Role for Irrigation and Debridement in Periprosthetic Infections

 

 Buy Article Permissions and Reprints

Abstract

Irrigation and debridement (I&D) has been described as a possible option to eradicate early postoperative periprosthetic hip and knee infections, as well as late, acute, and hematogenous ones. Still, the literature fails to uniquely assess the effectiveness of this procedure and often provides conflicting evidence. To reconcile this difference, a systematic review of the available literature from 1970 to 2013 was undertaken. Fifteen articles, for a total of 796 patients, met the inclusion criteria; the average success rate was 44.9 and 52% after a single or repeated I&D procedures, respectively, at an average of 4 years follow-up. Despite the methodological differences and the heterogeneity of the material reviewed, this study demonstrates that this procedure only attains a relatively low success rate of infection eradication, depending on when patients are selected for surgical intervention according to the timeframe of their symptoms.

• References

• 1 Buchholz HW, Elson RA, Engelbrecht E, Lodenkämper H, Röttger J, Siegel A. Management of deep infection of total hip replacement. J Bone Joint Surg Br 1981; 63-B (3) 342-353
  PubMedGoogle Scholar
• 2 Bittar ES, Petty W. Girdlestone arthroplasty for infected total hip arthroplasty. Clin Orthop Relat Res 1982; (170) 83-87
  PubMedGoogle Scholar
• 3 Carlsson AS, Josefsson G, Lindberg L. Revision with gentamicin-impregnated cement for deep infections in total hip arthroplasties. J Bone Joint Surg Am 1978; 60 (8) 1059-1064
  PubMedGoogle Scholar
• 4 McDonald DJ, Fitzgerald Jr RH, Ilstrup DM. Two-stage reconstruction of a total hip arthroplasty because of infection. J Bone Joint Surg Am 1989; 71 (6) 828-834
  PubMedGoogle Scholar
• 5 Nestor BJ, Hanssen AD, Ferrer-Gonzalez R, Fitzgerald Jr RH. The use of porous prostheses in delayed reconstruction of total hip replacements that have failed because of infection. J Bone Joint Surg Am 1994; 76 (3) 349-359
  PubMedGoogle Scholar
• 6 Romanò CL, Gala L, Logoluso N, Romanò D, Drago L. Two-stage revision of septic knee prosthesis with articulating knee spacers yields better infection eradication rate than one-stage or two-stage revision with static spacers. Knee Surg Sports Traumatol Arthrosc 2012; 20 (12) 2445-2453
  CrossrefPubMedGoogle Scholar
• 7 Romanò CL, Borens O, Monti L, Meani E, Stuyck J. What treatment for periprosthetic shoulder infection? Results from a multicentre retrospective series. Int Orthop 2012; 36 (5) 1011-1017
  CrossrefPubMedGoogle Scholar
• 8 Trampuz A, Zimmerli W. Prosthetic joint infections: update in diagnosis and treatment. Swiss Med Wkly 2005; 135 (17-18) 243-251
  PubMedGoogle Scholar
• 9 Moran E, Masters S, Berendt AR, McLardy-Smith P, Byren I, Atkins BL. Guiding empirical antibiotic therapy in orthopaedics: The microbiology of prosthetic joint infection managed by debridement, irrigation and prosthesis retention. J Infect 2007; 55 (1) 1-7
  CrossrefPubMedGoogle Scholar
• 10 Marculescu CE, Berbari EF, Hanssen AD , et al. Outcome of prosthetic joint infections treated with debridement and retention of components. Clin Infect Dis 2006; 42 (4) 471-478
  CrossrefPubMedGoogle Scholar
• 11 Zimmerli W, Ochsner PE. Management of infection associated with prosthetic joints. Infection 2003; 31 (2) 99-108
  CrossrefPubMedGoogle Scholar
• 12 Laffer RR, Graber P, Ochsner PE, Zimmerli W. Outcome of prosthetic knee-associated infection: evaluation of 40 consecutive episodes at a single centre. Clin Microbiol Infect 2006; 12 (5) 433-439
  CrossrefPubMedGoogle Scholar
• 13 Azzam KA, Seeley M, Ghanem E, Austin MS, Purtill JJ, Parvizi J. Irrigation and debridement in the management of prosthetic joint infection: traditional indications revisited. J Arthroplasty 2010; 25 (Suppl. 07) 1022-1027
  CrossrefPubMedGoogle Scholar
• 14 Silva M, Tharani R, Schmalzried TP. Results of direct exchange or debridement of the infected total knee arthroplasty. Clin Orthop Relat Res 2002; (404) 125-131
  PubMedGoogle Scholar
• 15 Deirmengian C, Greenbaum J, Lotke PA, Booth Jr RE, Lonner JH. 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 (7) (Suppl. 01) 22-26
  CrossrefPubMedGoogle Scholar
• 16 Mont MA, Waldman B, Banerjee C, Pacheco IH, Hungerford DS. Multiple irrigation, debridement, and retention of components in infected total knee arthroplasty. J Arthroplasty 1997; 12 (4) 426-433
  CrossrefPubMedGoogle Scholar
• 17 Sherrell JC, Fehring TK, Odum S , et al; Periprosthetic Infection Consortium. The Chitranjan Ranawat Award: fate of two-stage reimplantation after failed irrigation and débridement for periprosthetic knee infection. Clin Orthop Relat Res 2011; 469 (1) 18-25
  CrossrefPubMedGoogle Scholar
• 18 Hartman MB, Fehring TK, Jordan L, Norton HJ. Periprosthetic knee sepsis. The role of irrigation and debridement. Clin Orthop Relat Res 1991; (273) 113-118
  PubMedGoogle Scholar
• 19 Tsukayama DT, Goldberg VM, Kyle R. Diagnosis and management of infection after total knee arthroplasty. J Bone Joint Surg Am 2003; 85-A (Suppl. 01) S75-S80
  PubMedGoogle Scholar
• 20 Koyonos L, Zmistowski B, Della Valle CJ, Parvizi J. Infection control rate of irrigation and débridement for periprosthetic joint infection. Clin Orthop Relat Res 2011; 469 (11) 3043-3048
  CrossrefPubMedGoogle Scholar
• 21 Barberán J, Aguilar L, Carroquino G , et al. Conservative treatment of staphylococcal prosthetic joint infections in elderly patients. Am J Med 2006; 119 (11) e7-e10
  PubMedGoogle Scholar
• 22 Bradbury T, Fehring TK, Taunton M , et al. The fate of acute methicillin-resistant Staphylococcus aureus periprosthetic knee infections treated by open debridement and retention of components. J Arthroplasty 2009; 24 (6, Suppl) 101-104
  PubMedGoogle Scholar
• 23 Tattevin P, Crémieux AC, Pottier P, Huten D, Carbon C. Prosthetic joint infection: when can prosthesis salvage be considered?. Clin Infect Dis 1999; 29 (2) 292-295
  CrossrefPubMedGoogle Scholar
• 24 Brandt CM, Sistrunk WW, Duffy MC , et al. Staphylococcus aureus prosthetic joint infection treated with debridement and prosthesis retention. Clin Infect Dis 1997; 24 (5) 914-919
  CrossrefPubMedGoogle Scholar
• 25 Borden LS, Gearen PF. Infected total knee arthroplasty. A protocol for management. J Arthroplasty 1987; 2 (1) 27-36
  CrossrefPubMedGoogle Scholar
• 26 Burger RR, Basch T, Hopson CN. Implant salvage in infected total knee arthroplasty. Clin Orthop Relat Res 1991; (273) 105-112
  PubMedGoogle Scholar
• 27 Rasul Jr AT, Tsukayama D, Gustilo RB. Effect of time of onset and depth of infection on the outcome of total knee arthroplasty infections. Clin Orthop Relat Res 1991; (273) 98-104
  PubMedGoogle Scholar
• 28 Teeny SM, Dorr L, Murata G, Conaty P. Treatment of infected total knee arthroplasty. Irrigation and debridement versus two-stage reimplantation. J Arthroplasty 1990; 5 (1) 35-39
  CrossrefPubMedGoogle Scholar
• 29 Schoifet SD, Morrey BF. Treatment of infection after total knee arthroplasty by débridement with retention of the components. J Bone Joint Surg Am 1990; 72 (9) 1383-1390
  CrossrefPubMedGoogle Scholar
• 30 Fehring TK, Odum SM, Berend KR , et al. Failure of irrigation and débridement for early postoperative periprosthetic infection. Clin Orthop Relat Res 2013; 471 (1) 250-257
  CrossrefPubMedGoogle Scholar
• 31 Martínez-Pastor JC, Muñoz-Mahamud E, Vilchez F , et al. Outcome of acute prosthetic joint infections due to gram-negative bacilli treated with open debridement and retention of the prosthesis. Antimicrob Agents Chemother 2009; 53 (11) 4772-4777
  CrossrefPubMedGoogle Scholar
• 32 Bose WJ, Gearen PF, Randall JC, Petty W. Long-term outcome of 42 knees with chronic infection after total knee arthroplasty. Clin Orthop Relat Res 1995; (319) 285-296
  PubMedGoogle Scholar
• 33 Kilgus DJ, Howe DJ, Strang A. Results of periprosthetic hip and knee infections caused by resistant bacteria. Clin Orthop Relat Res 2002; (404) 116-124
  PubMedGoogle Scholar
• 34 Royo A, Bertrand ML, Ramos L, Fernandez-Gordillo F, Guerado E. Is there still a place for continuous closed irrigation in the management of periprosthetic total knee infection?. Open Orthop J 2013; 7: 205-210
  CrossrefPubMedGoogle Scholar
• 35 Archer NK, Mazaitis MJ, Costerton JW, Leid JG, Powers ME, Shirtliff ME. Staphylococcus aureus biofilms: properties, regulation, and roles in human disease. Virulence 2011; 2 (5) 445-459
  CrossrefPubMedGoogle Scholar
• 36 Urish KL, Demuth PW, Craft DW, Haider H, Davis III CM. Pulse lavage is inadequate at removal of biofilm from the surface of total knee arthroplasty materials. J Arthroplasty 2013;
  PubMedGoogle Scholar
• 37 Romanò CL, Toscano M, Romanò D, Drago L. Antibiofilm agents and implant-related infections in orthopaedics: where are we?. J Chemother 2013; 25 (2) 67-80
  CrossrefPubMedGoogle Scholar
• 38 Drago L, De Vecchi E, Mattina R, Romanò CL. Activity of N-acetyl-L-cysteine against biofilm of Staphylococcus aureus and Pseudomonas aeruginosa on orthopedic prosthetic materials. Int J Artif Organs 2013; 36 (1) 39-46
  CrossrefPubMedGoogle Scholar
• 39 Chiu FY, Chen CM. Surgical débridement and parenteral antibiotics in infected revision total knee arthroplasty. Clin Orthop Relat Res 2007; 461 (461) 130-135
  PubMedGoogle Scholar
• 40 Deirmengian C, Greenbaum J, Stern J , et al. Open debridement of acute gram-positive infections after total knee arthroplasty. Clin Orthop Relat Res 2003; (416) 129-134
  PubMedGoogle Scholar
• 41 Klouche S, Lhotellier L, Mamoudy P. Infected total hip arthroplasty treated by an irrigation-debridement/component retention protocol. A prospective study in a 12-case series with minimum 2 years' follow-up. Orthop Traumatol Surg Res 2011; 97 (2) 134-138
  CrossrefPubMedGoogle Scholar
• 42 Odum SM, Fehring TK, Lombardi AV , et al; Periprosthetic Infection Consortium. Irrigation and debridement for periprosthetic infections: does the organism matter?. J Arthroplasty 2011; 26 (6, Suppl): 114-118
  Google Scholar
• 43 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 (2) 113-116
  CrossrefPubMedGoogle Scholar
• 44 Van Kleunen JP, Knox D, Garino JP, Lee GC. Irrigation and débridement and prosthesis retention for treating acute periprosthetic infections. Clin Orthop Relat Res 2010; 468 (8) 2024-2028
  CrossrefPubMedGoogle Scholar
• 45 Vilchez F, Martínez-Pastor JC, García-Ramiro S , et al. Efficacy of debridement in hematogenous and early post-surgical prosthetic joint infections. Int J Artif Organs 2011; 34 (9) 863-869
  CrossrefPubMedGoogle Scholar