Timing of implant-removal in late acute periprosthetic joint infection: A multicenter observational study
Introduction
A periprosthetic joint infection (PJI) is a serious complication after joint arthroplasty and is accompanied by increased morbidity and mortality.1, 2 Clinical outcome is highly dependent on host related factors, clinical characteristics, the causative microorganism, and the applied antimicrobial therapy and surgical techniques.4,10,11 Therefore, optimizing treatment and composing tailored strategies are crucial to improve clinical outcome. We recently demonstrated that late acute PJIs have a relatively high failure rate when treated with surgical debridement and implant retention (DAIR).21 Failure seems to be most prominent when the infection is caused by Staphylococcus aureus, with reported failures of around 50%, which is higher than described for early acute/post-surgical PJIs.13,17,19, 20, 21 Moreover, several preoperative variables, defined according to the CRIME80-score (i.e. C-reactive protein >150 mg/L, Chronic obstructive pulmonary disease, Rheumatoid arthritis, fracture as Indication for the prosthesis, Male gender, not Exchanging the mobile components during debridement and an age above 80 years), expose patients to a higher failure risk as well.21 Despite the relatively high failure rate, a DAIR procedure is still recommended as the first line surgical approach for all acute PJIs if the implant is well fixed and if anti-biofilm antibiotics can be applied.15 However, revision of the prosthetic implant might be a better treatment modality in a subset of patients with late acute infections.17 For this reason, we compared the clinical outcome of patients with a late acute PJI treated with DAIR or immediate implant removal in a large multicenter observational cohort study and identified those patients who may benefit more from implant removal instead of DAIR. Propensity score matching was applied to correct for selection bias between both surgical techniques.
Section snippets
Study design and inclusion criteria
We performed an international multicenter retrospective observational study in which data of all consecutive patients with a late acute PJI of the hip or knee between January 2005 and December 2015 were collected. If centers were not able to provide cases during the complete study period, a minimum of at least 10 consecutive cases was required to participate in the study. Late acute PJI was defined as patients with a history of normal joint function and who developed a sudden onset of symptoms
Patient characteristics implant retention versus implant removal
A total of 445 patients from 27 centers were included in the analysis. Table 1 shows the preoperative differences between patients with late acute PJI treated with DAIR and implant retention (n = 340) versus patients in whom the implant was removed (n = 105). In the implant removal group, one-stage revision was performed in 20 cases (19.0%), two-stage revision in 78 cases (74.3%), and definitive implant removal in 7 cases (6.7%) (Girdlestone for hips [n = 5] and arthrodesis for knees [n = 2]).
Discussion
Current international guidelines still recommend a DAIR procedure for all acute PJIs when the implant is well fixed and an antibiotic regimen potent against biofilm infection can be administered.15 However, it is important to identify patients who have a high risk for DAIR failure prior to surgery in order to select the best surgical option. In line with this, using the same cohort of patients, we recently defined a preoperative risk score (CRIME80-score) to identify such high-risk patients for
Collaborators
Anne Gougeon, Harold Common, Anne Méheut, Joan Gomez-Junyent, Majd Tarabichi, Aybegum Demirturk, Taiana Ribeiro, Emerson Honda, Giancarlo Polesello, Paul Jutte, Joris Ploegmakers, Claudia Löwik, Guillem Bori, Laura Morata, Luis Lozano, Mikel Mancheño, Fernando Chaves, David Smolders, Phongsakone Inthavong, Adrian Taylor, Marc Digumber, Bernadette Genevieve Pfang, Eduard Tornero, Encarna Moreno, Ulrich Nöth, Cynthia Rivero, Pere Coll, Xavier Crusi, Isabel Mur, Juan Dapás, Pierre Tattevin, Jaime
Conflict of Interest
None.
Acknowledgments
None.
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