Paper of the Week: Open Debridement is Superior to Arthroscopic Debridement for the Infected Total Knee Arthroplasty

Brenton P. Johns, MBBS, Mark R. Loewenthal, MBBS, MMedSci, FRACP, Joshua S. Davis, MBBS, DTM&H, PhD, FRACP, David C. Dewar, MBBS, PhD, FRACS, FAOrthoA

The Journal of Arthroplasty 35.12 (2020): 3716 – 3723
DOI:
https://doi.org/10.1016/j.arth.2020.06.039 PMID: 32713724

Summary by Stephen DiMaria, BS

Periprosthetic joint infection is a disastrous complication that can follow total knee arthroplasty (TKA) with significant financial costs.1 Debridement, antibiotics, and implant retention (DAIR) is the most commonly used treatment for acute postoperative or acute hematogenous periprosthetic joint infection. Currently, it is not clear whether open debridement or arthroscopic debridement (as part of DAIR) is more effective in treating an acutely infected TKA. The purpose of this study was to compare the success of open vs. arthroscopic DAIR for acutely infected TKA.

In this study, the investigators performed a retrospective review of all patients with an acutely infected prosthetic TKA from January 2002 to February 2017. The primary outcome was successful treatment of PJI as defined by a previously developed international consensus criteria.2 The criteria include prosthesis retention, a healed wound without sinus formation, a painless joint, no infection recurrence, no repeat debridement after 14 days from initial debridement, and no periprosthetic joint infection-related mortality.  Secondary outcomes included comparing patients who were on antibiotic suppression, prosthesis retention, repeat debridement, amputation rate, mortality, length of stay, and range of motion.

A total of 141 patients were included in analysis with 96 patients receiving open debridement and 45 patients receiving arthroscopic debridement. Open debridement was more successful with 29% more patients in the open group compared to the arthroscopic group achieving infection-free survival (95% CI: 15-44%, p < 0.001). When those on antibiotic suppression were compared, the benefit of open surgery persisted with 24% (95% CI: 6.5% – 41%, p = 0.011) more open surgery patients achieving success than those who received arthroscopic surgery. The two groups did not differ with regards to prosthesis retention, repeat DAIR, amputation, mortality, length of stay, or range of motion.

Ultimately, this study found that for patients with infected TKA, open DAIR is the more successful initial procedure for treatment compared to those with arthroscopic DAIR. Additionally, this benefit persisted even for patients who were on antibiotic suppression prior to the index DAIR. Future prospective randomized controlled trials will be needed to help confirm these findings.

References:

  1. Kurtz SM, Lau EC, Son M-S, Chang ET, Zimmerli W, Parvizi J. Are We Winning or Losing the Battle With Periprosthetic Joint Infection: Trends in Periprosthetic Joint Infection and Mortality Risk for the Medicare Population. The Journal of Arthroplasty. 2018;33(10):3238-3245. http://www.sciencedirect.com/science/article/pii/S0883540318305266
  2. Diaz-Ledezma C, Higuera CA, Parvizi J. Success After Treatment of Periprosthetic Joint Infection: A Delphi-based International Multidisciplinary Consensus. Clinical Orthopaedics and Related Research®. 2013;471(7). https://journals.lww.com/clinorthop/Fulltext/2013/07000/Success_After_Treatment_of_Periprosthetic_Joint.51.aspx

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