Debridement, Antibiotics, and Implant Retention for Acute Periprosthetic Joint Infection

Abstract

Objective: To report on our clinical outcomes and on the experience of managing acute periprosthetic joint infection (PJI) with debridement, antibiotics, and implant retention (DAIR). Methods:We performed a retrospective review of all patients who were diagnosed with acute PJI after primary hip or knee replacement surgeries and who were managed with DAIR in our prospective joint replacement registry from 2008 to 2019. The diagnosis of PJI was made according to the 2011 Musculoskeletal Infection Society (MSIS) criteria. The symptom onset duration, inflammatory marker levels (i.e. C-reactive protein [CRP], erythrocyte sedimentation rate [ESR], white cell count [WBC], and synovial WBC count), functional scores including the Knee Society Score (KSS), the KSS functional score and the Harris Hip Score (HHS), bacteriology, and surgical outcomes of the patients were tracked and recorded. A paired sample of joint fluid and tissues was also sent for a metagenomic next-generation sequencing (mNGS) test. A paired-samples t-test was used to compare the differences in the inflammatory markers and functional scores before and after surgery.Results: A total of 24 patients with 7 infections after hip replacements and 17 infections after knee replacements were included. A total of 21 patients exhibited early postoperative infections, and 3 exhibited late acute hematogenous infections. During a mean follow-up time of 29.2 AE 15.1 months, 22 patients were successfully treated, whereas 2 patients were unsuccessfully treated and required repeated DAIR. The overall success rate of DAIR was 91.7%. For staphylococcal infections, DAIR had a 100% success rate. Five patients who presented with symptoms between 4 and 8 weeks also achieved a 100% success rate. At the last follow-up, the mean CRP level decreased from 52.6 AE 34.0 to 5.4 AE 3.5 (P < 0.001), and the mean ESR level decreased from 72.3 AE 34.3 to 20.2 AE 12.1 (P < 0.001). The mean KSS score increased from 44.8 AE 12.2 to 81.4 AE 9.2 (P < 0.001), and the mean KSS functional score increased from 38.1 AE 3.5 to 73.9 AE 23.0 (P < 0.001), and the mean HHS score increased from 34.4 AE 6.9 to 84.1 AE 15.1 (P < 0.001). The overall pathogen identification rate was 91.7% (22/24 cases). The success rates for Staphylococcus, Streptococcus, and the other pathogens were 100% (9/9 cases), 71.4% (5/7 cases), and 100% (6/6 cases), respectively.Conclusion: Debridement, antibiotics, and implant retention has a high success rate for the treatment of acute PJI and may be performed in selected patients whose symptoms have been sustained for over 4 weeks. A high rate of success for staphylococcal infections was reported with the use of DAIR.

Risk factors affect success rate of debridement, antibiotics and implant retention (DAIR) in periprosthetic joint infection

“…Although a 100% success rate of DAIR for Staphylococcus infection has been reported [23], most studies reported a higher failure rate of DAIR when performed to treat Staphylococcus infection [11,22,[24][25][26]. A multicenter observational study performed by Weston et al [22] reported a three-fold increased risk of failure after DAIR in cases of Staphylococcus infection.…”

“…Dixon et al [ 38 ] showed that arthroscopic debridement was more effective in patients with periprosthetic infection of the knee. Though findings of a meta-analysis [ 23 ] suggested a higher infection control rate for arthroscopic debridement compared with open debridement, the results were not significantly different. The pooled infection control rate for arthroscopic DAIR was based on only a few studies.…”

Diagnostic Value of Next‐Generation Sequencing in Periprosthetic Joint Infection: A Systematic Review

“…After excluding 29 duplicates and 38 irrelevant citations based on titles and abstracts, 20 citations remained for full‐text evaluation. Following this, we further excluded 11 articles because: (i) study designs did not meet the inclusion criteria (two reviews, one case report, and one editorial) 18 , 28 , 29 , 30 ; (ii) one study was related to therapeutics 31 ; (iii) the population or sample included in three studies was not relevant 20 , 32 , 33 ; (iv) the index test in one study did not include NGS 34 ; (v) one study did not use the MSIS criteria, IDSA criteria, or ICM criteria as a reference standard; and (vi) one study involved the establishment of a PJI diagnostic model in which the data relating to NGS diagnosis could not be obtained 19 , 35 . Nine articles were finally eligible for the review 14 , 15 , 16 , 17 , 36 , 37 , 38 , 39 , 40 .…”

Do Antibiotic-Loaded Calcium Sulfate Beads Improve Outcomes After Debridement, Antibiotics, and Implant Retention? A Matched Cohort Study

“…Of these, DAIR represents the least invasive option for surgical PJI management, with previous studies reporting shorter hospital stays and lower cost in addition to functional outcomes that are comparable to primary total joint arthroplasty [ [5] , [6] , [7] ]. Unfortunately, the efficacy of DAIR for PJI treatment remains unclear, with reported failure rates of DAIR procedures in the literature varying from 0% to as much as 84% [ [8] , [9] , [10] , [11] ].…”