Irrigation and debridement with component retention for acute injection after hip arthroplasty by Dr Bipul Borthakur

1. IRRIGATION AND DEBRIDEMENT
WITH COMPONENT RETENTION FOR ACUTE
INECTION
AFTER HIP ARTHROPLASTYJBJS, December 06, 2017:Volume 99-A, Number 23
Dr. Bipul Borthakur
PROFESSOR & HOD
Dept of Orthopaedics, SMCH

2. INTRODUCTION
 Periprosthetic joint infection following hip arthroplasty is a devastating complication
associated with substantial morbidity and societal cost.
 The frequency of acute postoperative periprosthetic joint infection is 60-70% of all
postoperative periprosthetic joint infection cases, making it a driver of early failure
after primary hip arthroplasty.

3. McPherson et al. criterias of patients-
 Early postoperative infections with onset of symptoms in less than or equal
to 4 weeks.
 Late hematogenous with onset of symptoms of more than 4 weeks after
surgical procedure.
 Patients with Systemic diseases
 Local factors

4. ACUTE EARLY POSTOPERATIVE INFECTION-
Defined as infection within 28 days of primary hip arthroplasty.
ACUTE HEMATOGENOUS INFECTION-
Defined as infection present for less than or equal to 21days since the symptoms
began.
CO-MORBIDITIES ASSOCIATED WITH POSTOPERATIVE INFECTION
ARE- Diabetes
Cardiac insufficiency Pulmonary
insufficiency HIV
Smoking or Nicotine use
Alcoholism Systemic
immune disorders

5. Criterias to diagnose ACUTE EARLY POSTOPERATIVE
INFECTION
1.Presence of wound drainage tracking to the deep joint,
2.Culture-positive aspiration of the affected prosthetic joint, OR
3.Positive culture from the deep joint during irrigation and debridement of presumed
infection
OR IF 3 OF THE FOLLOWING 4 WERE MET
1. ESR >44mm/hr
2. CRP >93MG/L 3.
Elevated Synovial WBC count >12,800WBC/ml 4.
Elevated Synovial NEUTROPHIL PERCENTAGE OF >89%

6. Criterias to Diagnose ACUTE HEMATOGENOUS INFECTION
1. Presence of Wound drainage tracking to the deep joint
OR
2. More than equal to 2 positive cultures from the deep joint for the same
bacterium at the time of irrigation and debridement for presumed infection
OR IF 4 OF THE FOLLOWING 6 CRITERIAS WERE MET
1. Elevated ESR OR Serum C-REACTIVE PROTIEN (CRP)
2. Elevated Synovial White blood cells WBC >3000 WBC/ml
3. Elevated Synovial neutrophil >80%
4. Presence of purulence in the affected joint
5. Isolation of a microorganism in 1 culture of periprosthetic tissue or fluid
AND/OR 6.
Neutrophils >5%

8. IRRIGATION AND DEBRIDEMENT
 The irrigation and Debridement included debridement of devitalized soft tissue and
irrigation with 6-9L of NORMAL SALINE solution by PULSATILE LAVAGE.
 No adjuvant dilute betadine (povidone iodine) wash or antibiotic powder in the
wound was used.
 There was no systematic mechanical debridement of the implant surfaces other
than pulsatile lavage.
 Hips were dislocated to allow thorough debridement and testing of component
fixation.

9. AFTER IRRIGATION AND DEBRIDEMENT
POSTOPERATIVELY
Patients were treated with broad-spectrum intravenous antibiotics
Followed by targeted therapy by infectious disease specialists.
Pateints were recommended to begin CHRONIC ANTIBIOTIC SUPPRESSION if they
had not undergone treatment failure during the first 6 weeks of treatment with
INTRAVENOUS OR INTRAVENOUS AND ORAL ANTIBIOTICS.

12. FAILURE
DIAZ-LEDEZMA ET AL. DEFINED FAILURE AS-
 FAILURE TO ERADICATE INFECTION characterized by-
Wound fistula
Drainage Intolerable
pain
Infection recurrence caused by the same organism strain
 SUBSEQUENT REMOVAL OF ANY COMPONENT FOR INFECTION
 UNPLANNED SECOND WOUND DEBRIDEMENT FOR ONGOING DEEP
INFECTION
AND/OR
 OCCURRENCE OF PERIPROSTHETIC JOINT INFECTION-RELATED MORTALITY
WHILE ALLOWING FOR PLANNED OR SUPERFICIAL SECOND IRRIGATION AND
DEBRIDEMENT

14. ORGANISMS ISOLATED IN FAILURES
ARE-
 Staphylococcus aureus
 Methicillin-Resistant S.aureus
 Staphylococcus epidermidis
 Group B Streptococcus
 Enterococcus
 Enterobacter cloacae

15. DISCUSSIONS
Periprosthetic joint infection is an important complication of total hip arthroplasty,
with an estimated rate of 1-2%.
The success of irrigation and debridement with component retention has been
variable, with a reported success rate of 14-90%.
At a mean follow-up of 6years, there was an 83% success rate defined as implant
retention and lack of clinically evident infection and McPherson criteria of patient
with Systemtic diseases has success rate of 92%.

16. Marculescu et al. reported a 78% failure of periprosthetic joint infection due to
S.aureus.
Rifampicin-based regimens either as a part of initial therapy or as a part
of chronic suppression therapy has shown lower rates of treatment failure in
those infected with a staphylococcal infections.
Siqueira et al. found increased infection-fee survivorship when chronic
suppression was used for periprosthetic joint infection after 2-stage
reimplantation of hip and knee replacements with periprosthetic infections.

17. In the author’s series, the high percentage of patients treated with chronic
suppression may have contributed to the high rate of success.
High success rate is shown in acute infection treated with modern surgical
techniques and modern antibiotic therapy which includes long term antibiotic
suppression therapy.