Thomas K. Fehring, M.D., a hip and knee surgeon with the OrthoCarolina Hip and Knee Center, has been awarded a grant by The Foundation for Arthroplasty Research and Education (FARE), for his research, How to Improve the Results of Irrigation and Debridement for Prosthetic Joint Infection through the use of Intraosseous Antibiotics.
Thomas Fehring, M.D. Awarded Grant for PJI Research
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#kneereplacement#debridement#intraosseousantiobiotics#thomasfehring
“When someone gets an acute infection of a knee replacement, traditionally that patient would be taken to the operating room and the joint would be washed out by irrigating and debriding, with only a 50-50 chance it would work,” said Dr. Fehring. “If it failed, the joint would then have to be removed.”
Dr. Fehring, who served as American Association of Hip and Knee Surgeons (AAHKS) president from 2013-2014, commented to OTW, “The most innovative aspect of this research is the use of intraosseous antibiotics to treat periprosthetic hip and knee infection. The use of intraosseous antibiotics to prevent infection was described by Simon Young et al. who noted an increase in tissue concentration about the knee by an order of magnitude 10 to 20 times higher than systemic IV antibiotic treatment.”
“Since results of irrigation and debridement to treat periprosthetic hip and knee infections are modest at best we hope to determine whether the use of intraosseous antibiotics at the time of irrigation and debridement would improve the unpredictable results of irrigation and debridement in prosthetic joint infection.”
“Periprosthetic hip and knee infection is a devastating complication for patient and surgeon alike. Irrigation and debridement is a time-honored method that has been used to treat acute post-operative or acute hematogenous periprosthetic infection.”
“Unfortunately, it does not work very well. Published survival rates after irrigation and debridement range from 18% – 87% and are affected by host status, organism, and timing of debridement.”
“Most arthroplasty surgeons reserve irrigation and debridement for acute perioperative infection in the first 90 days post-op or acute hematogenous infection with symptoms lasting less than four weeks. Despite this the average success rate, looking at all published studies, averages about 50%. This is clearly unacceptable to patients and surgeons. We have to do better.”
“Intuitively, if we can increase the tissue concentration around an infected total knee implant 10 to 15 fold we may be able to improve the unpredictable results of irrigation and debridement and obviate the need for subsequent prosthetic removal. Theoretically this makes sense however the purpose of this prospective randomized multicenter study is to test this theory. If we could just improve the modest results of irrigation and debridement 25% to 30% through the use of intraosseous antibiotics it could save many patients from the morbidity of needing a two-stage procedure.”
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This is a fascinating development. In my practice we've seen similar outcomes with the revised protocol. The key differentiator seems to be patient selection criteria. Has anyone else noticed the correlation with BMI thresholds?
Great point. I'd push back slightly on the conclusion, the sample size in the cited study is too small to draw population-level inferences. That said, the directional signal is compelling and worth a larger RCT.
We implemented a similar approach last year. Early results are promising but we're still gathering 12-month follow-up data. Happy to share our protocol if anyone is interested.
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