Dair approach in 7 infected total hip arthroplasties: our experience and current concepts of the literature

Main Article Content

Paolo Schiavi
Francesco Pogliacomi
Filippo Calderazzi
Marco Domenichini
Francesco Ceccarelli
Enrico Vaienti

Keywords

hip, arthroplasty, prosthesis, infection, DAIR.

Abstract

Abstract. Introduction: Periprosthetic joint infection (PJI) is one of the most challenging complications following total hip arthroplasty. In early infection, within four to twelve weeks from surgery, debridement, antibiotics and implant retention (DAIR) can be the initial treatment. The aim of this study is to report our case series and review current concepts reported in the literature about this topic. Materials and Methods: This was an observational cohort study that included 7 patients managed with DAIR for PJI following primary total hip replacement (THR) between 2014 and 2020. Inclusion criteria were a primary THR, direct anterior or lateral approach, DAIR procedure, and PJI. Exclusion criteria were a PJI following a revision total hip replacement or hemiarthroplasty, posterolateral approach, 1-stage revision, 2-stage revision, and Girdlestone procedure without prior DAIR. For each patient demographic characteristics, laboratory values, microorganisms involved, antibiotic therapy and outcome at one-year follow-up were registered. Results: The mean duration between THR and DAIR was 19 days. In all cases only one DAIR procedure was performed. Most infections were caused by Staphylococcus aureus (4 cases) [one methicillin resistant (MRSA)]. The other infections were caused by Streptococcus agalactiae, Staphylococcus coagulase negative and Escherichia coli. At the final follow-up, the procedure was considered as successful in 6 out of 7 patients (85%). The one with unsuccessful outcome underwent to a two-stage revision. Discussion: Our results were comparable with those of a recent systematic review of the literature. Factors that have been postulated to influence the outcome of DAIR in the management of PJIs include the timing and numbers of debridement, the exchange of components, the responsible microorganism and the duration of antibiotic treatment. In conclusion, the outcomes following DAIR are better as the indications are refined and risk factors identified. PJI prevention remains the key but the current literature still lacks well documented and effective PJI prevention protocols. (www.actabiomedica.it)

Downloads

Download data is not yet available.
Abstract 140 | PDF Downloads 41

References

1 Schiavi P, Calderazzi F, Pedrini MF, Tacci F, Vaienti E, Pogliacomi F. Efficacy and safety of viscosupplementation with hyaluronic acid for hip osteoarthritis: results from a cross-sectional study with a minimum follow-up of 4 years. Acta Biomed 2020 ;91(14-S): e2020032.

2 Pogliacomi F, Schiavi P, Paraskevopoulos A, Leigheb M, Pedrazzini A, Ceccarelli F, Vaienti E. When is indicated viscosupplementation in hip osteoarthritis? Acta Biomed 2018 Dec 18; 90(1-S): 67-74.

3 Pogliacomi F, Schiavi P, Grappiolo G, Ceccarelli F, Vaienti E. Outcome of short versus conventional stem for total hip arthroplasty in the femur with a high cortical index: a five year follow-up prospective multicentre comparative study. Int Orthop 2020; 44(1): 61-8.

4 Loppini M, Schiavi P, Rocca AD, et al. Double-trabecular metal cup technique for the management of Paprosky type III defects without pelvic discontinuity. Hip Int 2018; 28(2_suppl): 66-72.

5 Kamaruzaman H, Kinghorn P and Oppong R. Cost effectiveness of surgical interventions for the management of osteoarthritis: a systematic review of the literature. BMC Musculoskelet Disord 2017; 18: 183.

6. Varacallo M, Chakravarty R, Denehy K, et al. Joint perception and patient perceived satisfaction after total hip and knee arthroplasty in the American population. J Orthop 2018; 15: 495–99.

7 Senthi S, Munro JT and Pitto RP. Infection in total hip replacement: meta-analysis. Int Orthop 2011; 35: 253–60.

8. Bozic KJ, Kamath AF, Ong K, et al. Comparative epidemiology of revision arthroplasty: failed THA poses greater clinical and economic burdens than failed TKA. Clin Orthop Relat Res 2015; 473: 2131–8.

9 Riesgo AM, Liporace FA. Strategies for management of periprosthetic joint infection. Bull Hosp Jt Dis (2013) 2018; 76: 55–61.

10 Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med 2004; 351: 1645–54.

11 Parvizi J, Adeli B, Zmistowski B, Restrepo C, Greenwald AS. Management of Periprosthetic Joint Infection: The Current Knowledge. J Bone Joint Surg Am 2012 Jul 18; 94(14):e104.

12 Muller ME. Preservation of septic total hip replacement versus girdlestone operation. In: Harris W, ed. The Hip: Proceedings of the Second Open Scientific Meeting of The Hip Society. St. Louis: CV Mosby,1974.

13. Coventry MB. Treatment of infections occurring in total hip surgery. Orthop Clin North Am 1975; 6: 991–1003.

14 Pogliacomi F, Schiavi P, Calderazzi F, Ceccarelli F, Vaienti E. When is indicated fibular fixation in extra-articular fractures of the distal tibia? Acta Biomed. 2019 Jan 15; 89(4): 558-63.

15 Tsukayama DT, Estrada R, Gustilo RB. Infection after total hip arthroplasty. A study of the treatment of one hundred and six infections. J Bone Joint Surg [Am] 1996; 78-A: 512–23.

16. Brandt CM, Sistrunk WW, Duffy MC, et al. Staphylococcus aureus prosthetic joint infection treated with debridement and prosthesis retention. Clin Infect Dis 1997: 24: 914–9.

17. Whitehouse MR, Parry MC, Konan S, Duncan CP. Deep infection after hip arthroplasty: staying current with change. Bone Joint J 2016; 98-B (1 Suppl A): 27–30.

18. Drancourt M, Stein A, Argenson JN, et al. Oral rifampin plus ofloxacin for treatment of Staphylococcus-infected orthopedic implants. Antimicrob Agents Chemother 1993; 37: 1214–8.

19. Perry CR, Hulsey RE, Mann FA, Miller GA, Pearson RL. Treatment of acutely infected arthroplasties with incision, drainage, and local antibiotics delivered via an implantable pump. Clin Orthop Relat Res 1992; 281: 216–23.

20. Widmer AF, Gaechter A, Ochsner PE, Zimmerli W. Antimicrobial treatment of orthopedic implant-related infections with rifampin combinations. Clin Infect Dis 1992; 14: 1251–3.

21. Zimmerli W, Widmer AF, Blatter M, Frei R, Ochsner PE. Foreign-Body Infection (FBI) Study Group. Role of rifampin for treatment of orthopedic implant-related staphylococcal infections: a randomized controlled trial. JAMA 1998; 279: 1537–41.

22. Kilgus DJ, Howe DJ, Strang A. Results of periprosthetic hip and knee infections caused by resistant bacteria. Clin Orthop Relat Res 2002; 404:116–24.

23. Estes CS, Beauchamp CP, Clarke HD, Spangehl MJ. A two-stage retention débridement protocol for acute periprosthetic joint infections. Clin Orthop Relat Res 2010; 468: 2029–38.

24 Tintle SM, Forsberg JA, Potter BK, Islinger RB, Andersen RC. Prosthesis retention, serial debridement, and antibiotic bead use for the treatment of infection following total joint arthroplasty. Orthopedics 2009; 32: 87.

25 Corona Pérez-Cardona PS, Barro Ojeda V, Rodriguez Pardo D, et al. Clinical experience with daptomycin for the treatment of patients with knee and hip periprosthetic joint infections. J Antimicrob Chemother 2012; 67: 1749–54.

26 Slullitel PA, Oñativia JI, Buttaro MA, Sanchez ML, Comba F, Zanotti G, Piccaluga F. State-of-the-art diagnosis and surgical treatment of acute peri-prosthetic joint infection following primary total hip arthroplasty. EFORT Open Rev 2018 Jul 17; 3(7): 434-41.

27 Byren I, Bejon P, Atkins BL, et al. One hundred and twelve infected arthroplasties treated with ‘DAIR’ (debridement, antibiotics and implant retention): antibiotic duration and outcome. J Antimicrob Chemother 2009 Jun; 63(6): 1264-71.

28 Kuiper JW, Vos SJ, Saouti R, et al. Prosthetic joint-associated infections treated with DAIR (debridement, antibiotics, irrigation, and retention): analysis of risk factors and local antibiotic carriers in 91 patients. Acta Orthop 2013 Aug; 84(4): 380-6.

29 Tsang SJ, Ting J, Simpson AHRW, Gaston P. Outcomes following debridement, antibiotics and implant retention in the management of periprosthetic infections of the hip: a review of cohort studies. Bone Joint J 2017 Nov; 99- B(11) :1458-66.

30 Romanò CL, Manzi G, Logoluso N, Romanò D. Value of debridement and irrigation for the treatment of peri-prosthetic infections. A systematic review. Hip Int 2012; 22(suppl 8): S19–S24.

31 Estes CS, Beauchamp CP, Clarke HD, Spangehl MJ. A two-stage retention debridement protocol for acute periprosthetic joint infections. Clin Orthop Relat Res 2010; 468: 2029–38.

32 Tintle SM, Forsberg JA, Potter BK, Islinger RB, Andersen RC. Prosthesis retention, serial debridement, and antibiotic bead use for the treatment of infection following total joint arthroplasty. Orthopedics 2009; 32: 87.

33 Meehan AM, Osmon DR, Duffy MCT, Hanssen AD, Keating MR. Outcome of penicillin-susceptible streptococcal prosthetic joint infection treated with debridement and retention of the prosthesis. Clin Infect Dis 2003; 36: 845–9.

34 Moojen DJF. Similar success rates for single and multiple debridement surgery for acute hip arthroplasty infection--reply. Acta Orthop 2015; 86: 142.

35 Peel TN, Buising KL, Dowsey MM, et al. Outcome of debridement and retention in prosthetic joint infections by methicillin-resistant staphylococci, with special reference to rifampin and fusidic acid combination therapy. Antimicrob Agents Chemother 2013; 57: 350–5.

36 Hsieh P- H, Lee MS, Hsu K- Y, et al. Gram-negative prosthetic joint infections: risk factors and outcome of treatment. Clin Infect Dis 2009; 49: 1036–43.

37. Zmistowski B, Fedorka CJ, Sheehan E, et al. Prosthetic joint infection caused by gram-negative organisms. J Arthroplasty 2011; 26(suppl): 104–8.

38 Klouche S, Lhotellier L, Mamoudy P. Infected total hip arthroplasty treated by an irrigation-debridement/component retention protocol. A prospective study in a 12- case series with minimum 2 years’ follow-up. Orthop Traumatol Surg Res 2011; 97: 134–8.

39 Betz M, Abrassart S, Vaudaux P, et al. Increased risk of joint failure in hip prostheses infected with Staphylococcus aureus treated with debridement, antibiotics and implant retention compared to Streptococcus. Int Orthop 2015; 39: 397–401.

40 Tattevin P, Crémieux AC, Pottier P, Huten D, Carbon C. Prosthetic joint infection: when can prosthesis salvage be considered? Clin Infect Dis 1999; 29: 292–5.

41 Grammatopoulos G, Bolduc M- E, Atkins BL, et al. Functional outcome of debridement, antibiotics and implant retention in periprosthetic joint infection involving the hip: a case-control study. Bone Joint J 2017; 99-B: 614–22.

42 Gristina AG, Costerton JW. Bacterial adherence and the glycocalyx and their role in musculoskeletal infection. Orthop Clin North Am 1984; 15: 517–35.

43 Costerton JW, Stewart PS, Greenberg EP. Bacterial biofilms: a common cause of persistent infections. Science 1999; 284: 1318–22.

44 Donlan RM, Costerton JW. Biofilms: survival mechanisms of clinically relevant microorganisms. Clin Microbiol Rev 2002; 15: 167–93.

45 Fehring TK, Odum SM, Berend KR, et al. Failure of irrigation and debridement for early postoperative periprosthetic infection. Clin Orthop Relat Res 2013; 471: 250–7.

46 Sendi P, L¨otscher PO, Kessler B, Graber P, Zimmerli W, Clauss M. Debridement and implant retention in the management of hip periprosthetic joint infection: outcomes following guided and rapid treatment at a single center. Bone Joint J 2017; 99-B(3): 330-6.

47 Svensson K, Rolfson O, Nauclér E, et al. Exchange of Modular Components Improves Success of Debridement, Antibiotics, and Implant Retention: An Observational Study of 575 Patients with Infection After Primary Total Hip Arthroplasty. JBJS Open Access 2020 Dec 15; 5(4): e20.00110.

48 Fulkerson E, Valle CJ, Wise B, Walsh M, Preston C, Di Cesare PE. Antibiotic susceptibility of bacteria infecting total joint arthroplasty sites. J Bone Joint Surg Am 2006; 88(6): 1231–7.

49 Moran E, Masters S, Berendt AR, McLardy-Smith P, Byren I, Atkins BL. Guiding empirical antibiotic therapy in orthopaedics: The microbiology of prosthetic joint infection managed by debridement, irrigation and prosthesis retention. J Infect 2007; 55(1): 1–7.

50 Sousa R, Pereira A, Massada M, da Silva MV, Lemos R, Costa e Castro J. Empirical antibiotic therapy in prosthetic joint infections. Acta Orthop Belg 2010; 76(2): 254–9.

51 Ravi S, Zhu M, Luey C, Young SW Antibiotic resistance in early periprosthetic joint infection. ANZ J Surg 2016; 86(12): 1014–8.

52 Lee AS, de Lencastre H, Garau J, Kluytmans J, Malhotra-Kumar S, Peschel A, Harbarth S. Methicillin-resistant Staphylococcus aureus. Nat Rev Dis Primers 2018; 4: 18033.

53 Van Erp JHJ, Heineken AC, Van Wensen RJA, et al. Optimization of the empirical antibiotic choice during the treatment of acute prosthetic joint infections: a retrospective analysis of 91 patients. Acta Orthop 2019; 90(5): 455–9.

54 Konig C, Schwank S, Blaser J Factors compromising antibiotic activity against biofilms of Staphylococcus epidermidis. Eur J Clin Microbiol Infect Dis 2001; 20(1): 20–6.

55 Fux CA, Costerton JW, Stewart PS, Stoodley P. Survival strategies of infectious biofilms. Trends Microbiol 2005; 13(1): 34–40.

56 Deijkers RL, van Elzakker EPM, Pijls BG. Debridement, Antibiotics, and Implant Retention with the Direct Anterior Approach for Acute Periprosthetic Joint Infection Following Primary THA. JB JS Open Access 2020 May 9; 5(2): e0062.

Most read articles by the same author(s)

1 2 3 4 5 6 7 > >>