Debridement, antibiotic pearls, and retention of the implant in the treatment of infected total hip arthroplasty

Abstract

In this article the authors describe a modified surgical technique developed to enhance the classical irrigation and debridement procedure to improve the possibilities of retaining a total hip arthroplasty (THA) undergoing acute periprosthetic joint infection (PJI). 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. The combination of 3 different surgical techniques (tumour-like synovectomy, Argon Beam application and chlorhexidine gluconate brushing) might enhance the disruption and removal of the bacterial biofilm which is the main responsible of antibiotics and antibodies resistance. The timing of the diagnosis (6 weeks from the original surgery or 1 week from clinical symptoms appearance in the case of an hematogenous infection) and the preoperative isolation of the germ are fundamental in order to obtain a satisfactory outcome. A 12-week course of postoperative antibiotic therapy (6 weeks I.V. and 6 weeks oral) complete the postoperative protocol used by the authors. The DAPRI technique might represent a safe and more conservative treatment for acute and early hematogenous PJI.

Acute peri-prosthetic joint infection: improving diagnosis through the novel alpha-defensins test

“…This technique aims to remove the intra-articular biofilm by the combination of a tumor-like debridement of peri-prosthetic tissues, and argon beam application plus chlorhexidine gluconate brushing on the implant surfaces. This, combined with a higher and prolonged local antibiotic concentration by using calcium sulphate antibiotic-added beads, might enhance the disruption of the infection with an 80% rate of success in two recent consecutive preliminary studies 11,12 , which is higher than that reported with DAIR 38 . At our Institute, patients were routinely treated with DAPRI if the infection occurred in the first 3 post-operative weeks or in the first seven days after late hematogenous PJI.…”

“…In fact, in case of suspected early post-operative infections, different cut-off values have been proposed for serum C-reactive protein (CRP), D-dimer and erythrocyte sedimentation rate (ESR), while synovial white blood cell count (WBC) and leukocyte esterase strip test are not recommended during the first six post-operative weeks 9,10 . A novel and promising strategy to treat acute cases of PJIs was recently proposed, which consists in the combination of debridement, antibiotic pearls, and retention of the implant (DAPRI) 11,12 . DAPRI allows to remove only the polyethylene or modular component of the prosthesis, reducing the time of the revision surgery and the impact on patient recovery.…”

Clinical Application of Antibacterial Hydrogel and Coating in Orthopaedic and Traumatology Surgery

“…There is, on the other hand, literature regarding the efficacy of calcium sulphate antibiotic-loaded beads used as a local delivery system, which do not act as a coating, but are, however, capable of a longer-lasting targeted local antibiotic release [ 22 ]. This carrier was also tested in the DAIR strategy, modified in “debridement, antibiotic pearls, and retention of the implant, DAPRI”, where the use of the beads is associated with a debridement strategy associated with the use of an argon beam for the dislodgment of the biofilm from the implant in 10 patients, with promising results [ 26 ].…”

Adherence to a reliable PJI diagnostic protocol minimizes unsuspected positive cultures rate

“…Contrariwise, up to a 90% PJI success rate has been reported in the literature with similar functional outcomes to uninfected prosthesis [ 1 , 14 – 16 ]. The reported success rate slightly varies depending on the procedure [ 17 – 19 ]. All those studies follow a thorough work-up, diagnostic criteria and treatment for PJI with better outcomes when the patients are treated by specialists in PJI [ 20 – 22 ].…”