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A Multicenter Study of Irrigation and Debridement in Total Knee Arthroplasty Periprosthetic Joint Infection: Treatment Failure Is High
Authors/contributors
- Urish, Kenneth L. (Author)
- Bullock, Andrew G. (Author)
- Kreger, Alexander M. (Author)
- Shah, Neel B. (Author)
- Jeong, Kwonho (Author)
- Rothenberger, Scott D. (Author)
- Irrgang, James J. (Author)
- Klatt, Brian A. (Author)
- Hamlin, Brian R. (Author)
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
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.
Section
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