Study highlights failure rate of irrigation debridement for periprosthetic infection

Issue: August 2012

SAN FRANCISCO — Irrigation and debridement failed in 63% of patients with early postoperative periprosthetic infections, according to the results of a multicenter retrospective study.

“Periprosthetic infection is a devastating complication,” study presenter Thomas K. Fehring, MD, said. “There are a variety of treatment options that exist. Irrigation and debridement is an attractive, low-morbidity option for perioperative infection that is enthusiastically embraced by patients and surgeons attempting to save the implant. Unfortunately, it does not work well.”

Fehring presented his group’s findings at the American Academy of Orthopaedic Surgeons 2012 Annual Meeting.

Repeat surgery for infection

He noted that previous studies in the literature showed a 69% failure for irrigation and debridement of periprosthetic infections. Fehring and colleagues hypothesized irrigation and debridement would be more effective in the perioperative period before drug-resistant biofilm or osteomyelitis could develop.

They conducted a multicenter study of 86 patients (40 total hip and 46 total knee arthroplasties) who underwent irrigation and debridement for periprosthetic infections within 90 days of primary surgery. The primary outcome measure used was return to the operating room for infection. They used the Charlson Comorbidity Index (CCI) as the host factor surrogate. They conducted a logistic regression analysis to examine correlations between CCI, age, gender, joint, infectious organism, timing between index surgery and irrigation, and debridement and repeat surgery due to infection.

The researchers discovered 54 of 86 patients (63%) failed. Of patients who underwent irrigation and debridement within 1 month of primary surgery, 56% failed. Of patients who underwent irrigation and debridement between 1 month and 3 months, 76% failed. The investigators also found that 80% of patients who underwent irrigation and debridement within 10 days of surgery failed. The investigators found no significant differences between covariates or between host statuses in the CCI for revision surgery due to infection.

Rapid formation biofilms

“Irrigation and debridement, as we all know, is a time-honored procedure for orthopedic surgical site infections,” Fehring said. “Why does a procedure that fails two-thirds of the time continue to be frequently used? I think such enthusiasm persists given the emotional investment that all of us have as well as our patients, and the alternative — the removal of the implant — is perceived as radical.”

Fehring said he and colleagues found no significant differences between host factors for revision due to infection because the parental antibiotics may not have been able to penetrate the glycolax biofilm layer.

“Bacteria colonies attach to the implant. They secrete a protective matrix,” Fehring said. “Once mature, they shed bacteria, which start new colonies on the implant. This happens within minutes, and they form strong microcolonies within 2 to 4 hours. They are shedding more bacteria within 2 to 4 days. The best case scenario would be an irrigation and debridement in the perioperative period. Theoretically, we should be able to salvage this [joint]. I think rapid formation of biofilms may explain the results.”

He added, “Given the 63% failure rate, I think alternative forms of treatment should be considered for this problem.” – by Renee Blisard Buddle

Reference:

Fehring TK, Odum SM, Berend KR, et al. Efficacy of perioperative irrigation and debridement for prosthetic infection. Paper #40. Presented at the American Academy of Orthopaedic Surgeons 2012 Annual Meeting. Feb. 7-11. San Francisco.

For more information:

Thomas K. Fehring, MD, can be reached at OrthoCarolina, PA, Hip and Knee Center, 2001 Vail Avenue, Suite 200-A, Charlotte, NC, 28207; email: thomas.fehring@orthocarolina.com.
Disclosure: Fehring receives royalties, is a paid speaker and consultant for and receives research or institutional support from Depuy, a Johnson & Johnson Company.