2-Stage vs Irrigation for Infections in Unresectable Joints

What happens when patients with periprosthetic joint infection (PJI) undergo irrigation and debridement (I&D) instead of a two-stage exchange procedure?

A new unpublished study, “Outcomes of Irrigation and Debridement of Unresectable Revision Arthroplasty in Periprosthetic Joint Infection”, attempts to find an answer.

Co-author John R. Martin, M.D. told OTW, “The following study was performed to assess the clinical outcomes of patients that were treated for infection following total joint replacement in which the implants were deemed ‘unresectable.’”

“For most patients, this included revision components or extensive hardware that would be extremely debilitating or difficult to reconstruct if the implants were removed. Therefore, an I&D was performed on each patient at the discretion of the revising surgeon rather than attempting a two-stage replacement.”

“Two-stage exchange arthroplasty is currently the gold standard for treating infected total joint replacements in the United States. However, with increasing bone loss, revision constructs, and soft tissue loss, the risks of a two-stage procedure may potentially outweigh the benefits. As the clinical picture increases in complexity for this patient population, the more limited the treatment options become.”

“When patients typically reach this ‘unresectable’ stage, the goal of care in a shared-decision model change from infection eradication to keeping their implant and preserving function. In many of these patients that are considered ‘unresectable’ by the treating surgeon, irrigation and debridement may represent one of the last surgical options of preserving the patient’s limb. Therefore, we sought to report the clinical results of this patient population with an attempt at limb preservation.”

“Only about 5% of periprosthetic joint infections were deemed ‘unresectable.’ This cohort represented a very complex patient population with most patients having several revisions prior to their irrigation and debridement procedure. Approximately, 50% of patients required reoperation for infection. Very few patients had implant removal at the time of final follow-up. Finally, the majority of patients remained on chronic suppression at the final follow-up. Chronic antibiotic suppression is a desirable goal to allow patients to retain their implant and we do not consider these cases ‘failures.’”

Aldo M. Riesgo, M.D. co-author on the study and fellow with the Department of Orthopaedic Surgery at Cleveland Clinic Florida, told OTW, “The results of irrigation and debridement in this ‘unresectable’ cohort were relatively high but were not too different from patients with an infected primary total joint replacement undergoing irrigation and debridement.”

“Approximately 50% of patients will require a reoperation and the vast majority of patients will require chronic suppression. However, there are limited treatment options available. Irrigation and debridement was noted to have a low complication and mortality rate with a high success for limb salvage as an endpoint. We recommend selective use of irrigation and debridement for very complex cases in which the hardware or implants have been deemed ‘unresectable’ and the risks of the two-stage procedure outweigh the potential benefits.”