Orthopaedic Knowledge Update®: Musculoskeletal Infection 2 Print + Ebook (AAOS - American Academy of Orthopaedic Surgeons)

Chapter 16: Surgical Treatment of Hip and Knee Prosthetic Joint Infections

1.5-stage procedures for PJI are becoming more common and likely are the natural progression for some surgeons to move toward single-stage revisions. Single-stage revi sions are popular outside of North America but have become more prevalent at some centers within the United States. For the appropriately indicated patient (good host, known nonresistant organism, healthy soft-tissue envelope), these procedures are successful and more cost effective. Finally, salvage procedures should always remain an option in poor hosts, for which repeated sur geries add morbidity, with limited potential for success. KEY STUDY POINTS • Treatment for hip and knee PJI is usually surgical, with varying options available. • DAIR is the least-invasive surgical option with the greatest risk for infection recurrence, but is a good option in patients with an acute infection, a nonre sistant organism, and a good host. • Two-stage revision is still the standard treatment for PJI that has the highest rate of infection control. • Single-stage and 1.5-stage revisions are becoming more common and can have better outcomes and cost as the techniques and patient selection pro cesses are refined. 1. Chotanaphuti T, Courtney PM, Fram B, et al: Hip and knee section, treatment, algorithm: Proceedings of international consensus on orthopedic infections. J Arthroplasty 2019;34(2 suppl):S393-S397. This is an article on the proceedings of the ICM, with liter ature review. 2. Johns BP, Loewenthal MR, Davis JS, Dewar DC: Open debridement is superior to arthroscopic debridement for the infected total knee arthroplasty. J Arthroplasty 2020;35(12):3716-3723. This retrospective cohort study evaluated open DAIR pro cedures in 96 patients and arthroscopic DAIR procedures in 45 patients and found that the success rates were 45% and 16%, respectively. Level of evidence: IV. 3. Shohat N, Goswami K, Tan TL, et al: 2020 Frank Stinchfield Award: Identifying who will fail following irrigation and debridement for prosthetic joint infection. Bone Joint J 2020;102-B(7 suppl B):11-19. A machine learning algorithm analyzed 1,174 patients retro spectively to predict failure of a DAIR procedure. Variables associated with failure were serum C-reactive protein levels, positive blood cultures, an indication for index arthroplasty other than osteoarthritis, not exchanging the modular com ponents, the use of immunosuppressive medication, late acute ANNOTATED REFERENCES

(hematogenous) infections, methicillin-resistant S aureus infection, overlying skin infection, polymicrobial infection, and older age. Level of evidence: IV. 4. Argenson JN, Arndt M, Babis G, et al: Hip and knee sec tion, treatment, debridement and retention of implant: Proceedings of international consensus on orthopedic infec tions. J Arthroplasty 2019;34(2 suppl):S399-S419. This is an article on the proceedings of the ICM, with liter ature review. 5. Shah NB, Hersh BL, Kreger A, et al: Benefits and adverse events associated with extended antibiotic use in total knee arthroplasty periprosthetic joint infection. Clin Infect Dis 2020;70(4):559-565. A retrospective review of 108 patients who underwent treatment for PJI. Fifty-one of the 108 patients received an extended course of antibiotics treatment. A multivariate anal ysis determined that extended antibiotic therapy for longer than 6 weeks was an independent predictor of success. Level of evidence: IV. 6. Barry JJ, Geary MB, Riesgo AM, Odum SM, Fehring TK, Springer BD: Irrigation and debridement with chronic anti biotic suppression is as effective as 2-stage exchange in revi sion total knee arthroplasty with extensive instrumentation. J Bone Joint Surg Am 2021;103(1):53-63. In this study, 56 patients who underwent a DAIR procedure were compared with 31 patients who underwent a two-stage revision. The DAIR cohort had better patient function with no difference in reinfection. Surgical treatment was deter mined by the surgeon, and the DAIR cohort was on lifetime antibiotic suppression. Level of evidence: III. 7. Klare CM, Fortney TA, Kahng PW, Cox AP, Keeney BJ, Moschetti WE: Prognostic factors for success after irriga tion and debridement with modular component exchange for infected total knee arthroplasty. J Arthroplasty 2018;33(7):2240-2245. Retrospective cohort study reporting the outcome of 99 patients after irrigation and débridement with modular com ponent exchange. They report at 35% reoperation rate at average 2.6 year follow up. Level of evidence: IV. 8. Gardner J, Gioe TJ, Tatman P: Can this prosthesis be saved?: Implant salvage attempts in infected primary TKA. Clin Orthop Relat Res 2011;469(4):970-976. 9. Bradbury T, Fehring TK, Taunton M, et al: The fate of acute methicillin-resistant Staphylococcus aureus peri prosthetic knee infections treated by open debridement and retention of components. J Arthroplasty 2009;24(6 suppl):101-104. 10. Wouthuyzen-Bakker M, Sebillotte M, Lomas J, et al: Timing of implant-removal in late acute periprosthetic joint infection: A multicenter observational study. J Infect 2019;79(3):199-205. In this multicenter retrospective review of 445 patients, 340 of those who underwent DAIR demonstrated that a CRIME80 score greater than 3 is associated with DAIR treatment failure. Level of evidence: IV.

Section 4: Prosthetic Joint Infections

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Orthopaedic Knowledge Update ® : Musculoskeletal Infection 2