Implantation of Resorbable Gentamicin Sponges in Addition to Irrigation and Debridement in 34 Patients with Infection Complicating Total Hip Arthroplasty

Abstract

We evaluated a prosthesis-retaining treatment protocol for prosthetic joint infection in patients presenting at a mean of 116 days (range 10-1216 days) after primary arthroplasty. Our regime involved irrigation and debridement followed by implantation of biodegradable gentamicin loaded sponges which do not require removal after implantation. Of 34 patients with a deep infection after total hip arthroplasty, Twenty-five were treated successfully, with a mean follow-up of 35 months. There were no permanent complications. This success rate is comparable to earlier studies. Early initiation of treatment demonstrated a tendency for better results, and late chronic infections had a worse outcome. Because the sponges are degradable, a number of further surgical procedures were avoided.

Treatment of acute periprosthetic infections with prosthesis retention: Review of current concepts

“…The duration of the presenting symptoms and the time after initial surgery are also important contributors to treatment success, or failure. Some studies state that treatment outcomes decline when the patients undergo a debridement a mere > 2 d after onset of symptoms [79] , whereas other studies claim the cutoff is at 7 d [53] , 21 d [47] or even 28 d [62,80] . The time after index surgery showed an even greater scope, ranging from 15 d [81] to two years [82] .…”

“…resulting in high concentrations (approximately 1000 µg/ mL) for the first 40 h. Up to 3-5 sponges can be used in patients, without reaching toxic serum concentrations [61] . A disadvantage of gentamicin sponges might be prolonged and increased wound secretion [59] The clinical success rate of antibiotic loaded sponges in DAIR treatment for hip PJI has only been reported in one retrospective study, with a success rate of 70% [62] . Local continuous irrigation with an antibiotic pump or catheter is another option for local delivery.…”

“…The definition of DAIR treatment failure, just like the PJI definition, is not uniformly well described in the literature. Most studies do, however, consider DAIR as having failed when one or more of the following criteria are met after both surgical and medical treatment [15,62,52,83] :…”

“…Peel et al [76] specifically state MRSA infections as leading to a significant decrease in treatment success whereas Kuiper et al [53] report that coagulase negative Staphylococcus Azzam et al [6] Retrospective cohort -104 51 53 -46 44% 68 Odum et al [17] Retrospective cohort -150 53 97 -46 31% n.m. 1 Byren et al [43] Retrospective cohort -112 52 51 9 92 82% 27 Lora Tamayo et al [44] Retrospective cohort Staphylococcus aureus PJI 345 146 195 4 199 55% n.m. Cobo et al [46] Prospective cohort Early infections (< 30 d) 117 69 53 17 67 57% 24 Buller et al [47] Retrospective cohort -309 62 247 -160 52% 34 Koyonos et al [48] Retrospective cohort -138 60 78 -48 35% 54 El Helou et al [73] Prospective cohort compared to 2 retrospective cohorts Staphylococcal PJI 101 40 61 -69 68% 12 Tornero et al [81] Retrospective resulting from PJI. In the majority of the studies, after DAIR failure, most patients were treated with two-stage revision, but one-stage revision, resection arthroplasty without reimplantation and chronic suppression with antibiotics were described as well [15,16,52,62,[83][84][85] . One-stage and two-stage revisions are preferred if function and eradication are important, but the patient must then endure one or more additional elaborate surgical procedures.…”

“…If patient health status is poor, or his or her expectations are not high, an acceptable situation may be achieved with resection arthroplasty (Girdlestone arthroplasty) or the use of chronic suppressive antibiotics [2] . The choice of treatment after DAIR failure in the abovementioned cohorts was based on individual patient characteristics, if mentioned [15,62] . The recent IDSA (Infectious Diseases Society of America) guidelines advise individual judgment in all cases, but endorse the use of treatment algorithms when DAIR has failed, since it has been proven that their use increases treatment success [2] .…”