Joint Surg Am. 2015;97(15):1220–32. https://doi.org/10.2106/JBJS.N.00999. Described case-control study using postoperative antibiotic suppression for at least six months versus a matched cohort without suppression. Subset of patients undergoing DAIR had improved success rates with antibiotic suppression (65% versus 30%).

    Article  PubMed  Google Scholar 

  12. Triantafyllopoulos GK, Poultsides LA, Sakellariou VI, Zhang W, Sculco PK, Ma Y, et al. Irrigation and debridement for periprosthetic infections of the hip and factors determining outcome. Int Orthop. 2015;39(6):1203–9. https://doi.org/10.1007/s00264-015-2753-3.

    Article  PubMed  Google Scholar 

  13. Qasim SN, Swann A, Ashford R. The DAIR (debridement, antibiotics and implant retention) procedure for infected total knee replacement - a literature review. SICOT J. 2017;3:2. https://doi.org/10.1051/sicotj/2016038.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Azzam KA, Seeley M, Ghanem E, Austin MS, Purtill JJ, Parvizi J. Irrigation and debridement in the management of prosthetic joint infection: traditional indications revisited. J Arthroplast. 2010;25(7):1022–7. https://doi.org/10.1016/j.arth.2010.01.104.

    Article  Google Scholar 

  15. • Lora-Tamayo J, Murillo O, Iribarren JA, Soriano A, Sánchez-Somolinos M, Baraia-Etxaburu JM, et al. REIPI Group for the Study of prosthetic infection. A large multicenter study of methicillin-susceptible and methicillin-resistant Staphylococcus aureus prosthetic joint infections managed with implant retention. Clin Infect Dis. 2013;56(2):182–94. https://doi.org/10.1093/cid/cis746. Retrospective multicenter study on staphylococcal PJI treated with DAIR. Overall 55% survival rates with no difference between MRSA or MSSA. Addition of rifampin appeared to be beneficial.

    Article  PubMed  Google Scholar 

  16. Triantafyllopoulos GK, Poultsides LA, Zhang W, Sculco PK, Ma Y, Sculco TP. Periprosthetic knee infections treated with irrigation and debridement: outcomes and preoperative predictive factors. J Arthroplast. 2015 Apr;30(4):649–57. https://doi.org/10.1016/j.arth.2014.10.026.

    Article  Google Scholar 

  17. McPherson EJ, Woodson C, Holtom P, Roidis N, Shufelt C, Patzakis M. Periprosthetic total hip infection: outcomes using a staging system. Clin Orthop Relat Res. 2002;403:8–15.

    Article  Google Scholar 

  18. • Bryan AJ, Abdel MP, Sanders TL, Fitzgerald SF, Hanssen AD, Berry DJ. Irrigation and Debridement with Component Retention for Acute Infection After Hip Arthroplasty: Improved Results with Contemporary Management. J Bone Joint Surg Am. 2017;99(23):2011–8. 10.2106. Described outcomes of DAIR in the setting of chronic antibiotic suppression when possible and stratified by host characteristics. Overall survival was 83% with improved outcomes in McPherson host grade A patients (8% failure) and poor outcomes in McPherson host grade C (44% failure rate).

  19. Marculescu CE, Berbari EF, Hanssen AD, Steckelberg JM, Harmsen SW, Mandrekar JN, et al. Outcome of prosthetic joint infections treated with debridement and retention of components. Clin Infect Dis. 2006;42(4):471–8.

    Article  PubMed  CAS  Google Scholar 

  20. Gardner J, Gioe TJ, Tatman P. Can this prosthesis be saved?: implant salvage attempts in infected primary TKA. Clin Orthop Relat Res. 2011 Apr;469(4):970–6. https://doi.org/10.1007/s11999-010-1417-2.

    Article  PubMed  Google Scholar 

  21. Koyonos L, Zmistowski B, Della Valle CJ, Parvizi J. Infection control rate of irrigation and débridement for periprosthetic joint infection. Clin Orthop Relat Res. 2011;469(11):3043–8. https://doi.org/10.1007/s11999-011-1910-2.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Barberán J, Aguilar L, Carroquino G, Giménez MJ, Sánchez B, Martínez D, et al. Conservative treatment of staphylococcal prosthetic joint infections in elderly patients. Am J Med. 2006;119(11):993.e7–10.

    Article  Google Scholar 

  23. Chaussade H, Uçkay I, Vuagnat A, Druon J, Gras G, Rosset P, et al. Antibiotic therapy duration for prosthetic joint infections treated by debridement and implant retention (DAIR): similar long-term remission for 6 weeks as compared to 12 weeks. Int J Infect Dis. 2017;63:37–42. https://doi.org/10.1016/j.ijid.2017.08.002.

    Article  PubMed  Google Scholar 

  24. Zürcher-Pfund L, Uçkay I, Legout L, Gamulin A, Vaudaux P, Peter R. Pathogen-driven decision for implant retention in the management of infected total knee prostheses. Int Orthop. 2013;37(8):1471–5. https://doi.org/10.1007/s00264-013-1923-4.

    Article  PubMed  PubMed Central  Google Scholar 

  25. • Grammatopoulos G, Kendrick B, MCnally M, Athanasou NA, Atkins B, McLardy-Smith P, et al. Outcome Following Debridement, Antibiotics, and Implant Retention in Hip Periprosthetic Joint Infection-An 18-Year Experience. J Arthroplast. 2017;32(7):2248–55. https://doi.org/10.1016/j.arth.2017.02.066. Described 18 year experience with DAIR in hip PJI. Allowed for multiple DAIR with overall success rates 84%. Early (<6 week) postoperative PJI and exchange of modular parts were associated with improved outcomes.

    Article  Google Scholar 

  26. Flierl MA, Culp BM, Okroj KT, Springer BD, Levine BR, Della Valle CJ. Poor outcomes of irrigation and debridement in acute Periprosthetic joint infection with antibiotic-impregnated calcium sulfate beads. J Arthroplast. 2017;32(8):2505–7. https://doi.org/10.1016/j.arth.2017.03.051.

    Article  Google Scholar 

  27. Tsukayama DT, Estrada R, Gustilo RB. Infection after total hip arthroplasty. A study of the treatment of one hundred and six infections. J Bone Joint Surg Am. 1996;78(4):512–23.

    Article  PubMed  CAS  Google Scholar 

  28. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med. 2004;351(16):1645–54.

    Article  PubMed  CAS  Google Scholar 

  29. Vilchez F, Martínez-Pastor JC, García-Ramiro S, Bori G, Tornero E, García E, et al. Efficacy of debridement in hematogenous and early post-surgical prosthetic joint infections. Int J Artif Organs. 2011;34(9):863–9. https://doi.org/10.5301/ijao.5000029.

    Article  PubMed  CAS  Google Scholar 

  30. Choi HR, von Knoch F, Zurakowski D, Nelson SB, Malchau H. Can implant retention be recommended for treatment of infected TKA? Clin Orthop Relat Res. 2011;469(4):961–9. https://doi.org/10.1007/s11999-010-1679-8.

    Article  PubMed  Google Scholar 

  31. Ilahi OA, Al-Habbal GA, Bocell JR, Tullos HS, Huo MH. Arthroscopic debridement of acute periprosthetic septic arthritis of the knee. Arthroscopy. 2005;21(3):303–6.

    Article  PubMed  Google Scholar 

  32. Liu CW, Kuo CL, Chuang SY, Chang JH, Wu CC, Tsai TY, et al. Results of infected total knee arthroplasty treated with arthroscopic debridement and continuous antibiotic irrigation system. Indian J Orthop. 2013;47(1):93–7. https://doi.org/10.4103/0019-5413.106925.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Chung JY, Ha CW, Park YB, Song YJ, Yu KS. Arthroscopic debridement for acutely infected prosthetic knee: any role for infection control and prosthesis salvage? Arthroscopy. 2014;30(5):599–606. https://doi.org/10.1016/j.arthro.2014.02.008.

    Article  PubMed  Google Scholar 

  34. Waldman BJ, Hostin E, Mont MA, Hungerford DS. Infected total knee arthroplasty treated by arthroscopic irrigation and débridement. J Arthroplast. 2000;15(4):430–6.

    Article  CAS  Google Scholar 

  35. Peel TN, Cheng AC, Choong PF, Buising KL. Early onset prosthetic hip and knee joint infection: treatment and outcomes in Victoria, Australia. J Hosp Infect. 2012;82(4):248–53. https://doi.org/10.1016/j.jhin.2012.09.005.

    Article  PubMed  CAS  Google Scholar 

  36. Schwechter EM, Folk D, Varshney AK, Fries BC, Kim SJ, Hirsh DM. Optimal irrigation and debridement of infected joint implants: an in vitro methicillin-resistant Staphylococcus aureus biofilm model. J Arthroplast. 2011;26(6 Suppl):109–13. https://doi.org/10.1016/j.arth.2011.03.042.

    Article  Google Scholar 

  37. Geurts JA, Janssen DM, Kessels AG, Walenkamp GH. Good results in postoperative and hematogenous deep infections of 89 stable total hip and knee replacements with retention of prosthesis and local antibiotics. Acta Orthop. 2013;84(6):509–16. https://doi.org/10.3109/17453674.2013.858288.

  38. Tintle SM, Forsberg JA, Potter BK, Islinger RB, Andersen RC. Prosthesis retention, serial debridement, and antibiotic bead use for the treatment of infection following total joint arthroplasty. Orthopedics. 2009;32(2):87. 17453674.2013.858288.

    PubMed  Google Scholar 

  39. Kallala R, Haddad FS. Hypercalcaemia following the use of antibiotic-eluting absorbable calcium sulphate beads in revision arthroplasty for infection. Bone Joint J. 2015;97-B(9):1237–41. https://doi.org/10.1302/0301-620X.97B9.34532.

    Article  PubMed  CAS  Google Scholar 

  40. Kuiper JW, Brohet RM, Wassink S, van den Bekerom MP, Nolte PA, Vergroesen DA. Implantation of resorbable gentamicin sponges in addition to irrigation and debridement in 34 patients with infection complicating total hip arthroplasty. Hip Int. 2013;23(2):173–80. https://doi.org/10.5301/HIP.2013.10612.

    Article  PubMed  Google Scholar 

  41. Kuiper JW, Vos SJ, Saouti R, Vergroesen DA, Graat HC, Debets-Ossenkopp YJ, et al. Prosthetic joint-associated infections treated with DAIR (debridement, antibiotics, irrigation, and retention): analysis of risk factors and local antibiotic carriers in 91 patients. Acta Orthop. 2013;84(4):380–6. https://doi.org/10.3109/17453674.2013.823589.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Riesgo AM, Park BK, Herrero CP, Yu S, Schwarzkopf R, Iorio R. Vancomycin povidone-iodine protocol improves survivorship of Periprosthetic joint infection treated with irrigation and debridement. J Arthroplast. 2018;33(3):847–50. https://doi.org/10.1016/j.arth.2017.10.044.

    Article  Google Scholar 

  43. Lora-Tamayo J, Euba G, Cobo J, Horcajada JP, Soriano A, Sandoval E, et al. Prosthetic joint infection Group of the Spanish Network for research in infectious diseases—REIPI. Short- versus long-duration levofloxacin plus rifampicin for acute staphylococcal prosthetic joint infection managed with implant retention: a randomised clinical trial. Int J Antimicrob Agents. 2016;48(3):310–6. https://doi.org/10.1016/j.ijantimicag.2016.05.021.

    Article  PubMed  CAS  Google Scholar 

  44. Jacqueline C, Caillon J. Impact of bacterial biofilm on the treatment of prosthetic joint infections. J Antimicrob Chemother. 2014;69(Suppl 1):i37–40. https://doi.org/10.1093/jac/dku254.

    Article  PubMed  CAS  Google Scholar 

  45. Zimmerli W, Widmer AF, Blatter M, Frei R, Ochsner PE. Role of rifampin for treatment of orthopedic implant-related staphylococcal infections: a randomized controlled trial. Foreign-body infection (FBI) study group. JAMA. 1998;279(19):1537–41.

    Article  PubMed  CAS  Google Scholar 

  46. Fiaux E, Titecat M, Robineau O, Lora-Tamayo J, El Samad Y, Etienne M, et al. G4 bone and joint infection study group (G4BJIS). Outcome of patients with streptococcal prosthetic joint infections with special reference to rifampicin combinations. BMC Infect Dis. 2016;16(1):568.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  47. Silva M, Tharani R, Schmalzried TP. Results of direct exchange or debridement of the infected total knee arthroplasty. Clin Orthop Relat Res. 2002;404:125–31.

    Article  Google Scholar 

  48. Fehring TK, Odum SM, Berend KR, Jiranek WA, Parvizi J, Bozic KJ, et al. Failure of irrigation and débridement for early postoperative periprosthetic infection. Clin Orthop Relat Res. 2013;471(1):250–7. https://doi.org/10.1007/s11999-012-2373-9.

    Article  PubMed  Google Scholar 

  49. Grammatopoulos G, Bolduc ME, Atkins BL, Kendrick BJL, McLardy-Smith P, Murray DW, et al. Functional outcome of debridement, antibiotics and implant retention in periprosthetic joint infection involving the hip: a case-control study. Bone Joint J. 2017;99-B(5):614–22. https://doi.org/10.1302/0301-620X.99B5.BJJ-2016-0562.R2.

    Article  PubMed  CAS  Google Scholar 

  50. Marculescu CE, Berbari EF, Hanssen AD, Steckelberg JM, Harmsen SW, Mandrekar JN, et al. Outcome of prosthetic joint infections treated with debridement and retention of components. Clin Infect Dis. 2006 Feb 15;42(4):471–8. Epub 2006 Jan 5

  51. Odum SM, Fehring TK, Lombardi AV, Zmistowski BM, Brown NM, Luna JT, et al. Periprosthetic infection consortium. Irrigation and debridement for periprosthetic infections: does the organism matter? J Arthroplast. 2011;26(6 Suppl):114–8. https://doi.org/10.1016/j.arth.2011.03.031.

    Article  Google Scholar 

  52. Ricciardi BF, Bostrom MP, Lidgren L, Ranstam J, Merollini KM, W-Dahl A. Prevention of surgical site infection in total joint arthroplasty: an international tertiary care center survey. HSS J. 2014;10(1):45–51. https://doi.org/10.1007/s11420-013-9369-1.

    Article  PubMed  Google Scholar 

  53. Van Kleunen JP, Knox D, Garino JP, Lee GC. Irrigation and débridement and prosthesis retention for treating acute periprosthetic infections. Clin Orthop Relat Res. 2010;468(8):2024–8. https://doi.org/10.1007/s11999-010-1291-y.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Nodzo SR, Boyle KK, Nocon AA, Henry MW, Mayman DJ, Westrich GH. The influence of a failed irrigation and debridement on the outcomes of a subsequent 2-stage revision knee arthroplasty. J Arthroplast. 2017;32(8):2508–12. https://doi.org/10.1016/j.arth.2017.03.026.

    Article  Google Scholar 

  55. Brimmo O, Ramanathan D, Schiltz NK, Pillai AL, Klika AK, Barsoum WK. Irrigation and debridement before a 2-stage revision Total knee arthroplasty does not increase risk of failure. J Arthroplast. 2016;31(2):461–4. https://doi.org/10.1016/j.arth.2015.08.044.

    Article  Google Scholar 

  56. Rajgopal A, Panda I, Rao A, Dahiya V, Gupta H. Does prior failed debridement compromise the outcome of subsequent two-stage revision done for peri-prosthetic joint infection following total knee arthroplasty? J Arthroplast. 2018; https://doi.org/10.1016/j.arth.2018.02.087.

  57. Sherrell JC, Fehring TK, Odum S, Hansen E, Zmistowski B, Dennos A, et al. Periprosthetic infection consortium. The Chitranjan Ranawat award: fate of two-stage reimplantation after failed irrigation and débridement for periprosthetic knee infection. Clin Orthop Relat Res. 2011;469(1):18–25. https://doi.org/10.1007/s11999-010-1434-1.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Orthopedic Surgery, University of Rochester School of Medicine, Highland Hospital, 1000 South Avenue, Rochester, NY, 14620, USA

    Douglas A. Zaruta, Bowen Qiu, Andrew Y. Liu & Benjamin F. Ricciardi

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  1. Douglas A. Zaruta
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  2. Bowen Qiu
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Correspondence to Benjamin F. Ricciardi.

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Zaruta, D.A., Qiu, B., Liu, A.Y. et al. Indications and Guidelines for Debridement and Implant Retention for Periprosthetic Hip and Knee Infection. Curr Rev Musculoskelet Med 11, 347–356 (2018). https://doi.org/10.1007/s12178-018-9497-9

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