Authors: Estes C, Beauchamp C, Clarke H, Spangehl M, Phoenix, AZ
Title: A Retention Debridement Protocol for the Treatment of Acute Periprosthetic Joint Infections
Purpose: In 2002, a retention debridement protocol for the treatment of acute periprosthetic total joint infections was developed at our institution. This study was conducted in order to quantify the success rate of this procedure.
Methods: A review of all patients treated with this technique was performed. Inclusion criteria include: 1) At least 1 of 4 diagnostic criteria for infection met (see Table 1); 2) Infection onset to debridement interval less than 28 days; 3) Mechanically stable components at debridement; 4) Minimum follow-up of 6 months beyond the discontinuation of all antibiotics or 6 months from the time of initial surgical debridement for those treated with prophylactic suppressive antibiotics. Exclusion criteria include: 1) Prior history of periprosthetic infection in the involved joint; 2) Missed postoperative infections (This group includes patients with infections diagnosed greater than 4 weeks postoperatively) The treatment protocol consists of two-stage open retention debridement. During stage I, all modular components are removed and sterilized. A thorough debridement is performed. The joint is irrigated and the sterilized modular components are replaced. Finally, high-dose antibiotic-impregnated cement beads are placed in the joint space and the wound is closed. The patient returns to the operating room 3-7 days later for the second-stage debridement. At this time a repeat debridement is performed, the beads are removed and new modular parts are inserted. Intravenous antibiotics are employed for 6 weeks. Depending on the clinical situation, selective patients are continued with long-term antibiotic suppression. Treatment failure was defined as recurrence of infection requiring additional surgery or clinically apparent infection diagnosed with a positive aspiration and treated with long-term antibiotic suppression. Primary outcomes reported include infection cure rate and number of patients treated with long-term, prophylactic antibiotic suppression without signs of recurrence (infection control rate).
Results: Twenty-four joint infections met the inclusion criteria with an average follow-up of 24 months (range 6-80 months). One patient (4%) was found to have persistent infection. There were no failures in the acute postoperative group (0/4). There was 1 failure in the acute hematogenous group (1/20). Of the 23 patients without evidence of persistent infection, 13 (56.5%) patients are no longer on antibiotics and are considered cured of their infection. However, 10 (43.5%) compromised hosts were treated with long-term antibiotics. Despite no clinical evidence of ongoing infection in these 10 patients, we consider their infection "controlled".Results were also calculated for the 7 patients with infection duration greater than 28 days treated with this protocol. Four (57%) were treated successfully, two of whom were kept on long-term antibiotics.
Discuassion and Conclusion: Historically, the average success rate of retention debridement for the treatment of acute periprosthetic infections is approximately 63%. The data presented here compares favorably with an overall success rate of 96%. Of the successfully treated infections, 56.5% are no longer on antibiotics and considered "cured." Forty-three point five percent were treated with prophylactic long-term antibiotics and are considered "controlled."