Increased Failure after Irrigation and Debridement for Acute Hematogenous Periprosthetic Joint Infection

Introduction: Acute periprosthetic joint infection (PJI) is difficult to treat. This study investigates the success rate of irrigation and debridement (I&D) in patients with acute (post-surgical) and acute hematogenous PJI, and attempts to identify predictors of failure.

Methods: We retrospectively reviewed 199 revision total joint arthroplasties (TJA) undergoing I&D for PJI at a single center from 2005-2016. Only patients meeting the Musculoskeletal Infection Society (MSIS) criteria for PJI were included. Patient demographics, comorbidities, physical examination findings, laboratory results and organism profile were identified. Treatment failure defined by the Delphi criteria was determined at minimum 1-year follow up. Primary statistical analysis involved univariate and multivariate regression.

Results: The failure rate was 37.7% (75/199) at 1-year follow up. In patients with acute hematogenous infections, the rate of failure (55.8%, 29/52) was almost two times higher compared to patients with acute infection (31.3%, 46/147) (Adjusted odds ratio (OR) 2.36, 95% confidence interval (CI) 1.16-4.81, p=0.018). Host predictors of failure included prior revision surgery (Adjusted OR 2.55, 95% CI 1.22-5.32, p=0.013) and higher Charlson comorbidity index (Adjusted OR 1.22, 95% CI 1.01-1.51, p=0.048). Specific comorbidities associated with failure included pulmonary disease (p=0.026), diabetes (p=0.004), and history of malignancy (p=0.005). Patients with polymicrobial infections (Adjusted OR 2.40, 95% CI 1.10-5.20, p=0.028) were also more likely to fail after I&D. In addition, the clinical and laboratory risk factors associated with failure were presence of intraoperative purulence (p=0.05) and higher serum CRP (p=0.003).

Conclusion: The present study reveals that irrigation and debridement carries a high rate of failure in patients with acute hematogenous PJI. The study also identified a number of risk factors for failure, some of which are modifiable. The findings of this study may allow better decision making by surgeons regarding surgical management of patients with acute PJI.