Paper of the Week: A Second Surgical Debridement for Acute Periprosthetic Joint Infections Should Not Be Discarded

Wouthuyzen-Bakker M, Löwik CAM, Ploegmakers JJW, Knobben BAS, Dijkstra B, de Vries AJ, Mithoe G, Kampinga G, Zijlstra WP, Jutte PC; Northern Infection Network Joint Arthroplasty (NINJA)

J Arthroplasty. 2020 Aug;35(8):2204-2209.
doi: 10.1016/j.arth.2020.02.043. Epub 2020 Feb 26. PMID: 32192835.

Summary by: Graham Goh

The first-line treatment for acute periprosthetic joint infection (PJI) is surgical debridement, antibiotics, and implant retention (DAIR). However, literature has shown that treatment success following this procedure varies greatly, often ranging from 30% to 80% depending on multiple factors. One controversial issue in PJI management is whether a repeat DAIR is useful in clinically failed cases. During the second International Consensus Meeting in 2018, it was strongly recommended “after one failed DAIR procedure, strong consideration should be given to removal of components”.

To evaluate the efficacy of a second surgical debridement and identify patients who would benefit from this repeat procedure, Wouthuyzen-Bakker et al. conducted a multicenter study on 144 patients who underwent a second DAIR for acute PJI between 2006 and 2016. Treatment failure was defined as (1) the need for additional surgery to control infection, (2) need for suppressive antibiotics to control infection, or (3) PJI related death. All patients were followed up for at least 1 year.

The authors found that the failure rate for second DAIR was 37 of 144 cases (26%). Implant removal was needed to achieve infection control in 23 cases (16%). Risk factors for failure included positive cultures in the second procedure (OR 3.16, 95% CI 1.29-7.74) and chronic renal insufficiency (OR 13.6, 95% CI 2.03-91.33). The following factors had no influence on failure rates: polyethylene exchange in the first DAIR, time interval between the two DAIRs, type and location of prosthesis, initial clinical presentation and causative microorganism. In patients with positive cultures, no difference in failure rate was found for infection with the same or different microorganism (31.6% vs 34.6%, p=0.83).         

Overall, the authors proposed that a repeat DAIR should be considered in patients with acute PJIs who fail the first procedure, as a high success rate (74%) could still be achieved. While the small cohort size may limit statistical power, it is still worth noting that this is currently the largest study in the literature reporting outcomes after a second DAIR. In addition, a large number of patients had negative cultures during second DAIR (62%), suggesting that these patients had a low risk of persistent infection, leading to possible selection bias in the study. Lastly, given the small number with late acute PJI (n=15), limited conclusions can be drawn about this subgroup.