Timing of implant-removal in late acute periprosthetic joint infection: A multicenter observational study

doi:10.1016/j.jinf.2019.07.003

Journal of Infection

Volume 79, Issue 3, September 2019, Pages 199-205

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https://doi.org/10.1016/j.jinf.2019.07.003 Get rights and content

Highlights

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Patients with late acute PJI have a better outcome when treated with revision surgery instead of DAIR.
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Patients with late acute PJI can be selected for revision surgery according to the preoperative risk of DAIR failure defined by the CRIME80 score.
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The causative microorganism and its susceptibility to antibiotics should ideally be taken into account as well to decide for the best surgical approach.

Abstract

Objectives

We evaluated the treatment outcome in late acute (LA) periprosthetic joint infections (PJI) treated with debridement and implant retention (DAIR) versus implant removal.

Methods

In a large multicenter study, LA PJIs of the hip and knee were retrospectively evaluated. Failure was defined as: PJI related death, prosthesis removal or the need for suppressive antibiotic therapy. LA PJI was defined as acute symptoms <3 weeks in patients more than 3 months after the index surgery and with a history of normal joint function.

Results

445 patients were included, comprising 340 cases treated with DAIR and 105 cases treated with implant removal (19% one-stage revision (n = 20), 74.3% two-stage revision (n = 78) and 6.7% definitive implant removal (n = 7). Overall failure in patients treated with DAIR was 45.0% (153/340) compared to 24.8% (26/105) for implant removal (p < 0.001). Difference in failure rate remained after 1:1 propensity-score matching. A preoperative CRIME80-score ≥3 (OR 2.9), PJI caused by S. aureus (OR 1.8) and implant retention (OR 3.1) were independent predictors for failure in the multivariate analysis.

Conclusion

DAIR is a viable surgical treatment for most patients with LA PJI, but implant removal should be considered in a subset of patients, especially in those with a CRIME80-score ≥3.

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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Periprosthetic joint infection (PJI) following unicompartmental knee replacement (UKR) is an uncommon, yet serious, complication. There is a paucity of evidence regarding the effectiveness of Debridement-Antibiotics-and-Implant-Retention (DAIR) in this setting. The aim of this study is to investigate the effectiveness of DAIR for acute UKR PJI.
Between 2006 and 2019, 5195 UKR were performed at our institution. Over this period, sixteen patients underwent DAIR for early, acute PJI. All patients met MSIS PJI diagnostic criteria. The median age at DAIR was 67 years (range 40–73) and 12 patients were male (75.0%). The median time to DAIR was 24 days (range 6–60). Patients were followed up for a median of 6.5 years (range1.4–10.5) following DAIR.
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Early, acute PJI after UKR is rare. DAIR had a moderate success rate, with infection-free survivorship of 57% at 5 years. Those successfully treated with DAIR had excellent functional outcome and implant survival.
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The diagnosis of periprosthetic joint infection (PJI) remains a labor-intensive and challenging issue, with life-threatening complications associated with misdiagnoses. Superior diagnostic approaches are therefore urgently needed, and synovial biomarkers are gaining substantial attention in this capacity. A new aptamer-based sandwich assay was developed where the aptamer probes specific to one such biomarker, alpha-defensin human neutrophil protein 1 (HNP 1), was integrated herein into a new microfluidic platform. The magnetic beads coated with the primary aptamer probe were able to bind the target protein with high affinity and high specificity in synovial fluid and a fluorescent-labelled secondary aptamer were further used to quantify HNP 1 in a sandwich approach. Up to four clinical samples with low volume (∼50 μL each) in a much faster assay including detection within <60 min with 100% accuracy (with totally 13 clinical samples without the need of sample pretreatment) through the use of the aptamer-based sandwich assay were automatically detected on a single chip. The wide dynamic range of this compact device, 0.5–100 mg/L, highlights its utility for future PJI diagnostics in the clinic.
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The current standard of care for implant infections is a combination of aggressive surgical debridement, target and systemic antibiotic regimens. However, the risk of bacterial infection for bone plates remains as high as 5-10% [1] and up to 30% in open fractures [2–4]. The colonization of bacteria and the formation of biofilms on the implant surface are the main causes of fracture site infection, which decreases antibiotic efficacy and evades immune system attack.
Infection remains the devastating complications associated with surgical fixation of bones fractured during trauma. In this study, we report a low-alloyed Zn-Mg-Ag that simultaneously has optimized strength degeneration profiles during degradation, outstanding antibacterial efficacy and osteogenic activity. Our results showed that Zn-0.05Mg-0.1Ag alloy had favorable mechanical properties (UTS: 247.8 ± 1.6 MPa, Elong.: 35 ± 2.2 %) and presented a better hold of mechanical integrity than pure Zn during 28 days corrosion, 2.6 % vs. 18.7 % reduction. After one-year of natural aging, the alloy still preserved an elongation of 24.07 ± 3.84 %. As verified by microbial cultures, Zn-0.05Mg-0.1Ag alloy demonstrated high antibacterial performance against Gram-positive and Gram-negative strains, as well as antibiotic-resistant strains (MRSA) in vitro and in vivo due to the synergistic antibacterial actions of Zn²⁺ and Ag⁺. Meanwhile, Zn-Mg-Ag alloy also exhibited enhanced viability, osteogenic differentiation, and gene expressions of osteoblasts in vitro, as well as promoted osteogenic activity than pure Zn in the femoral condyle defect repair model. The co-releasing of Zn, Mg and Ag ions did not induce toxic side effects. Collectively, low alloyed Zn-0.05Mg-0.1Ag indicated long-lasting mechanical integrity during degradation, and presented the ability to synergistically inhibit bacteria and promote osteogenesis, possessing tremendous potential in treating implant-associated infections.
Infection after fracture fixation (IAFF) remains the most common and serious side effects of orthopedic surgery. Additionally, widespread antibiotic use contributes to the development of multi-drug resistant bacteria such as methicillin-resistant staphylococcus aureus (MRSA), which exacerbates IAFF treatment and prevention. IAFF treatment and prevention remain clinically challenging, so implants with dual antibacterial and osteogenic functions are in high demand. The antibacterial efficacy and osteogenic activity of low-alloyed Zn-Mg-Ag (≤0.1 wt.% Mg, Ag) alloys were investigated in vitro and in vivo. The results showed that micro addition of Mg and Ag could significantly improve osseointegration function, mechanical properties, and antibacterial performance. These quantification findings shed new light on the development and understanding of dual functional Zn-based orthopedic implants.
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Coagulase-negative staphylococci (CoNS) are biofilm-producing pathogens whose role in periprosthetic joint infection (PJI) is increasing. There is little data on the prognosis and treatment considerations in the setting of PJI. We sought to evaluate the clinical characteristics, outcomes, and complications in these patients.
This is a retrospective cohort study of adult patients at a single tertiary medical center from 2009 to 2020 with culture-proven CoNS PJI after total knee arthroplasty, as diagnosed by Musculoskeletal Infection Society criteria. The primary outcome was treatment success, with failure defined as recurrent CoNS PJI, recurrent PJI with a new pathogen, and/or chronic oral antibiotic suppression at one year postoperatively.
We identified 55 patients with a CoNS total knee arthroplasty PJI with a mean follow-up of 29.8 months (SD: 16.3 months). The most commonly isolated organism was Staphylococcus epidermidis (n = 36, 65.5%). The overall prevalence of methicillin resistance was 63%. Surgical treatment included surgical debridement, antibiotics, and implant retention in 25 (45.5%) cases and two-stage revision (22 articulating and eight static antibiotic-impregnated spacers). At one-year follow-up, only 47% of patients had successful management of their infection. The surgical debridement, antibiotics, and implant retention cohort had the higher rate of treatment failure (60.0%) compared to two-stage revision (46.7%).
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Timing of implant-removal in late acute periprosthetic joint infection: A multicenter observational study

Highlights

Abstract

Objectives

Methods

Results

Conclusion

Introduction

Section snippets

Study design and inclusion criteria

Patient characteristics implant retention versus implant removal

Discussion

Collaborators

Conflict of Interest

Acknowledgments

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arhroplasty

J Arthroplasty

J Arthroplasty

Clin Microbiol Infect

J Infect

Current concepts in the management of prosthetic joint infection

Intern Med J

The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization

J Bone Joint Surg Am

Functional outcomes of acutely infected knee arthroplasty: a comparison of different surgical treatment options

Can J Surg