Washout and Debridement: for Acutely Infected TKR

- See: TKR Infection Menu

- debridement w/o component removal:
    - see debridement and washout of infected THR
    - IV antibiotic therapy has limited success in treatment of infected TKR; managed with wound debridement, polyethyene exchange,
             application of temporary antibiotic beads, and IV antibiotics;
    - acute hematogenous infection:
             - early acute hematogenous infection occurring around previously secure & well functioning prosthesis;
                    - Segawa et al: 5/7 hematogenous infection treated successfully with debridement, IV antibiotics, and prosthetic retention;
                    - Arthroscopic irrigation and debridement of infected total knee arthroplasty: report of two cases.
                    - Infection After Total Knee Arthroplasty. A Retrospective Study of the Treatment of Eighty-one Infections.

    - post operative infection: (see calcium sulfate vance beads)
             - post operative infection may be successfully treated w/ ATB and debridement, if delay of treatment is less than 3-4 weeks;
             - in chronic infections, infectious process often extends to bone-cement interface, resulting in loosening and resistent infection;
             - good outcomes:
                    - Estes, et al: 
                            -  initial débridement with prosthesis retention and placement of antibiotic-impregnated cement beads
                            - second débridement within 7 days, at which time the beads are removed and new modular parts inserted
                            - 2 / 20 patients had persistent infection
                            - no failures in the acute postoperative group (0 of 2) and two of 18 in the acute hematogenous group   
                            - A Two-stage Retention Débridement Protocol for Acute Periprosthetic Joint Infections 
                    - Tintle, et al:
                            - serial irrigation and debridements, polyethylene exchange when applicable, interval placement and exchange
                                      of tobramycin/vancomycin polymethylmethacrylate beads and 6 weeks of IV antibiotics
                            - authors noted all infections were eradicated while retaining prosthetic components;
                            - Prosthesis retention, serial debridement, and antibiotic bead use for the treatment of infection following total joint arthroplasty.
                    - Is There Still a Role for Irrigation and Debridement With Liner Exchange in Acute Periprosthetic Total Knee Infection?

             - intermediate outcomes:
                    -
Success Rates of  (I+D) and Prosthesis Retention for Treatment of Acute Deep Prosthetic Infections
             - poor outcomes:
                    - Segawa, et al: 5 out of 10 deep infections which were diagnosed in the acute postoperative period were successfully
                    - Fehring, et al: 54 of 86 patients (63%) failed;
                    - Koyonos, et al: infection control was not achieved in 90/136 joints (65%) - staph was risk factor for failure;
                    - Gardner, et al (2011):  25 / 44 patients (57%) failed ODPE (open debridement and liner exchange);
                    - Choi, et al: 31% - higher rate of success with non-S. aureus infection and was higher with polyethylene exchange;
                    - Van Kleunen, et al: salvage was successful in 8/13 joints with deep infection; polymicrobial infections had poor results;
                    - Marculescu, et al: 2-year survival rate free of treatment failure was 60% 
                    - Hsieh, et al: comparing gram positive post op joint infection, treating gram negative PJI with debridement was associated
                                with a lower 2-year cumulative probability of success (27% vs. 47%, p= 0.0016); 
                    - Fehring, et al (2013): 63% failure rate;
                    - references
                             Infection After Total Knee Arthroplasty. A Retrospective Study of the Treatment of Eighty-one Infections.
                             Failure of Irrigation and Débridement for Early Postoperative Periprosthetic Infection
                             Infection Control Rate of Irrigation and Débridement for Periprosthetic Joint Infection
                             Can This Prosthesis Be Saved?: Implant Salvage Attempts in Infected Primary TKA
                             Can Implant Retention be Recommended for Treatment of Infected TKA?
                             Irrigation and Débridement and Prosthesis Retention for Treating Acute Periprosthetic Infections
                             Outcome of Prosthetic Joint Infections Treated with Debridement and Retention of Components
                             Gram-negative Prosthetic Joint Infections: Risk Factors and Outcome of Treatment
    - relative contra-indications:
             - success w/ gm negative infections is dismal and success w/ resistant staph infections is fair to poor;
    - management: (see antibiotics)
             - with definite infection, procede with open debridement, liner removal, and insertion of antibiotic spacer;
             - need for tissue biopsy cultures from the component membrane interface
                     - remember that in the case of biofilm, there may be minimal infection in joint fluid and capsule, and the main area of
                                infection will be over the component /bone-membrane interface;
                                - ref: A microbiological evaluation of 54 patients undergoing revision surgery due to prosthetic joint loosening.
             - antibiotic spacer is shaped similar to size and thickness of poly liner (apply when still soft - careful to not trespass into
                       poplieal space)
                       - rest of available space can be filled with cement





Methylene Blue–Guided Debridement as an Intraoperative Adjunct for the Surgical Treatment of Periprosthetic Joint Infection

Treatment of infection after total knee arthroplasty by débridement with retention of the components.

Open debridement of acute gram-positive infections after total knee arthroplasty.

Arthroscopic debridement of acute periprosthetic septic arthritis of the knee.

Multiple irrigation, debridement, and retention of components in infected total knee arthroplasty.

Prosthesis retention, serial debridement, and antibiotic bead use for the treatment of infection following total joint arthroplasty.

A Two-stage Retention Débridement Protocol for Acute Periprosthetic Joint Infections 

                    - consider postoperative articular antibiotic infusion



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Wednesday, September 13, 2017 8:37 am