Infection in Total Knee Arthroplasty. How Long Do You Retain the Components? A New Proposal

Periprosthetic infections (PPI) are among the most complex and devastating complications in joint surgery. PPIs represent one of the major causes of prosthesis revision over time,[1] and are devastating for both patients and their doctors. Their incidence ranges from 1– to %2,[2] [3] generating an explosive increase in healthcare costs, a severe impact on the quality of life, and increased morbidity and mortality.[4] [5]

Component retention is always well accepted by both patients and doctors. Its surgical indications and techniques are subjects of constant controversy.

Infection treatment depends on patient factors, organism type, and timing. The most common alternatives are debridement and antibiotics with implant retention (known as “DAIR” in the English literature) and component revision one or two times. Other salvage options (resection arthroplasty, arthrodesis, and amputation) are only for patients with persistent PPI or at high risk of failure to undergo a revision or re-revision.[6]

In general terms, DAIR has historically been reserved for acute and hematogenous post-operative infections with symptoms for a short time. In contrast, a component review is indicated for chronic infections with methicillin-resistant Staphylococcus aureus, multiple organisms, sepsis, negative cultures,[7] Since the main factor in selecting a treatment is the timing of the infection, it is critical to determine if a PPI is “acute”. Numerous published classifications present different cutoff points. Tsukayama,[8] for instance, defines it as lower than three months. However, for most authors, an acute infection occurs before one month of surgery.[9]

DAIR is an attractive alternative for patients and doctors as it is much less invasive, causes lower bone stock loss, better functional outcomes, and less morbidity.[10] Nonetheless, it requires a good indication because the patient may face a future replacement with a significant increase in risks and costs. The success rate varies greatly, from 18 to 94%.[11] As a result, the surgeon must appropriately study the factors of a patient who is a good candidate for implant retention.

New Concepts

Initially, DAIR was reserved for “very early” PPI (before 10 to 14 days after surgery. However, the indication regarding the timing of the surgery index has changed over time. Some groups consider DAIR before four weeks or even before three months. Furthermore, it is possible to consider hematogenous infections with less than two weeks of symptoms when biofilm presence should not be significant.[7]

Some current studies demonstrate the DAIR performance within three months of surgery has acceptable success rates. For instance, De Vries et al.[12] achieved an 84% rate of component retention. However, these authors mentioned the fundamental role of a stable component, an identified and treatable organism, symptoms for less than three weeks, and intact soft parts. Van der Ende et al. published a Dutch series comparing DAIR effectiveness in patients operated on before four weeks of the index surgery (group 1) or four to 12 weeks (group 2) after the index surgery. These authors defined “success" as the absence of component review 12 months post-DAIR. They demonstrated that hip prostheses success in groups 1 and 2 were 92 and 91% respectively. Meanwhile, the success rate in knee prostheses was 91% and 83% in groups 1 and 2, respectively.[13] Although we could see the increased knee prosthesis failure as “significant,” we believe that an 83% success rate should make one consider component maintenance since it is an acceptable result that would prevent a large proportion of prosthetic replacements and their consequences.

In recent years, studies showed the experience with the “Double-DAIR” treatment promoted by the Mayo Clinic group.[14] This procedure involves a two-staged debridement, initially increasing costs. However, success rates are higher, ultimately resulting in cost savings by implant retention in a higher number of cases. The first stage of this procedure consists of thorough debridement and cleansing, taking culture samples, cleaning the insert on the working table, repositioning it, and placing cement beads with an antibiotic agent. The second stage, four to seven days later, consists of bead removal, new cleaning, and changing the insert for a new one. In the case history of this Mayo Clinic group, the “Double-DAIR” procedure achieves a 94% success rate for primary prosthesis infections, warranting its recommendation.[15] It is worth noting that all cases from these studies only include patients operated on less than four weeks after the index procedure. To our knowledge, the success rate of this intervention in patients operated on four to 12 weeks after the index procedure has not been published. The effectiveness of the classic DAIR versus the “Double-DAIR” procedures has been studied with a Markovian model, showing a higher cost-effective ratio for the “Double-DAIR” group in terms of health utility (QALYs) and final costs.[16]

 

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Our Recommendation

Our group tries to retain the components whenever possible in acute infections (progressing for less than three months postoperatively) or hematogenous infections with symptoms for less than two weeks as long as the pathogen is identified and treatable, there are no signs of component loosening, and the soft parts are adequate. We began to consider the “Double-DAIR” procedure this year (as described by the Mayo Clinic group but changing the insert in the first and second stages, not in the second stage alone). So far, we had good outcomes, and we believe prosthetic component retention is a valid treatment alternative.

 

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Die Autoren geben an, dass kein Interessenkonflikt besteht.

• References

• 1 American Joint Replacement Registry (AJRR). Annual Report. Rosemont: American Academy of Orthopaedic Surgeons; 2021
• 2 Karachalios T, Komnos GA. Management strategies for prosthetic joint infection: long-term infection control rates, overall survival rates, functional and quality of life outcomes. EFORT Open Rev 2021; 6 (09) 727-734
• 3 Ong KL, Kurtz SM, Lau E, Bozic KJ, Berry DJ, Parvizi J. Prosthetic joint infection risk after total hip arthroplasty in the Medicare population. J Arthroplasty 2009; 24 (6, Suppl) 105-109
• 4 Kurtz SM, Lau EC, Son MS, Chang ET, Zimmerli W, Parvizi J. Are we winning or losing the battle with periprosthetic joint infection? Trends in periprosthetic joint infection and mortality risk for the Medicare population. J Arthroplasty 2018; 33 (10) 3238-3245
• 5 Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J. Economic burden of periprosthetic joint infection in the United States. J Arthroplasty 2012; 27 (8, Suppl) 61-5.e1
• 6 Ries MD, Nunley RM. . (2018) Revision total knee arthroplasty, 2nd edn. Springer International Publishing; Cham:
• 7 Okafor CE, Nghiem S, Byrnes J. One-stage revision versus debridement, antibiotics, and implant retention (DAIR) for acute prosthetic knee infection: an exploratory cohort study. Arch Orthop Trauma Surg 2023; 143 (09) 5787-5792
• 8 Tsukayama DT, Estrada R, Gustilo RB. Infection after total hip arthroplasty. A study of the treatment of one hundred and six infections. J Bone Joint Surg Am 1996; 78 (04) 512-523
• 9 Zimmerli W, Ochsner PE. Management of infection associated with prosthetic joints. Infection 2003; 31 (02) 99-108
• 10 Qasim SN, Swann A, Ashford R. The DAIR (debridement, antibiotics and implant retention) procedure for infected total knee replacement - a literature review. SICOT J 2017; 3: 2
• 11 Ariza J, Cobo J, Baraia-Etxaburu J. et al; Spanish Network for the Study of Infectious Diseases and the Sociedad Española de Enfermedades Infecciosas, Microbiología Clínica (SEIMC). Executive summary of management of prosthetic joint infections. Clinical practice guidelines by the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC). Enferm Infecc Microbiol Clin 2017; 35 (03) 189-195
• 12 de Vries L, van der Weegen W, Neve WC, Das H, Ridwan BU, Steens J. The Effectiveness of Debridement, Antibiotics and Irrigation for Periprosthetic Joint Infections after Primary Hip and Knee Arthroplasty. A 15 Years Retrospective Study in Two Community Hospitals in the Netherlands. J Bone Jt Infect 2016; 1: 20-24
• 13 van der Ende B, van Oldenrijk J, Reijman M. et al. Timing of debridement, antibiotics, and implant retention (DAIR) for early post-surgical hip and knee prosthetic joint infection (PJI) does not affect 1-year re-revision rates: data from the Dutch Arthroplasty Register. J Bone Jt Infect 2021; 6 (08) 329-336
• 14 McQuivey KS, Bingham J, Chung A, Clarke H, Schwartz A, Pollock JR, Beauchamp C, Spangehl MJ. The Double DAIR: A 2-Stage Debridement with Prosthesis-Retention Protocol for Acute Periprosthetic Joint Infections. JBJS Essent Surg Tech 2021; 11 (01) e19.00071
• 15 Chung AS, Niesen MC, Graber TJ. et al. Two-Stage Debridement With Prosthesis Retention for Acute Periprosthetic Joint Infections. J Arthroplasty 2019; 34 (06) 1207-1213
• 16 Antonios JK, Bozic KJ, Clarke HD, Spangehl MJ, Bingham JS, Schwartz AJ. Cost-effectiveness of Single vs Double Debridement and Implant Retention for Acute Periprosthetic Joint Infections in Total Knee Arthroplasty: A Markov Model. Arthroplast Today 2021; 11: 187-195

Publikationsverlauf

Artikel online veröffentlicht:
26. Dezember 2023