Local antibiotic treatment with calcium sulfate as carrier material improves the outcome of debridement, antibiotics, and implant retention procedures for periprosthetic joint infections after hip arthroplasty – a retrospective study

Abstract

Abstract. Purpose: Debridement, antibiotics, and implant retention (DAIR) is an established treatment modality in periprosthetic joint infections (PJIs), but success rates vary. This study compared the success of DAIR for PJIs after a total hip arthroplasty (THA), with or without local antibiotic delivery with CaSO4 as the carrier material. Methods: A retrospective review of DAIR for PJIs after THA performed between 2010 and 2018, including 41 patients is conducted. A total of 27 patients were treated by DAIR with local antibiotics with CaSO4 as the carrier material, and 14 patients were treated by a standard DAIR. The endpoints were treatment failure, defined as the need for a reoperation, either a second DAIR or a prosthesis removal or exchange due to persistent or recurrent infection, the initiation of a long-term suppressive antibiotic treatment, or death related to infection. Results: Considering any reoperation as an outcome, 11 of 14 cases treated without AB-CaSO4 (79 %) and 4 of the 27 cases treated with AB-CaSO4 failed (15 %). Considering revision as an outcome, 9 out of 14 cases treated without AB-CaSO4 (64 %) and 4 of the 27 cases treated with AB-CaSO4 (15 %) failed. A Kaplan–Meier survival analysis showed that local antibiotic delivery with CaSO4 as the carrier material led to a significantly longer infection-free survival, considering any surgical revision (p<0.0001; hazard ratio 8.9 (95 % CI 2.8–28.2)) or revision with component exchange (p=0.0015; hazard ratio 5.6 (95 % CI 1.7–18.2)) as the endpoint. Conclusion: The addition of local antibiotics with CaSO4 as the carrier material to DAIR for PJIs after THA significantly increases success rates, such as infection-free survival, any reoperation, and revision with component exchange in particular.

Wound fluid ceftriaxone concentrations after local application with calcium sulphate as carrier material in the treatment of orthopaedic device-associated hip infections

“… 5 , 13 , 14 , 16 In addition, the mode of action of these antibiotics may be inadequate for local delivery, as it requires an oxygen-dependent active transport against the proton gradient, which is particularly unfavourable for treating bacteria with low metabolic activity in an acidic environment. 58 The addition of antibiotic-loaded CaSO 4 to standard of care did greatly improve outcomes in two studies examining debridement, antibiotics and implant retention procedures in hip 22 or knee 54 PJI, but had no effect in two other studies. 59 , 60 A potential explanation is insufficient quantities or concentrations.…”

“…Uncontrolled infection may also cause prolonged wound drainage and require reoperations, a risk mitigated by the local application of antibiotic-loaded CaSO 4 . 22 Placement of a subcutaneous suction drain may allow the skin to heal without prolonged oozing, without aspirating relevant quantities of the antibiotic placed in the depth of a hip. As mentioned, we remove this drain on day 5 at the latest.…”

“… 53 This, however, may have been due to application of inappropriate antibiotics as well as poor carrier materials. 22 , 54 The historically used standard carrier material PMMA is non-resorbable and may serve as substrate for biofilm formation, despite active antibiotic drug release. 55 , 56 PMMA may have to be removed for mechanical reasons, thus requiring reoperations with consecutive supplementary risks negating any advantages of local delivery.…”

“… 17 Furthermore, the concentrations are below the local toxicity threshold and therefore are not expected to have any negative impact on regenerative capacity of the tissues. First clinical results for antibiotic-loaded CaSO 4 are encouraging, 22 , 54 but further studies are necessary to determine the ceftriaxone time-concentration profiles necessary for eradication of the various bacteria causing ODAIs and their associated biofilm.…”

“… 12 , 17 Furthermore, it has excellent activity against streptococci and covers a large portion of Gram-negative bacterial species, offering interesting new treatment options. 18 - 21 We aimed to study the release kinetics of CaSO 4 loaded with ceftriaxone in various ODAIs when local application of the well-established vancomycin-loaded CaSO 4 8 , 22 was not deemed adequate.…”