An Aggressive Protocol for Managing Acute PJI

    This protocol, applied to total hip and total knee arthroplasty patients, has successfully eradicated acute periprosthetic joint infection in up to 91% of patients – a much higher success rate than the typical irrigation and debridement protocol.

    Historically, irrigation and debridement (I&D) for acute periprosthetic joint infection (PJI) has not been a resounding success, with studies typically showing less than 50% of infections eradicated.

    Some research has even suggested that patients who fail I&D will be more likely to have a poorer outcome with 2-stage exchange than those who go directly to 2-stage exchange.

    To increase the chances of success, in 2002 Henry D. Clarke, MD, and Mark J. Spangehl, MD, from Mayo Clinic Arizona in Phoenix, initiated a 2-stage I&D protocol for acute PJI – defined as symptoms for less than 4 weeks – for total hip and total knee arthroplasty patients that includes:

    • Aggressive debridement
    • Irrigation with 2 solutions: povidone-iodine and chlorhexidine
    • Retention of modular parts, which are flash sterilized or scrubbed with and soaked in povidone-iodine and then chlorhexidine
    • Insertion of high-dose antibiotic beads
    • Removal of the beads after 3 to 7 days, with further debridement and irrigation
    • Insertion of new modular parts
    • Intravenous antibiotics for 6 weeks
    • Oral antibiotics use after the IV antibiotics

    A small series by Estes et al [1] reported a 91% success rate with this protocol. An expansion of the study found an overall 84% success rate, with 91% for primary total joint arthroplasty patients and 75% for revision patients.

    In this video article, Dr. Spangehl discusses the rationale for the technique and describes the results from the 2 studies in more detail. Dr. Clarke presents a video demonstration of the steps in the technique.

    Click the image above to watch the video article.


    1. Estes CS, Beauchamp CP, Clarke HD, Spangehl MJ. A two-stage retention débridement protocol for acute periprosthetic joint infections. Clin Orthop Relat Res. 2010 Aug;468(8):2029-38. doi: 10.1007/s11999-010-1293-9.