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Proceedings of the International Consensus Meeting on Periprosthetic Joint Infection

Javad Parvizi MD, FRCS
Thorsten Gehrke MD


Title:
Irrigation and Debridement

Liaisons:
Carl Haasper MD, PhD, MSc

Leaders:
Martin Buttaro MD (International), William Hozack MD (US)

Delegates:
Craig A Aboltins MD, Olivier Borens MD, JJ Callaghan MD, Pedro Ivo de Carvalho MD, Yuhan Chang MD, Pablo Corona MD, Ferdinando Da Rin MD, Silvano Esposito MD, Thomas K Fehring MD, Xavier Flores Sanchez MD, Gwo-Chin Lee MD, JC Martinez-Pastor MD, SM Javad Mortazavi MD, Nicolas O Noiseux MD, Kuo-Ti Peng MD, Harold Delano Schutte MD, Daniel Schweitzer MD, Rihard Trebše MD, Eleftherios Tsiridis MD, Leo Whiteside MD

Vol 1, Num S1, September 2014

 

   

Question 1A: When can irrigation and debridement (I&D) be considered?

Consensus: I&D may be performed for early postoperative infections that occur within 3 months of index primary arthroplasty with less than 3 weeks of symptoms.

Delegate Vote: Agree: 84%, Disagree: 13%, Abstain: 3% (Strong Consensus)


Question 1B: Can I&D be considered for late hematogenous infections?

Consensus: I&D may be performed for patients with late hematogenous infection that occurred within 3 weeks of an inciting event or with symptoms not longer than 3 weeks.

Delegate Vote: Agree: 88%, Disagree: 9%, Abstain: 3% (Strong Consensus)


Question 2: What are the contraindications for I&D?

Consensus: The inability to close a wound or the presence of a sinus tract are absolute contraindications to performing an I&D and retention of the prosthesis. Another absolute contraindication is the presence of a loose prosthesis.

Delegate Vote: Agree: 95%, Disagree: 4%, Abstain: 1% (Strong Consensus)


Question 3A: When performing an I&D for hematoma after total knee arthroplasty (TKA), should the deep fascia be opened?

Consensus: The fascia/arthrotomy should always be opened in patients with TKA and hematoma formation.

Delegate Vote: Agree: 87%, Disagree: 8%, Abstain: 5% (Strong Consensus)


Question 3B: When performing an I&D for hematoma after total hip arthroplasty (THA), should the deep fascia be opened?

Consensus: Aspiration of the joint, either prior to surgery or at the time of I&D, should be performed. For patients with a clear fascial defect or hematoma/fluid deep to the fascia confirmed by aspiration, the fascia should be opened.

Delegate Vote: Agree: 87%, Disagree: 9%, Abstain: 4% (Strong Consensus)


Question 4: How should I&D be performed for periprosthetic joint infection (PJI)?

Consensus: An I&D of a prosthetic joint needs to be performed meticulously and according to the detailed protocol provided. Briefly this includes:
1- Preoperative optimization of the patient
2- Good visualization and thorough debridement
3- Obtaining multiple culture samples
4- Copious irrigation (6 to 9 L) of the joint
5- Explantation of the prosthesis if indicated.

Delegate Vote: Agree: 90%, Disagree: 6%, Abstain: 4% (Strong Consensus)


Question 5: Should the modular part always be exchanged during I&D?

Consensus: Yes. All modular components should be removed and exchanged, if possible, during I&D.

Delegate Vote: Agree: 92%, Disagree: 8%, Abstain: 0% (Strong Consensus)


Question 6: Do useful classification systems (such as the Tsukayama classification) exist that may guide a surgeon in deciding on the appropriateness of an I&D?

Consensus:: The available classification system is inadequate in guiding a surgeon in selecting the appropriate surgical intervention for management of early PJI. There is a need for further studies to identify risk factors for failure of I&D in patients with acute PJI.

Delegate Vote: Agree: 84%, Disagree: 5%, Abstain: 11% (Strong Consensus)


Question 7: Is I&D an emergency procedure or can the patient be optimized prior to the procedure?

Consensus: No. I&D is not an emergency procedure in a patient without generalized sepsis. All efforts should be made to optimize the patients prior to surgical intervention.

Delegate Vote: Agree: 92%, Disagree: 6%, Abstain: 2% (Strong Consensus)


Question 8: Does arthroscopy have a role in I&D?

Consensus: Arthroscopy has no role in I&D of an infected prosthetic joint.

Delegate Vote: Agree: 91%, Disagree: 7%, Abstain: 2% (Strong Consensus)


Question 9: How many I&Ds are reasonable before implant removal is considered?

Consensus: Following the failure of one I&D, the surgeon should give consideration to implant removal.

Delegate Vote: Agree: 94%, Disagree: 6%, Abstain: 0% (Strong Consensus)


Question 10: Should culture samples be taken during I&D? If so how many and from where?

Consensus: Representative tissue and fluid samples, between 3 and 6, from the periprosthetic region should be taken during I&D.

Delegate Vote: Agree: 98%, Disagree: 2%, Abstain: 0% (Strong Consensus)


Question 11: Should extended antibiotic treatment be given to patients following I&D? If so, what are the indications, type of antibiotic, dose, and duration of treatment?

Consensus: No. Extended antibiotic should only be administered to patients that meet the criteria for PJI (see workgroup 7). The type, dose and duration of antibiotic treatment for infected cases should be determined in consultation with an ID specialist.

Delegate Vote: Agree: 75%, Disagree: 20%, Abstain: 5% (Strong Consensus)


Question 12: Is there a role for intra-articular local antibiotic treatment after I&D? If so, define indications.

Consensus: No. There is inadequate evidence to support administration of continuous intra-articular antibiotics for the treatment of PJI.

Delegate Vote: Agree: 89%, Disagree: 7%, Abstain: 4% (Strong Consensus)


Question 13: Is there a role for the use of resorbable antibiotic-impregnated pellets (calcium sulfate, etc)? If so, define indications for use.

Consensus: No. Currently there is no conclusive evidence that the use of antibiotic-impregnated resorbable material improves the outcome of surgical intervention for I&D.

Delegate Vote: Agree: 88%, Disagree: 6%, Abstain: 6% (Strong Consensus)