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Infection treatment option proves effective in joint reconstruction cases
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PRAGUE — There was 78% eradication of infection in total joint replacement procedures at 3 years follow-up with a simple protocol used by orthopaedic surgeons at the University of Oxford. These results were comparable to those with staged revision as an approach to infection treatment, according to data presented at the 16th EFORT Congress.
The protocol consists of debridement, antibiotics and implant retention (DAIR).
DAIR proved to be cost-effective and was associated with good functional outcomes in patients, William Jackson, BSc, MBBS FRCS(Orth), said.
William Jackson
By comparison, washout results for periprosthetic infection range from 26% to 71% infection eradication. “It is only recommended in very acute infections,” Jackson said.
Infection eradication rates for single- and two-stage revision are generally 80% to 90%, he said.
“Probably two-stage is still the gold standard, but there are encouraging results coming out with single-stage revision, particularly in certain situations,” Jackson said.
However, he said patients are not functioning well following revision procedures. Data from the National Joint Registry of England, Wales and Northern Ireland showed Oxford Knee Scores were 24.9 points following one-stage revision and 22.8 points following two-stage revision for infection, which indicates limited function.
“DAIR depends on your view of the implant and its viability,” Jackson said.
It should be considered as a first option in patients with infected, but well-fixed total knee arthroplasty (TKA) implants, but he noted that expert debridement is essential.
“The rationale for this requires a very aggressive surgical debridement,” Jackson said.
The procedure takes as long as a primary joint replacement to complete, patients need 6 weeks of postoperative intravenous antibiotics, depending on the organisms grown from tissue cultures, and 1 year of oral antibiotic therapy.
The Oxford group takes a minimum of six intraoperative samples using separate instruments to prevent cross-contamination to determine the patient’s infectious status after DAIR and whether the prosthesis can be retained.
In a study conducted by Jackson and colleagues of 120 cases of total joint infections, most of which were primary arthroplasties of the hip and knee, the length of time an implant was in place and the presence of Staphylococcus aureus were important to the results with the DAIR technique.
“We see there was a trend for getting better results with early implants and the acute infections seem to do better than ones that had an implant in for over 90 days,” he said.
Jackson said they found S. aureus cases and revision arthroplasty that later became infected tended to do worse after DAIR treatment.
Reference
Jackson W. Oxford experience of debridement, antibiotics and implant retention (DAIR) in prosthetic knee infections. Presented 28 May: The 16th EFORT Congress; May 27-29 2015; Prague.
Disclosure:Jackson reports he is a paid consultant to and speaker for Biomet; a paid speaker to DePuy, a Johnson & Johnson Company; a paid speaker for and has stock with Smith & Nephew; and a paid speaker for Stryker.