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A Multicenter Study of Irrigation and Debridement in Total Knee Arthroplasty Periprosthetic Joint Infection: Treatment Failure Is High

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Authors/contributors
Abstract
Background In total knee arthroplasty (TKA) periprosthetic joint infection (PJI), irrigation and debridement (I&D) with component retention is a treatment option with a wide variation in reported failure rates. The purpose of this study was to determine failure rates, outcomes, and factors that predict failure in I&D for TKA PJI. Methods A multicenter observational study of patients with a TKA PJI and subsequently undergoing an I&D with retention of components was conducted. The primary outcome was failure rate of I&D, where failure was defined as any subsequent surgical procedures. Results Two hundred sixteen cases of I&D with retention of components performed on 206 patients met inclusion criteria. The estimated long-term failure rate at 4 years was 57.4%. Time-to-event analyses revealed that the median survival time was 14.32 months. Five-year mortality was 19.9%. Multivariable modeling revealed that time symptomatic and organism were independent predictors of I&D failure. Culture-negative status had a higher hazard for failure than culture-positive patients. When primary organism and time symptomatic were selected to produce an optimized scenario for an I&D, the estimated failure rate was 39.6%. Conclusion I&D with retention of components has a high failure rate, and there is a high incidence of more complex procedures after this option is chosen. The patient comorbidities we investigated did not predict I&D success. Our results suggest that I&D has a limited ability to control infection in TKA and should be used selectively under optimum conditions.
Publication
The Journal of Arthroplasty
Date
04/2018
DOI
10.1016/j.arth.2017.11.029
URL
https://linkinghub.elsevier.com/retrieve/pii/S0883540317310343
Notes

Summary:

Key Question: What is the failure rate, timing of failure, and factors predicting failure for irrigation and debridement with component retention in treating periprosthetic joint infection of total knee arthroplasty?

Key Findings:

  • The overall failure rate was 57.4% at 4 years.
  • The median time to failure was 14 months.
  • 89.9% of failures occurred within the first year.
  • Duration of symptoms >1 week and Staphylococcus aureus infection were independent predictors of failure.

Clinical Implications:

  • Irrigation and debridement with component retention has a high failure rate in treating TKA periprosthetic joint infection.
  • It should be used selectively in optimal conditions (symptoms <1 week, non-S. aureus organism).

Strengths:

  • Multicenter study with large sample size (n=216)
  • Extended follow-up time (median 31.5 months)
  • Used validated measures (e.g. Charlson Comorbidity Index)
  • Performed multivariable analysis to identify predictors of failure

Limitations:

  • Retrospective observational design
  • Heterogeneous surgical treatment and postoperative care
  • Did not assess antibiotic therapy duration/type
  • Definition of failure based solely on need for additional procedures

Level of Evidence:

GRADE assessment: Moderate

Rationale: This was a well-designed multicenter observational cohort study. However, the retrospective design and lack of controlling for confounding factors reduces the level of evidence. The study did have several strengths including a large sample size, extended follow-up time, and use of validated measures. However it’s limitations like the heterogeneity in treatment and lack of assessing antibiotic therapy prevent a rating of high quality evidence.

Citation
1.
Urish KL, Bullock AG, Kreger AM, et al. A Multicenter Study of Irrigation and Debridement in Total Knee Arthroplasty Periprosthetic Joint Infection: Treatment Failure Is High. The Journal of Arthroplasty. 2018;33(4):1154-1159.
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