The Benefice of Mobile Parts' Exchange in the Management of Infected Total Joint Arthroplasties with Prosthesis Retention (DAIR Procedure)

Stefanie Hirsiger, Michael Betz, Dimitrios Stafylakis, Tobias Götschi, Daniel Lew, Ilker Uçkay, Stefanie Hirsiger, Michael Betz, Dimitrios Stafylakis, Tobias Götschi, Daniel Lew, Ilker Uçkay

Abstract

Background: The management of prosthetic joint infections (PJI) with debridement and retention of the implant (DAIR) has its rules. Some authors claim that lacking the exchange of mobile prosthetic parts is doomed to failure, while others regard it as optional. Methods: Single-center retrospective cohort in PJIs treated with DAIR. Results: We included 112 PJIs (69 total hip arthroplasties, 9 medullary hip prostheses, 41 total knee arthroplasties, and 1 total shoulder arthroplasty) in 112 patients (median age 75 years, 52 females (46%), 31 (28%) immune-suppressed) and performed a DAIR procedure in all cases-48 (43%) with exchange of mobile parts and 64 without. After a median follow-up of 3.3 years, 94 patients (84%) remained in remission. In multivariate Cox regression analysis, remission was unrelated to PJI localization, pathogens, number of surgical lavages, duration of total antibiotic treatment or intravenous therapy, choice of antibiotic agents, immune-suppression, or age. In contrast, the exchange of mobile parts was protective (hazard ratio 1.9; 95% confidence interval 1.2⁻2.9). Conclusions: In our retrospective single-center cohort, changing mobile parts of PJI during the DAIR approach almost doubled the probability for long-term remission.

Keywords: DAIR; antibiotic duration; mobile parts’ exchange; orthopaedic surgery; treatment failure.

Conflict of interest statement

All authors declare no conflict of interest. I.U. has received research donations for another project. D.L. has received salary for other, unrelated activity.

Figures

Figure 1
Figure 1
Flow chart displaying the inclusions and exclusions of our study.
Figure 2
Figure 2
Kaplan–Meier curve stratified upon the exchange of mobile parts. Echangeparties = exchange of mobile parts. Of note, the benefit of exchange is only visible during the first year (first 400 days). Thereafter, the curves remain parallel. The corresponding hazard ratios and 95% confidence of the exchange are 1.9; 1.2–2.9; and, for non-exchange 0.5, 0.8–1.0, respectively.

References

    1. Chaussade H., Uçkay I., Vuagnat A., Druon J., Gras G., Rosset P., Lipsky B.A., Bernard L. Antibiotic therapy duration for prosthetic joint infections treated by Debridement and Implant Retention (DAIR): Similar long-term remission for 6 weeks as compared to 12 weeks. Int. J. Infect. Dis. 2017;63:37–42. doi: 10.1016/j.ijid.2017.08.002.
    1. Tsang S.J., Ting J., Simpson A.H.R.W., Gaston P. Outcomes following debridement, antibiotics and implant retention in the management of periprosthetic infections of the hip: A review of cohort studies. Bone Joint. J. 2017;99:1458–1466. doi: 10.1302/0301-620X.99B11.BJJ-2017-0088.R1.
    1. Moojen D.J., Zwiers J.H., Scholtes V.A., Verheyen C.C., Poolman R.W. Similar success rates for single and multiple debridement surgery for acute hip arthroplasty infection. Acta. Orthop. 2014;85:383–388. doi: 10.3109/17453674.2014.927729.
    1. Haasper C., Buttaro M. Irrigation and Debridement; Proceedings of the International Consensus Meeting on Prosthetic Joint Infection; Philadelphia, PA, USA. 31 July–1 August 2013; pp. 273–285.
    1. Uçkay I., Hoffmeyer P., Lew D., Pittet D. Prevention of surgical site infections in orthopaedic surgery and bone trauma: State-of-the-art update. J. Hosp. Infect. 2013;84:5–12. doi: 10.1016/j.jhin.2012.12.014.
    1. Jugun K., Vaudaux P., Garbino J., Pagani L., Hoffmeyer P., Lew D., Uçkay I. The safety and efficacy of high-dose daptomycin combined with rifampicin for the treatment of Gram-positive osteoarticular infections. Int. Orthop. 2013;37:1375–1380. doi: 10.1007/s00264-013-1856-y.
    1. Sendi P., Christensson B., Uçkay I., Trampuz A., Achermann Y., Boggian K., Svensson D., Widerström M., Zimmerlim W., GBS PJI Study Group Group B streptococcus in prosthetic hip and knee joint-associated infections. J. Hosp. Infect. 2011;79:64–69. doi: 10.1016/j.jhin.2011.04.022.
    1. Bouvet C., Lübbeke A., Bandi C., Pagani L., Stern R., Hoffmeyer P., Uçkay I. Is there any benefit in pre-operative urinary analysis before elective total joint replacement? Bone Joint. J. 2014;96:390–394. doi: 10.1302/0301-620X.96B3.32620.
    1. Ferry T., Uçkay I., Vaudaux P., François P., Schrenzel J., Harbarth S., Laurent F., Bernard L., Vandenesch F., Etienne J., et al. Risk factors for treatment failure in orthopedic device-related methicillin-resistant Staphylococcus aureus infection. Eur. J. Clin. Microbiol. Infect. Dis. 2010;29:171–180. doi: 10.1007/s10096-009-0837-y.
    1. Uçkay I., Lübbeke A., Harbarth S., Emonet S., Tovmirzaeva L., Agostinho A., Longtin Y., Peter R., Hoffmeyer P., Pittet D. Low risk despite high endemicity of methicillin-resistant Staphylococcus aureus infections following elective total joint arthroplasty: A 12-year experience. Ann. Med. 2012;44:360–368. doi: 10.3109/07853890.2010.550932.
    1. Teterycz D., Ferry T., Lew D., Stern R., Assal M., Hoffmeyer P., Bernard L., Uçkay I. Outcome of orthopedic implant infections due to different staphylococci. Int. J. Infect. Dis. 2010;14:913–918. doi: 10.1016/j.ijid.2010.05.014.
    1. Schindler M., Bernard L., Belaieff W., Gamulin A., Racloz G., Emonet S., Lew D., Hoffmeyer P., Uçkay I. Epidemiology of adverse events and Clostridium difficile-associated diarrhea during long-term antibiotic therapy for osteoarticular infections. J. Infect. 2013;67:433–438. doi: 10.1016/j.jinf.2013.07.017.
    1. Osmon D.R., Berbari E.F., Berendt A.R., Lew D., Zimmerli W., Steckelberg J.M., Rao N., Hanssen A., Wilson W.R., Infectious Diseases Society of America Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin. Infect. Dis. 2013;56:1–25. doi: 10.1093/cid/cis966.
    1. Mont M.A., Waldman B., Banerjee C., Pacheco I.H., Hungerford D.S. Multiple irrigation; debridement; and retention of components in infected total knee arthroplasty. J. Arthroplasty. 1997;12:426–433. doi: 10.1016/S0883-5403(97)90199-6.
    1. Marculescu C.E., Berbari E.F., Hanssen A.D., Steckelberg J.M., Harmsen S.W., Mandrekar J.N., Osmon D.R. Outcome of prosthetic joint infections treated with debridement and retention of components. Clin. Infect. Dis. 2006;42:471–478. doi: 10.1086/499234.
    1. Deirmengian C., Greenbaum J., Lotke P.A., Booth R.E., Jr., Lonner J.H. Limited success with open debridement and retention of components in the treatment of acute Staphylococcus aureus infections after total knee arthroplasty. J. Arthroplasty. 2003;18:22–26. doi: 10.1016/S0883-5403(03)00288-2.
    1. Theis J.C., Gambhir S., White J. Factors affecting implant retention in infected joint replacements. ANZ J. Surg. 2007;77:877–879. doi: 10.1111/j.1445-2197.2007.04263.x.
    1. Tsumura H., Ikeda S., Ono T., Itonaga I., Taira H., Torisu T. Synovectomy, debridement, and continuous irrigation for infected total knee arthroplasty. Int. Orthop. 2005;29:113–116. doi: 10.1007/s00264-004-0626-2.
    1. Grammatopoulos G., Kendrick B., McNally M., Athanasou N.A., Atkins B., McLardy-Smith P., Taylor A., Gundle R. Outcome Following Debridement; Antibiotics; and Implant Retention in Hip Periprosthetic Joint Infection-An 18-Year Experience. J. Arthroplasty. 2017;32:2248–2255. doi: 10.1016/j.arth.2017.02.066.
    1. Buller L.T., Sabry F.Y., Easton R.W., Klika A.K., Barsoum W.K. The preoperative prediction of success following irrigation and debridement with polyethylene exchange for hip and knee prosthetic joint infections. J. Arthroplasty. 2012;27:857–864. doi: 10.1016/j.arth.2012.01.003.
    1. Gardner J., Gioe T.J., Tatman P. Can this prosthesis be saved? Implant salvage attempts in infected primary TKA. Clin. Orthop. Relat. Res. 2011;469:970–976. doi: 10.1007/s11999-010-1417-2.
    1. Vilchez F., Martínez-Pastor J.C., García-Ramiro S., Bori G., Maculé F., Sierra J., Font L., Mensa J., Soriano A. Outcome and predictors of treatment failure in early post-surgical prosthetic joint infections due to Staphylococcus aureus treated with debridement. Clin. Microbiol. Infect. 2011;17:439–444. doi: 10.1111/j.1469-0691.2010.03244.x.
    1. Koyonos L., Zmistowski B., Della Valle C.J., Parvizi J. Infection control rate of irrigation and debridement for periprosthetic joint infection. Clin. Orthop. Relat. Res. 2011;469:3043–3048. doi: 10.1007/s11999-011-1910-2.
    1. Puhto A.P., Puhto T., Niinimäki T., Ohtonen P., Leppilahti J., Syrjälä H.S. Predictors of treatment outcome in prosthetic joint infections treated with prosthesis retention. Int. Orthop. 2015;39:1785–1791. doi: 10.1007/s00264-015-2819-2.
    1. Peel T.N., Buising K.L., Dowsey M.M., Aboltins C.A., Daffy J.R., Stanley P.A., Coong P.F. Outcome of Debridement and Retention in Prosthetic Joint Infections by Methicillin-Resistant Staphylococci; with Special Reference to Rifampin and Fusidic Acid Combination Therapy. Antimicrob. Agents. Chemother. 2013;57:350–355. doi: 10.1128/AAC.02061-12.
    1. Achermann Y., Stasch P., Preiss S., Lucke K., Vogt M. Characteristics and treatment outcomes of 69 cases with early prosthetic joint infections of the hip and knee. Infection. 2014;42:511–519. doi: 10.1007/s15010-014-0584-6.
    1. Sukeik M., Patel S., Haddad F.S. Aggressive early debridement for treatment of acutely infected cemented total hip arthroplasty. Clin. Orthop. Relat. Res. 2012;470:3164–3170. doi: 10.1007/s11999-012-2500-7.
    1. Westberg M., Grøgaard B., Snorrason F. Early prosthetic joint infections treated with debridement and implant retention: 38 primary hip arthroplasties prospectively recorded and followed for median 4 years. Acta. Orthop. 2012;83:227–232. doi: 10.3109/17453674.2012.678801.
    1. Geurts J.A., Janssen D.M., Kessels A.G., Walenkamp G.H. Good results in postoperative and hematogenous deep infections of 89 stable total hip and knee replacements with retention of prosthesis and local antibiotics. Acta. Orthop. 2013;84:509–516. doi: 10.3109/17453674.2013.858288.
    1. Tornero E., Morata L., Martínez-Pastor J.C., Bori G., Climent C., García-Velez D.M., Bosch J., Mensa J., Soriano A. KLIC-score for predicting early failure in prosthetic joint infections treated with debridement, implant retention and antibiotics. Clin. Microbiol. Infect. 2015;21:9–17. doi: 10.1016/j.cmi.2015.04.012.
    1. Konigsberg B.S., Della Valle C.J., Ting N.T., Qiu F., Sporer S.M. Acute hematogenous infection following total hip and knee arthroplasty. J. Arthroplasty. 2014;29:469–472. doi: 10.1016/j.arth.2013.07.021.
    1. Duque A.F., Post Z.D., Lutz R.W., Orozco F.R., Pulido S.H., Ong A.C. Is There Still a Role for Irrigation and Debridement With Liner Exchange in Acute Periprosthetic Total Knee Infection? J. Arthroplasty. 2017;32:1280–1284. doi: 10.1016/j.arth.2016.10.029.
    1. Sendi P., Lötscher P.O., Kessler B., Graber P., Zimmerli W., Clauss M. Debridement and implant retention in the management of hip periprosthetic joint infection: Outcomes following guided and rapid treatment at a single centre. Bone Joint. J. 2017;99:330–336. doi: 10.1302/0301-620X.99B3.BJJ-2016-0609.R1.
    1. Lora-Tamayo J., Senneville E., Ribera A., Bernard L., Dupon M., Zeller V., Li H.K., Arvieux C., Clauss M., Uçkay I., et al. The Not-So-Good Prognosis of Streptococcal Periprosthetic Joint Infection Managed by Implant Retention: The Results of a Large Multicenter Study. Clin. Infect. Dis. 2017;64:1742–1752. doi: 10.1093/cid/cix227.
    1. Rodríguez-Pardo D., Pigrau C., Lora-Tamayo J., Soriano A., Del Toro M.D., Cobo J., alomino J., Euba G., Riera M., Sánchez-Somolinos M., et al. Gram-negative prosthetic joint infection: outcome of a debridement; antibiotics and implant retention approach. A large multicentre study. Clin. Microbiol. Infect. 2014;20:911–919. doi: 10.1111/1469-0691.12649.
    1. Choi H.R., von Knoch F., Kandil A.O., Zurakowski D., Moore S., Malchau H. Retention treatment after periprosthetic total hip arthroplasty infection. Int. Orthop. 2012;36:723–729. doi: 10.1007/s00264-011-1324-5.
    1. Choi H.R., von Knoch F., Zurakowski D., Nelson S.B., Malchau H. Can implant retention be recommended for treatment of infected TKA? Clin. Orthop. Relat. Res. 2011;469:961–969. doi: 10.1007/s11999-010-1679-8.
    1. Bernard L., Legout L., Zürcher-Pfund L., Stern R., Rohner P., Peter R., Assal M., Lew D., Hoffmeyer P., Uçkay I. Six weeks of antibiotic treatment is sufficient following surgery for septic arthroplasty. J. Infect. 2010;61:125–132. doi: 10.1016/j.jinf.2010.05.005.
    1. Uçkay I., Pires D., Agostinho A., Guanziroli N., Öztürk M., Bartolone P., Tscholl P., Betz M., Pittet D. Enterococci in orthopaedic infections: Who is at risk getting infected? J. Infect. 2017;75:309–314. doi: 10.1016/j.jinf.2017.06.008.
    1. Fehring T.K., Odum S.M., Berend K.R., Jiranek W.A., Parvizi J., Bozic K.J., Della Valle C.J., Gioe T.J. Failure of irrigation and debridement for early postoperative periprosthetic infection. Clin. Orthop. Relat. Res. 2013;471:250–257. doi: 10.1007/s11999-012-2373-9.

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir