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Irrigation and debridement linked with increased failure rate in patients with acute hematogenous vs acute postsurgical PJI
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Irrigation and debridement correlated with a higher failure rate in patients with an acute hematogenous periprosthetic joint infection than in patients with an acute postsurgical periprosthetic joint infection, according to recently published results.
“The increase failure rate for [debridement and implant retention] DAIR performed for acute hematogenous infection may indicate that these patients may be manifesting an acute on chronic infection,” Javad Parvizi, MD, FRCS, told Healio.com/Orthopedics. “It is likely that some patients may have had a chronic subclinical infection that is then exacerbated by a second event, leading to clinical infection. Some of these cases, thus, are not truly acute infections and it is not a surprise that DAIR fails for some of these patients.”
Researchers retrospectively reviewed 199 total joint arthroplasty patients who underwent irrigation and debridement for acute postsurgical periprosthetic joint infection (PJI) or acute hematogenous PJI between 2006 and 2016. Investigators identified patient demographics, comorbidities, physical examination findings, laboratory results and organism profile.
Results showed that at 1 year, the failure rate was 37.7%. The failure rate for patients with acute hematogenous PJI was twice that of patients with acute postsurgical PJI (56% vs. 31%). Investigators noted prior revision surgery and a higher Charlson Comorbidity Index were among the host predictors of failure. Chronic obstructive pulmonary disease, diabetes and a history of malignancy were among the specific comorbidities correlated with failure.
Treatment failure after irrigation and debridement was seen more in patients with polymicrobial infections. The presence of intraoperative purulence, elevated systolic blood pressure, tachycardia and a high serum C-reactive protein level were among the clinical and laboratory risk factors correlated with failure. – by Monica Jaramillo
Disclosures: The authors report no relevant financial disclosures.
Perspective
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Robert S. Namba, MD
In this article the authors present results of a retrospective review from a single institution on the surgical management of periprosthetic joint infections. They evaluated treatment failure (Delphi criteria) of irrigation and debridement with implant retention (DAIR) procedures in two cohorts – post-surgical TJR infection and acute hematogenous infection – treated within 3 weeks of symptom onset. The authors found that acute hematogenous PJI was associated with a high failure rate. They also identified patients risk factors associated with failure: revision surgery, increased co-morbidities, diabetes mellitus, and history of malignancy. Polymicrobial infections were also at increased risk. They conclude that for cases of hematogenous PJI instead of DAIR, consideration should be made for exchange arthroplasty.
The paper provides the surgeon and patient with valuable information which can help manage expectations for DAIR procedures. Despite increased risk of failure for hematogenous infections there remains a practical role for DAIR. In the community setting, a surgeon may not have availability of operating room time, or skilled OR personnel, for performing implant removal and placement of an articulating antibiotic spacer. Since PJI are unplanned, medical optimization may not be possible, therefore, the less invasive nature of DAIR may reduce patient morbidity. Even if DAIR has reduced chance of definitive PJI eradication, the potential to avoid systemic sepsis, or spread of infection to other artificial joints or cardiac valves, warrants consideration. In the future, investigation of additional measures such as intraosseous antibiotics, antibiotic impregnated beads, and continuous intra-articular antibiotic instillation may enhance success of DAIR procedures.
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