Paper of the week: Irrigation and debridement with chronic antibiotic suppression for the management of infected total knee arthroplasty

Irrigation and debridement with chronic antibiotic suppression for the management of infected total knee arthroplasty, Weston JT, Watts CD, Mabry TM, Hanssen AD, Berry DJ, Abdel MP. Bone Joint J. 2018 Nov;100-B(11):1471-1476.
doi: 10.1302/0301-620X.100B11.BJJ-2018-0515.R1.

Summary and editorial by Sreeram Penna

Above study is a single center retrospective review of 134 infected total knee arthroplasty cases ( acute post-operative infection in 23 and acute hematogenous infection in 111). All patients had Irrigation debridement using normal saline and retention of components except modular poly-ethylene components which were replaced. All patients had organism-specific antibiotic followed by long-term antibiotic suppression.

The study found the infection-free survival of 72% at two years and 66% at five years. The study also showed that age less than 60 and infection with staphylococcal species was associated with increased risk of subsequent infection. Culture-negative infection cases have a lower risk of recurrence or subsequent infections. Musculoskeletal Infection Society host type, body mass index (BMI), the duration of symptoms, gender, and the presence of a monoblock tibial component did not have any influence on the outcome.

In another study Siqueira et al., has shown similar infection-free prosthetic implant survival (68.5% at five years) following irrigation and debridement, polyethylene exchange and chronic antibiotic suppression. [1] However in that study cases with staphylococcal infection fared better following chronic antibiotic suppression compared to those who did not receive suppressive antibiotics following irrigation and debridement. Similarly Rao et al., showed favorable results in 86% of patients at 5 years were able to maintain functioning prosthesis.[2] In another study on patients with osteomyelitis Nowak et al showed successful suppression of the disease. [3] In this study diabetes was associated with a high failure rate and also there was a high incidence (25%) of adverse reactions associated with suppressive antibiotics.

References

[1] Siqueira MBP, Saleh A, Klika AK, O’Rourke C, Schmitt S, Higuera CA, et al. Chronic Suppression of Periprosthetic Joint Infections with Oral Antibiotics Increases Infection-Free Survivorship. J Bone Joint Surg Am 2015;97:1220–32. doi:10.2106/JBJS.N.00999.

[2] Rao N, Crossett LS, Sinha RK, Le Frock JL. Long-term suppression of infection in total joint arthroplasty. Clin Orthop Relat Res 2003:55–60. doi:10.1097/01.blo.0000087321.60612.cf.

[3] Nowak MA, Winner JS, Beilke MA. Prolonged oral antibiotic suppression in osteomyelitis and associated outcomes in a Veterans population. Am J Health Syst Pharm 2015;72:S150-155. doi:10.2146/sp150022.