Role for Irrigation and Debridement in Periprosthetic Infections

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.

Keywords

hip - knee - prosthesis - infection - irrigation - debridement

• 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
• 2 Bittar ES, Petty W. Girdlestone arthroplasty for infected total hip arthroplasty. Clin Orthop Relat Res 1982; (170) 83-87
• 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
• 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
• 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
• 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
• 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
• 8 Trampuz A, Zimmerli W. Prosthetic joint infections: update in diagnosis and treatment. Swiss Med Wkly 2005; 135 (17-18) 243-251
• 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
• 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
• 11 Zimmerli W, Ochsner PE. Management of infection associated with prosthetic joints. Infection 2003; 31 (2) 99-108
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 25 Borden LS, Gearen PF. Infected total knee arthroplasty. A protocol for management. J Arthroplasty 1987; 2 (1) 27-36
• 26 Burger RR, Basch T, Hopson CN. Implant salvage in infected total knee arthroplasty. Clin Orthop Relat Res 1991; (273) 105-112
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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;
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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