Modular component exchange and outcome of DAIR for hip and knee periprosthetic joint infection

Gerritsen, Maxime; Khawar, Abdullah; Scheper, Henk; Wal, Robert van der; Schoones, Jan W; Boer, Mark de; Nelissen, Rob G H H; Pijls, Bart G

doi:10.1302/2633-1462.210.bjo-2021-0090.r1

Cited by 24 publications

(22 citation statements)

References 24 publications

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“…13,14 A recent systematic review, which included 6,630 patients, reported that the overall success rate of dAir after thA and tKA was 67%. 15 there was an improvement of outcome with the passage of time, without a significant difference between primary and revision arthroplasties. in a multicentre, retrospective study from new Zealand, Zhu et al 13 reported a success rate of dAir after primary tKA of 66% (71/107) after a mean of 6.9 years.…”

Section: Discussionmentioning

confidence: 80%

“…As previously described, the success rate of dAir was slightly lower after tKA in our cohort than after thA, but this difference was not statistically significant. 13,[15][16][17] because of the low sample size, we could not perform a robust subgroup analysis in an attempt to identify separate factors associated with failure for patients with a thA or tKA. we noted a higher bmi in patients who underwent a revision tKA.…”

Section: Discussionmentioning

confidence: 99%

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Debridement, antibiotics, and implant retention after revision arthroplasty

Veerman

Raessens

Telgt

et al. 2022

The Bone & Joint Journal

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Aims Debridement, antibiotics, and implant retention (DAIR) is a widely accepted form of surgical treatment for patients with an early periprosthetic joint infection (PJI) after primary arthroplasty. The outcome of DAIR after revision arthroplasty, however, has not been reported. The aim of this study was to report the success rate of DAIR after revision arthroplasty with a follow-up of two years. Methods This retrospective study, conducted at the Sint Maartenskliniek, Nijmegen, the Netherlands, included 88 patients who underwent DAIR within 90 days of revision total hip or total knee arthroplasty between 2012 and 2019. Details of the surgical procedures and PJI were collected. Univariate analysis and a subgroup analysis of the culture-positive group were performed. Kaplan-Meier survivorship curves were constructed. Results The overall success rate of DAIR, with respect to the retention of components and the cure of infection, was 68% after two years. DAIR performed with an interval of > 30 days after the index revision procedure (odds ratio (OR) 0.24 (95% confidence interval (CI) 0.08 to 0.72); p = 0.008), a repeated DAIR within 90 days (OR 0.37 (95% CI 0.14 to 0.97); p = 0.040), and the use of an immunosuppressive agent (OR 0.13 (95% CI 0.02 to 0.67); p = 0.012) were associated with a significantly reduced success rate. In the culture-positive group, a mismatch between the antibiotic treatment and the susceptibility of the organism was associated with a significantly lower success rate (OR 0.13 (95% CI 0.03 to 0.62); p = 0.007). Conclusion DAIR is an acceptable form of surgical treatment for patients with a suspected early PJI after revision arthroplasty of the hip or knee. DAIRs performed after a prolonged interval, multiple DAIRs, and antibiotic mismatches were significantly associated with an increased risk of failure. Optimization of the host immune response and the prevention of antibiotic mismatch are modifiable factors that may improve the outcome. The high rate of mismatches was an important finding, underlining the need for a review of the local microbiological data, which might improve the outcome. Cite this article: Bone Joint J 2022;104-B(4):464–471.

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Section: Discussionmentioning

confidence: 80%

Section: Discussionmentioning

confidence: 99%

Debridement, antibiotics, and implant retention after revision arthroplasty

Veerman

Raessens

Telgt

et al. 2022

The Bone & Joint Journal

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“…The practice of exchanging all mobile components and liners is considered to theoretically improve infection eradication by two means; first, to improve the exposure of the joint to aid debridement of all areas where a potential infectious focus is present, especially posterior aspects of the knee; 19 and second, replacing mobile parts to remove a potential site of bacterial adherence that cannot always be achieved by debridement and irrigation, limiting the bacterial load present in the joint. 15 Despite some research showing that replacing mobile components does not relate to improved outcomes, 27,30 a notable amount of literature reports significant improvements in implant survivability 4,19,28 and infection eradication in both early and late PJI. 18,28 Exchange of mobile components is an independent factor related to DAIR success.…”

Section: Component Exchangementioning

confidence: 99%

Truth or DAIR? A review of debridement, antibiotics and implant retention

2022

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Debridement, antibiotics and implant retention (DAIR) is a viable treatment option in early postoperative and acute haematogenous periprosthetic joint infections (PJIs) with a stable implant. Despite lower success rates compared to one- and two-stage revisions, DAIR maintains satisfactory outcomes in selected patient groups and, if successful, has similar functional outcomes to primary arthroplasty. DAIR remains an attractive treatment option, providing satisfactory outcomes with decreased healthcare costs, reduced surgical burden on the patient and shorter hospital stays. With success rates of 37-90%, various factors need to be considered when deciding on DAIR as the appropriate treatment option for PJI. The risk of DAIR failure needs to be weighed against the potential benefits of DAIR success. Factors that increase success rates include an open DAIR procedure performed for a low-virulence, antibiotic-sensitive organism, within a short duration between symptom onset and/or index surgery and DAIR. The procedure involves intraoperative exchange of mobile components and copious wound irrigation, followed by an appropriate antibiotic regimen for a minimum of six weeks that can be administered either intravenously or orally in a well-optimised host, without significant soft tissue defects or contraindications to surgery. Factors increasing the risk for DAIR failure include chronic/late PJIs with resistant organisms, especially methicillin-resistant Staphylococcus aureus (MRSA) in poor hosts with significant comorbidities, such as chronic obstructive pulmonary disease (COPD), liver cirrhosis, rheumatoid arthritis, advanced age > 80 years, patients with fracture indications for arthroplasty and those who cannot tolerate rifampicin- and fluoroquinolone-based antibiotic regimens. Unfortunately, there is no definitive factor to serve as an indication of whether DAIR will be successful, but with recent data showing that a failed DAIR procedure does not lower success in future staged revisions, then even in the face of a 50% success rate, DAIR can maintain its role as an initial treatment option in the management of PJIs

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“…4,6,7 Treatment of PJIs with DAIR is based on mechanical cleaning of the implant surface and subsequent antibiotic therapy. Presently, success rates vary from 60% to 80%, 6,8 which leaves room for improvement. It is therefore paramount that new treatments for PJI are being developed.…”

Section: Introductionmentioning

confidence: 99%

Effectiveness of mechanical cleaning, antibiotics, and induction heating on eradication of Staphylococcus aureus in mature biofilms

Pijls

Sanders

Kuijper

et al. 2022

Bone & Joint Research

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Aims Here we used a mature seven-day biofilm model of Staphylococcus aureus, exposed to antibiotics up to an additional seven days, to establish the effectiveness of either mechanical cleaning or antibiotics or non-contact induction heating, and which combinations could eradicate S. aureus in mature biofilms. Methods Mature biofilms of S. aureus (ATCC 29213) were grown on titanium alloy (Ti6Al4V) coupons for seven days and were subjected to the following treatments or their combinations: antibiotics, mechanical cleaning, or heat shock by induction heating of 60°C for one minute. Experiments were repeated at least five times. Results In the untreated biofilm, growth up to 1.8×1011 colony-forming units (CFU)/cm2 was observed. Treatment with ciprofloxacin, flucloxacillin, vancomycin, cefuroxime, and amoxicillin all with rifampicin gave 6.0 log, 6.1 log, 1.4 log, 4.8 log, and 3.6 log reduction in CFU/cm2, respectively. Mechanical cleaning alone resulted in 4.9 log reduction and induction heating in 7.3 log reduction. There was an additional effect of ciprofloxacin, flucloxacillin, and induction heating when used in combinations. There was no additional effect for mechanical cleaning. No bacterial growth could be detected after induction heating followed by seven days of ciprofloxacin with rifampicin. Conclusion Mechanical cleaning, antibiotics, and non-contact induction heating reduced the bacterial load of mature S. aureus biofilms with approximately 5 log or more as a single treatment. The effect of mechanical cleaning on mature S. aureus biofilms was limited when used in combination with antibiotics and/or induction heating. Cite this article: Bone Joint Res 2022;11(9):629–638.

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Modular component exchange and outcome of DAIR for hip and knee periprosthetic joint infection

Cited by 24 publications

References 24 publications

Debridement, antibiotics, and implant retention after revision arthroplasty

Debridement, antibiotics, and implant retention after revision arthroplasty

Truth or DAIR? A review of debridement, antibiotics and implant retention

Effectiveness of mechanical cleaning, antibiotics, and induction heating on eradication of Staphylococcus aureus in mature biofilms

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