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    PRACTICE PEARLS: A Role for Debridement of Acute Infection

    Dr. Henry Clarke reviews the technique he and his colleagues use to eradicate early infection in total joint arthroplasty patients.

    Periprosthetic joint infection (PJI) is one of the most devastating complications following joint replacement surgery. The current “gold standard” for treating infection is a 2-stage removal reimplantation procedure.

    But is that the best treatment option for the acute PJI that presents in less than 3 weeks after the original procedure? Or is there another way to effectively manage these patients?

    Yes, there is, according to Henry D. Clarke, MD, from Mayo Clinic in Phoenix, Arizona, who says open debridement with prosthesis retention may be that option.

    At ICJR’s Instructional Course at the 9th Congress of the Chinese Association of Orthopaedic Surgeons, Dr. Clarke reviewed the literature, indications, and technical pearls for this debridement technique.

    Open debridement with prosthesis retention can be either a 1-stage procedure with polyethylene exchange or a 2-stage procedure with polyethylene exchange and antibiotic beads, Dr. Clarke said.

    The indications for either procedures are:

    • Acute post-operative infection
    • Acute hematogenous infection
    • A well-fixed prosthesis
    • Duration of symptoms less than 3 weeks

    The type of infectious organism may influence the choice of treatment.

    Historically, the results of 1-stage open debridement with prosthesis retention have been less than ideal, Dr. Clarke said, with at best a 50% chance of eradicating the infection. [1]

    Later research from the Mayo Clinic [2] showed slightly better results with 60% success at 2 year follow-up. This study also concluded that duration of symptoms of less than 7 days was associated with an increased chance of success.

    A 2010 study from The Rothman institute [3] showed only a 44% success rate, however. And a multi-center study from 2009 [4] looked at more-virulent methicillin-resistant Staphylococcus aureus (MRSA) infections in total knee arthroplasty and showed an 84% failure rate at 2 years.

    So if there is a 50% chance of eradicating the infection with a 1-stage procedure, why not try it on all patients? The problem, Dr. Clarke said, is that patients who fail a 1-stage open debridement do not do as well when they are later treated with a 2-stage revision with implant removal and antibiotic cement spacers. [5]

    In other words, 1-stage debridement “burns bridges” for the subsequent salvage procedure.

    Because of the historically poor results of 1-stage open debridement with prosthesis retention, Dr. Clarke and his colleagues at Mayo Clinic developed a new protocol for patients who present with acute infection: the 2-stage debridement with antibiotic beads protocol.

    This protocol is used in patients presenting with acute PJI within 4 weeks of the original surgery. The diagnosis is based on presentation:

    • Erythrocyte sedimentation rate, C-reactive protein, and synovial white cell count
    • Fluid analyzed for crystals
    • Cultures, although there often is not enough time to wait for cultures

    The initial experience with this protocol was published in 2010 [6]. With a mean follow-up of 3.5 years, the study had no reoperations and a 90% success rate (18 of 20 patients), with no evidence of active infection. Two patients who were considered failures received suppressive antibiotic treatment.

    With this 2-stage technique, the patient is taken to surgery in an expedited manner, preferably 12 to 24 hours after presentation. Dr. Clarke explained the steps of the technique:

    • Perform an aggressive, thorough debridement and synovectomy.
    • Remove all modular parts of the prosthesis and either flash sterilize or soak and scrub them in an aseptic solution such as povidone-iodine.
    • Thoroughly scrub the implants with a sterile toothbrush to remove the biofilm contaminant.
    • Soak the joint for 3 to 5 minutes using copious amounts of povidone-iodine irrigation in a concentration of 35 mL of povidone-iodine in 1L of normal saline, followed by a 3- to 5-minute soak using a chlorhexidine solution.
    • Reinsert the cleaned implants. Dr. Clarke noted that it is important to record the component sizes so those sizes are available for the second stage of the procedure.
    • Add high-dose antibiotic beads to the joint space. These beads, which Dr. Clarke prefers to create by hand, are made from 1 batch of bone cement with 3.6 grams of gentamicin or tobramycin, 3 grams of vancomycin, and 2 grams of cefazolin.
    • Count the number of beads placed in the joint to ensure all beads are retrieved during the second stage.
    • Close the arthrotomy with a running suture.
    • Take the patient back to the operating room 3 to 7 days later. Remove the antibiotic bead, scrub the implants again, repeat debridement and irrigation, and insert new modular parts.

    Dr. Clarke believes one of the keys to the success of this technique is that it is possible to obtain very high levels of local antibiotics. Fluid obtained from patients in the study showed local antibiotic levels 10 to 100 times higher than what is possible with intravenous (IV) antibiotics.

    After the second debridement stage, patients are managed with 6 to 8 weeks of IV antibiotics followed by 3 to 6 months of oral antibiotics.

    Dr. Clarke and his colleagues recently reviewed all patients treated with the 2-stage technique between 2002 and 2014. This patient cohort was similar to the patients in the original study, with 36 of 44 knees having an acute hematogenous infection and 8 having an immediate postoperative infection. A variety of organisms were cultured, including 7 MRSA infections.

    The success rate of this follow-up study mirrors the original study: 86% success rate, with a mean follow-up of 43.6 months. In this cohort of patients, it was clear that early intervention led to a higher chance of a successful outcome.

    Dr. Clarke summarized these findings: Using the 2-stage open debridement with high-dose antibiotic beads, it is possible to achieve a success rate of 80% to 90% in the treatment of PJI following primary and revision procedures.

    The time from onset of symptoms to first debridement influences the chance of a successful outcome, as the treatment is significantly more likely to be successful when surgery is performed within 5 days of the onset of symptoms.

    Click the image above to watch Dr. Clarke’s presentation.

    References

    1. Tattevin P, Cremieux AC, Pottier P, et al. Prosthetic joint infection: when can prosthesis salvage be considered? Clin Infect Dis. 1999;29:292–5
    2. Marculescu CE, Berbari EF, Hanssen AD, et al. Outcome of prosthetic joint infections treated with debridement and retention of components. Clin. Infect. Dis. 2006 42:471–478.
    3. Azzam KA, Seeley M, Ghanem E, Austin MS, Purtill JJ, Parvizi J (2010) Irrigation and debridement in the management of prosthetic joint infection: traditional indications revisited. J. Arthroplasty 25(7), 2010, 1022-1027.
    4. 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, 24:101–104
    5. Sherrell JC, Fehring TK, Odum S, Hansen E, Zmistowski B, Dennos A, Kalore N The Chitranjan Ranawat Award: fate of two-stage reimplantation after failed irrigation and debridement for periprosthetic knee infection. Clin Orthop Related Res2011 469(1): 18-25
    6. 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): 2029–2038.