First results of a uniform regional treatment protocol and registration for acute prosthetic join infection in the South-East of the Netherlands

Abstract

Abstract. Introduction: Prosthetic joint infection (PJI) is a relatively uncommon (average incidence 0.5-2%) but devastating complication, with significant morbidity and leading to tremendously increased health care costs. In 2013, delegates from nine hospitals covering a large region in the South-East Netherlands composed one combined treatment protocol for acute PJI of total hip and knee arthroplasty (THA and TKA). This protocol was based on the definition of acute PJI according to Workgroup of the American Musculoskeletal Infection Society (MSIS) and the principles of debridement, antibiotics, irrigation and retention (DAIR).Methods: Patients with a THA or TKA treated with DAIR because of suspicion of PJI were selected from the online PJI database. PJI was defined as at least two phenotypically identical pathogens, isolated in cultures from at least two separate tissues, obtained from the affected prosthetic joint. Acute PJIs, occurring within 90 days after primary implantation, between January 2014 and December 2016, were analyzed. We analyzed the PJI incidence rate, patient clinical and microbiological characteristics of PJI, outcome of the DAIR treatment and adherence to the regional protocol.Results: A total of 310 primary THA or TKA with a suspected PJI were registered in the regional PJI database, 236 met the definition of acute PJI, representing overall incidence of 1.12%. Following the regional treatment protocol replacement of exchangeable parts took place in 45% in 2014 to 70% in 2016. After 12 months follow-up, prosthesis retention was achieved in 87% and 3% of the patients died within one year after the primary surgery.Conclusion: Results of the regional cohort are in line with the available literature. Regional collaboration and regular feedback on registered data resulted in better adherence to the combined treatment protocol. Despite our attempts to improve PJI care, PJI remains a serious complication of THA and TKA with a significant mortality rate and burden for the patient.

Exchange of Modular Components Improves Success of Debridement, Antibiotics, and Implant Retention

“…At best, the participating clinics may have had a routine for the procedure, but this is unknown. However, the effect of adherence to standardized treatment protocols has not yet been evaluated 7 .…”

“…To our knowledge, the current study is the largest on DAIR after primary THA. As DAIR fails in 13% to 63% of patients 3 - 10 , additional efforts, such as evaluating the procedure in randomized trials, should be made to identify how DAIR should best be conducted and who benefits from it 3 - 7 .…”

“…With regard to surgical factors, the exchange of modular components is associated with a higher success rate than non-exchange 4 , 8 , 11 , 12 . Although the exchange of components has become more common 7 , both methods are still used and current evidence is based on case series, mainly with small study samples and in cohorts mixing primary and revision THAs. Using the Swedish Hip Arthroplasty Register (SHAR) and data from case records, we aimed to evaluate the success rate of DAIR in a relatively large cohort of patients with first-time PJI and to determine if the exchange of components is a means of improving outcome in patients treated with DAIR.…”

Higher 1-year risk of implant removal for culture-positive than for culture-negative DAIR patients following 359 primary hip or knee arthroplasties

“…A regional collaboration of eight hospitals, covering a region in the southeastern Netherlands, committed to a standardized diagnostic and treatment protocol for suspected PJI. All suspected PJI cases were recorded in a regional database (Kamp et al, 2019). The regional hospitals included one academic hospital, five regional hospitals, one specialized hospital, and one private clinic.…”

“…DAIR was repeated if clinical symptoms and laboratory signs did not improve within 10 d of the first DAIR procedure, according to the regional protocol, which allowed a maximum of two DAIR procedures. If the infection was still present after these DAIR procedures, the decision and arrangements to remove the implant were made by the treating surgical team (Kamp et al, 2019). Data regarding patient characteristics, type of surgery (primary hip or knee prosthesis), time between the index surgery and the DAIR procedure, features of infection (persistent wound leakage or fever), infection parameters (CRP and ESR), exchange of components during the DAIR procedure, and microbiology cultures were collected from the regional database.…”