Infection Control Rate of Irrigation and Débridement for Periprosthetic Joint Infection

Background  

Irrigation and débridement with retention of prosthesis is commonly performed for periprosthetic joint infection. Infection control is reportedly dependent on timing of irrigation and débridement relative to the index procedure.     

Irrigation,Débridement,and Implant Retention for Recurrence of Periprosthetic Joint Infection Following Two-Stage Revision Total Knee Arthroplasty: A Matched Cohort Study

BackgroundWe investigated clinical/functional outcomes and implant survivorship in patients who underwent 2-stage revision total knee arthroplasty (TKA) after periprosthetic joint infection (PJI), experienced acute PJI recurrence, and underwent irrigation, débridement, and polyethylene exchange (IDPE) with retention of stable implant.MethodsTwenty-four patients (24 knees) were identified who underwent 2-stage revision TKA for PJI, experienced acute PJI recurrence, and then underwent IDPE between 2005 and 2016 (minimum 2-year follow-up). After IDPE, intravenous antibiotics (6 weeks) and oral suppression therapy (minimum 6 months) were administered. Data were compared with 1:2 matched control group that underwent 2-stage revision TKA for chronic PJI and did not receive IDPE.ResultsAverage IDPE group follow-up was 3.8 years (range, 2.4-7.2). Reinfection rate after IDPE was 29% (n = 7): 3 of 7 underwent second IDPE (2 of 3 had no infection recurrence) and 5 (one was patient who had recurrent infection after second IDPE) underwent another 2-stage revision TKA. Control group reinfection rate was 27% (n = 13) (P = .85). For IDPE group, mean time to reinfection after 2-stage revision TKA was 4.6 months (range, 1-8 months) (patients presented with acute symptoms less than 3 weeks duration). At latest follow-up, mean Knee Society Score was 70 (range, 35-85) in IDPE group and 75 (range, 30-85) in control group (P = .53).ConclusionIDPE for acute reinfection following 2-stage revision TKA with well-fixed implants had a 71% success rate. These patients had comparable functional outcome as patients with no IDPE after 2-stage revision TKA. IDPE followed by long-term suppression antibiotic therapy should be considered in patients with acute infection and stable components.     

The Biomechanical Case for Labral Débridement

Background

Labral repair is increasingly performed in conjunction with open and arthroscopic surgical procedures used to treat patients with mechanically related hip pain. The current rationale for labral repair is based on restoring the suction-seal function and clinical reports suggesting improved clinical outcome scores when acetabular rim trimming is accompanied by labral repair. However, it is unclear whether available scientific evidence supports routine labral repair.

Questions/Purposes

The questions raised in this review were: (1) does labral repair restore normal histologic structure, tissue permeability, hip hydrodynamics, load transfer, and in vivo kinematics; and (2) does labral repair favorably alter the natural course of femoroacetabular impingement (FAI) treatment or age-related degeneration of the acetabular labrum?

Methods

An electronic literature search for the keywords acetabular labrum was performed. Three hundred fifty-five abstracts were reviewed and 52 selected for full-text review that described information concerning pertinent aspects of labral formation, development, degeneration, biomechanics, and clinical results of labral repair or resection.

Results

Several clinical studies support labral repair when performed in conjunction with acetabular rim trimming. Little data support or refute the use of routine labral repair for all patients with symptomatic labral damage associated with FAI. It is not known whether or how labral repair affects the natural course of FAI.

Conclusions

Based on the current understanding of labral degenerative changes associated with mechanical hip abnormalities, the low biologic likelihood of restoring normal tissue characteristics, and mechanical data suggesting minimal consequence from small labral resections, routine labral repair over labral débridement is not supported.     

Procalcitonin and α-Defensin for Diagnosis of Periprosthetic Joint Infections

Background

Current methods to diagnose periprosthetic joint infection (PJI) before revision surgery have limited diagnostic accuracy. This meta-analysis was performed to estimate the accuracy of procalcitonin (PCT) and α-defensin for the diagnosis of PJI.

Is There Still a Role for Irrigation and Debridement With Liner Exchange in Acute Periprosthetic Total Knee Infection?

Background

Periprosthetic joint infection (PJI) is an important cause of failure in total knee arthroplasty. Irrigation and debridement including liner exchange (I&D/L) success rates have varied for acute PJI. The purpose of this study is to present results of a specific protocol for I&D/L with retention of total knee arthroplasty components.

Acute compartment syndrome following intramedullary pulse lavage and débridement for osteomyelitis of the tibia

The implantation of gentamicin loaded polymethylmethacrylate (PMMA) beats and other local antibiotic carriers is a common practice in the treatment of chronic osteomyelitis as is the use of local jet lavage débridement. This article presents the case of a patient with chronic osteomyelitis of the tibia, who had no complication after débridement, intramedullary reaming and pulse lavage without tourniquet but sustained a compartment syndrome 2 weeks later during a second procedure in which an intraoperative tourniquet and pulse lavage were combined.     

Débridement arthroplasty for primary osteoarthritis of the elbow

BACKGROUND: Formal and more aggressive débridement procedures have been described for the treatment of advanced primary osteoarthritis of the elbow. However, the literature contains little information on the results of long-term follow-up. The purpose of this study was to evaluate outcomes at an average of ten years after débridement arthroplasties performed through a posteromedial approach. METHODS: Thirty-three elbows with primary osteoarthritis in thirty-two patients treated with débridement arthroplasty were available for clinical follow-up evaluation. Through a posteromedial approach, the flexor-pronator muscle origin was reflected from the medial epicondyle and the joint was opened, preserving the anterior oblique bundle of the medial collateral ligament. The ulnar nerve was decompressed in all patients. Osteophytes were removed from the anterior, medial, and posterior sides of the elbow joint. In nine elbows, osteophytes from the lateral compartment were removed through an additional lateral approach. The mean age at the time of the operation was fifty years. The mean duration of follow-up was 121 months, and nineteen elbows were followed for more than ten years. RESULTS: The mean preoperative limitation of extension of 31 degrees was reduced to 24 degrees, and the mean preoperative flexion of 101 degrees improved to 118 degrees (p < 0.001). The mean arc of movement improved by 24 degrees. The mean Japanese Orthopaedic Association elbow score was 83 points at the latest follow-up evaluation compared with 60 points preoperatively (p < 0.001). Of twenty-five patients who had performed heavy manual work, nineteen (76%) returned to their previous job or an equivalent job. At the latest examination of the nineteen elbows followed for more than ten years, the limitation of extension was found to have increased by 7 degrees compared with the limitation noted at one year (p < 0.009); the mean arc of flexion had remained the same. Three elbows required a reoperation. Overall, 85% of the elbows were satisfactory to the patients. CONCLUSIONS: Débridement arthroplasty through a posteromedial approach can provide stable and reliable long-term results with regard to relief of pain, gains in range of motion, and the patient's ability to return to his or her previous occupation. In our series, a modest loss of extension was observed at ten years, whereas the arc of flexion remained consistent.     

Débridement of Gunshot Wounds: Semantics and Surgery

Débridement is a well established modality for management of gunshot wounds. The word “débridement” is originally French. It was used for the first time during the eighteenth century in the surgical context and meant “wound incision.” For French surgeons, it has retained to this day its original meaning. In medical English, though, the use of the term has been marred by persisting confusion about its definition. Two quite different surgical procedures still compete for the definition of débridement: wound incision and wound excision. These procedures are also at the center of a modern controversy about the management of gunshot wounds. The orthodox doctrine, inherited from military surgeons, consists of aggressive tissue excision around the bullet track. This radical policy is being challenged by advocates of a more conservative approach. Minimal tissue excision is sufficient and safe in many cases provided careful monitoring of the wound is instituted. Wound incision alone to relieve tension and allow drainage is possible in certain cases. The tug-of-war between excision and incision is outlined herein with reference to the semantic tribulations of the word “débridement” and the implications for patient care.     

What Is the Optimal Irrigation Solution in the Management of Periprosthetic Hip and Knee Joint Infections?

BackgroundThorough irrigation and debridement using an irrigation solution is a well-established treatment for both acute and chronic periprosthetic joint infections (PJIs). In the absence of concrete data, identifying the optimal irrigation agent and protocol remains challenging.MethodsA thorough review of the current literature on the various forms of irrigations and their additives was performed to evaluate the efficacy and limitations of each solution as pertaining to pathogen eradication in the treatment of PJI. As there is an overall paucity of high-quality literature comparing irrigation additives to each other and to any control, no meta-analyses could be performed. The literature was therefore summarized in this review article to give readers concise information on current irrigation options and their known risks and benefits.ResultsAntiseptic solutions include povidone-iodine, chlorhexidine gluconate, acetic acid, hydrogen peroxide, sodium hypochlorite, hypochlorous acid, and preformulated commercially available combination solutions. The current literature suggests that intraoperative use of antiseptic irrigants may play a role in treating PJI, but definitive clinical studies comparing antiseptic to no antiseptic irrigation are lacking. Furthermore, no clinical head-to-head comparisons of different antiseptic irrigants have identified an optimal irrigation solution.ConclusionFurther high-quality studies on the optimal irrigation additive and protocol for the management of PJI are warranted to guide future evidence-based decisions.     

Débridement and primary closure of nonhealing foot wounds

Fifty-eight chronic nonhealing foot wounds (51 patients) were treated with irrigation, aggressive débridement, and primary tension-free closure. Factors such as wound location, wound size, presence of infection, and healing outcome were recorded. In addition, medical comorbidities and preoperative laboratory test results were reviewed. Thirty-seven (64%) of the 58 wounds healed after primary closure. Of the other 21 wounds, 16 healed after repeat irrigation, debridement, and closure or local wound care; 2 patients were lost to follow-up after initial failed wound healing, 1 patient died after initial failed wound healing, and 2 cases were salvaged with amputation. Failed primary closures were thought not to increase wound size; all but 3 of these closures decreased wound size significantly. Differences between the wounds that healed primarily and the wounds that failed healing were not statistically significant. Diabetes was present in 46% of the patients whose wounds healed primarily versus 71% of the patients whose wounds failed healing (P = .06). Irrigation, débridement, and primary closure of nonhealing foot wounds can be a useful treatment option for most such patients. Complete healing or reduced wound size occurs in 95% of cases.     

Irrigation and Debridement for Early Periprosthetic Knee Infection: Is It Effective?

Background

Irrigation and debridement (I&D) is performed for early management of periprosthetic joint infection (PJI) following total knee arthroplasty (TKA). Symptom reporting is a subjective measure and may miss direct management of PJI. Utilizing an objective time interval from index procedure to I&D may better inform treatment decisions.

Aggressive Early Débridement for Treatment of Acutely Infected Cemented Total Hip Arthroplasty

Background  

Up to 2% of THAs are complicated by infection, leading to dissatisfied patients with poor function and major social and economic consequences. The challenges are control of infection, restoration of full function, and prevention of recurrence. Irrigation and débridement with or without exchange of modular components remains an attractive alternative to two-stage reimplantation in acutely infected THAs but with variable results from previous studies.     

Arthroscopic débridement for osteoarthritis of the knee

BACKGROUND: The role of arthroscopic débridement in the treatment of osteoarthritis of the knee remains to be defined, and few clinical and radiographic characteristics have been quantitatively associated with the outcome. The hypothesis of this study was that the outcome of arthroscopic débridement for osteoarthritis of the knee is associated with preoperative clinical and radiographic features and intraoperative characteristics and that there are subsets of patients who are more and less likely to respond favorably to the treatment. METHODS: We performed a cross-sectional study of a consecutive cohort of 122 patients who underwent arthroscopic débridement for the treatment of osteoarthritis of the knee that had been unresponsive to anti-inflammatory therapy. One hundred and ten patients were followed for a mean of thirty-four months. Pain was assessed with the pain domain of the Knee Society scoring system. Radiographs were scored with the Kellgren-Lawrence method, and limb alignment and the widths of the medial and lateral joint spaces were measured. The severity of cartilage lesions was scored intraoperatively with a modified Noyes grading system. Specific methods of data collection and analysis were incorporated to minimize bias. RESULTS: Fifty-two (90%) of fifty-eight knees with mild arthritis, normal alignment, and a joint space width of > or = 3 mm were improved after arthroscopic débridement. Conversely, only five (25%) of twenty knees with severe arthritis, limb malalignment, and a joint space width of < 2 mm had substantial relief of symptoms. Of seventy-two patients who had improvement, forty-four (61%) had it within six months after the arthroscopy. The severity of the lesion was highly predictive of the clinical outcome both in patients with mild arthritis and in those with severe arthritis. CONCLUSIONS: The severity of the arthritis, as assessed preoperatively with radiography and intraoperatively by rating the severity of cartilage lesions, influences the clinical outcome of arthroscopic débridement of an osteoarthritic knee. Knees with severe arthritis fare poorly, whereas those with mild arthritis fare well. We could not predict the outcome for knees with moderate arthritis. We believe that these observations are relevant for establishing indications for arthroscopy in patients with osteoarthritis of the knee and may be useful for designing studies with a more rigorous experimental design.     

Débridement and Reconstruction Improve Postoperative Sagittal Alignment in Kyphotic Cervical Spinal Tuberculosis

Clinical Orthopaedics and Related Research® - Cervical spinal tuberculosis is relatively common in some developing countries. It erodes vertebrae and discs, which sometimes results in cervical...     

Irrigation and Debridement With Implant Retention: Does Chronicity of Symptoms Matter?

BackgroundPeriprosthetic joint infection (PJI) remains a rare, yet devastating complication of total joint arthroplasty (TJA). Chronic infection is generally considered a contraindication to debridement, antibiotics, and implant retention (DAIR); however, outcomes stratified by chronicity have not been well documented.MethodsA retrospective review of all DAIR cases performed at a single institution from 2008 to 2015 was performed. Chronicity of PJI was categorized as acute postoperative, chronic, or acute hematogenous. Failure after DAIR, defined as re-revision for infection recurrence with the same organism, was evaluated between the 3 chronicity groups at 90 days as well as at a minimum 2-year follow-up.ResultsOverall, 248 patients undergoing DAIR for total hip arthroplasty or total knee arthroplasty PJI were included. Categorization of PJI was acute (acute postoperative) in 59 cases (24%), chronic in 54 (22%), and acute hematogenous in 135 (54%). DAIR survivorship was 47% (range 0.3-10 years). Overall, there were 118 (47.6%) treatment failures after DAIR with a minimum of 2-year follow-up. There was no difference in failure rate between total hip or total knee arthroplasty patients (P = .07). Patients infected with Staphylococcus conferred a higher risk of failure for all DAIR procedures regardless of chronicity category.ConclusionIdentification of microbial species prior to undertaking DAIR may be more clinically relevant than stratification according to chronicity category when considering treatment options.