Infection Watch

Eradicate periprosthetic infection with irrigation and debridement

I frequently receive emails from surgeons presenting cases of patients with “acute” periprosthetic joint infection asking me whether irrigation and debridement should be performed. The reason for surgeons to second-guess themselves is the number of recent publications demonstrating that irrigation and debridement (I&D) may not be as successful as previously thought. This is particularly true for infections caused by virulent organisms, such as Staphylococcus aureus. Even more alarmingly, it has been suggested that the success of a two-stage exchange arthroplasty may be compromised by a previous I&D. These findings are concerning enough to justify surgeons to revisit the traditional indications for I&D.

It is a fallacy that biofilm forms during a 3-week to 4-week period, and if one “catches” the infection within this period, then retention of prosthesis may be possible. Based on laboratory studies pathogens are found to form a mature biofilm within a few hours to days of coming into contact with the foreign material. Thus, we have to accept the fact that no I&D will ever remove all pathogens. This surgical procedure is merely an exercise to remove as much of the “bioburden” as possible to allow the subsequent antibiotics and host immune surveillance to eradicate the remaining organisms. So, how does one perform an I&D?

Removal of modular components

First and foremost, the modular components should be removed to allow access to the interface between two components where biofilm readily forms, and enable the surgeon to access hard-to-reach corners of the joint. Although there is no study proving or disproving that removal of modular components enhances the success of I&D, in my opinion it is intuitive to assume that a thorough debridement will not possible without removing the modular components. If we accept that removal of modular components is essential, then we agree there is no role for arthroscopic debridement of an infected prosthetic joint.

Javad Parvizi 

Javad Parvizi

Erik Hansen 

Erik Hansen

Second, I&D should not be relegated to a junior member of the surgical team to merely sprinkle irrigation solution in the joint. This surgical procedure needs to be performed meticulously and methodically by an experienced surgeon. Upon exposure of the joint, the surgeon needs to perform an extensive synovectomy removing the inner most layer that was in contact with pus. This means coming into close contact with collateral ligaments of the knee or periarticular muscles around the hip. The posterior capsule of the knee needs to be exposed and debrided thoroughly, again bringing the knife in close proximity to neurovascular structures. Removing all infected tissue in these cases should be treated analogous to an orthopedic oncologist removing a soft tissue sarcoma.

Debridement

Irrigation begins once debridement is performed. I personally irrigate the joint in a five steps. The first irrigation solution introduced into the joint is Dakin’s solution or hydrogen peroxide solution. I allow the solution to immerse the components while vigorously scrubbing the exposed prostheses. Dakin’s solution is potentially caustic and cytotoxic if left in contact with tissue for prolonged periods of time, thus I use 3 L of saline to irrigate out the Daikin’s solution after 3 minutes.

The next solution to be introduced is dilute betadine (0.3%) which is made by adding 17 mL of sterile 10% povidone-iodine to 500 mL saline in a basin. We allow this solution to stay in contact with the soft tissues and prosthesis for 3 minutes while scrubbing the prosthesis further. Betadine solution is then irrigated out using another 3-L solution of saline. The final solution is another 3 L of saline containing polymixin B (500,000 U) and bacitracin (50,000 U).

As the final solution is being utilized, new “sterile” environment is prepared. New draping is applied, all personnel change their gloves, suction tip is exchanged, and all instruments are removed and placed in back table. Upon completion of irrigation, the wound is closed meticulously with monofilament sutures while minimal handling of soft tissues. We apply a compressive dressing on the wound and maintain this for 48 hours. Although we do not utilize surgical drains routinely, this patient population is perhaps the most appropriate group for the use of drain to minimize collection of fluid in intra-articular space and allow for bacterial growth.

Additional steps

Here are some additional steps:

  1. Administer weight-based combined antibiotics (cephalosporin and vancomycin) at least 30 minutes prior to surgical incision and start of I&D.
  2. For an infected total knee, we often avoid using a tourniquet to allow assessing infected tissue and reach bleeding tissues.
  3. The incisional edges should be “freshened up”/sharply debrided to allow for a better closure.
  4. It is imperative to obtain between three and five tissue cultures from various parts of the infected joint. It is critically important that each sample be removed with a separate, clean instrument and placed directly into a tissue specimen container. All samples are sent to the microbiology culture for standard culture and sensitivity analysis. If there is any concern that the infecting microbe may be an atypical organism (e.g., immunosuppressed patient, etc.), then we will ask the lab to hold the specimens for a minimum of 2 weeks and also use special plating techniques with various enriched media for isolation of fungi and atypical bacteria.
  5. Until final culture data is available, we keep patients on a weight adjusted dose of IV vancomycin as our institution has a high percentage of MRSA infections. In collaboration with our infectious disease colleagues, an ultimate plan for a minimum of 2 weeks of IV antibiotics is determined.

By performing a systematic and methodical I&D, the potential for eradication of infection and retention of components can be optimized.

References

  • Azzam KA, Seeley M, Ghanem E, et al. Irrigation and debridement in the management of prosthetic joint infection: traditional indications revisited. J Arthroplasty. 2010;25:1022-1027.
  • Bedair H, Ting N, Jacovides C, et al. The Mark Coventry Award: Diagnosis of early postoperative TKA infection using synovial fluid analysis. Clin Orthop Relat Res. 2011;469:34-40.
  • Ghanem E, Parvizi J, Clohisy J, et al. Perioperative antibiotics should not be withheld in proven cases of periprosthetic infection. Clin Orthop Relat Res. 2007;461:44-47.
  • Odum SM, Fehring TK, Lombardi AV, et al. Irrigation and debridement for periprosthetic infections: Does the organism matter? J Arthroplasty. 2011; 26:114-118.
  • Parvizi J, Jacovides C, Antoci V, Ghanem E. Diagnosis of periprosthetic joint infection: The utility of a simple yet unappreciated enzyme. J Bone Joint Surg Am. 2011;93:2242-2248.
  • Sherrell JC, Fehring TK, Odum S, et al. The Chitranjan Ranawat Award: Fate of two-stage reimplantation after failed irrigation and debridement for periprosthetic knee infection. Clin Orthop Relat Res. 2011;469:18-25.

For more information:

  • Javad Parvizi, MD, FRCS, editor of Infection Watch, can be reached at the Rothman Institute, 925 Chestnut St., 5th Floor, Philadelphia, PA 19107; 267-339-3617; email: parvj@aol.com.
  • Disclosures: Parvizi is a consultant to Stryker. Hansen has no relevant financial disclosure.

I frequently receive emails from surgeons presenting cases of patients with “acute” periprosthetic joint infection asking me whether irrigation and debridement should be performed. The reason for surgeons to second-guess themselves is the number of recent publications demonstrating that irrigation and debridement (I&D) may not be as successful as previously thought. This is particularly true for infections caused by virulent organisms, such as Staphylococcus aureus. Even more alarmingly, it has been suggested that the success of a two-stage exchange arthroplasty may be compromised by a previous I&D. These findings are concerning enough to justify surgeons to revisit the traditional indications for I&D.

It is a fallacy that biofilm forms during a 3-week to 4-week period, and if one “catches” the infection within this period, then retention of prosthesis may be possible. Based on laboratory studies pathogens are found to form a mature biofilm within a few hours to days of coming into contact with the foreign material. Thus, we have to accept the fact that no I&D will ever remove all pathogens. This surgical procedure is merely an exercise to remove as much of the “bioburden” as possible to allow the subsequent antibiotics and host immune surveillance to eradicate the remaining organisms. So, how does one perform an I&D?

Removal of modular components

First and foremost, the modular components should be removed to allow access to the interface between two components where biofilm readily forms, and enable the surgeon to access hard-to-reach corners of the joint. Although there is no study proving or disproving that removal of modular components enhances the success of I&D, in my opinion it is intuitive to assume that a thorough debridement will not possible without removing the modular components. If we accept that removal of modular components is essential, then we agree there is no role for arthroscopic debridement of an infected prosthetic joint.

Javad Parvizi 

Javad Parvizi

Erik Hansen 

Erik Hansen

Second, I&D should not be relegated to a junior member of the surgical team to merely sprinkle irrigation solution in the joint. This surgical procedure needs to be performed meticulously and methodically by an experienced surgeon. Upon exposure of the joint, the surgeon needs to perform an extensive synovectomy removing the inner most layer that was in contact with pus. This means coming into close contact with collateral ligaments of the knee or periarticular muscles around the hip. The posterior capsule of the knee needs to be exposed and debrided thoroughly, again bringing the knife in close proximity to neurovascular structures. Removing all infected tissue in these cases should be treated analogous to an orthopedic oncologist removing a soft tissue sarcoma.

Debridement

Irrigation begins once debridement is performed. I personally irrigate the joint in a five steps. The first irrigation solution introduced into the joint is Dakin’s solution or hydrogen peroxide solution. I allow the solution to immerse the components while vigorously scrubbing the exposed prostheses. Dakin’s solution is potentially caustic and cytotoxic if left in contact with tissue for prolonged periods of time, thus I use 3 L of saline to irrigate out the Daikin’s solution after 3 minutes.

The next solution to be introduced is dilute betadine (0.3%) which is made by adding 17 mL of sterile 10% povidone-iodine to 500 mL saline in a basin. We allow this solution to stay in contact with the soft tissues and prosthesis for 3 minutes while scrubbing the prosthesis further. Betadine solution is then irrigated out using another 3-L solution of saline. The final solution is another 3 L of saline containing polymixin B (500,000 U) and bacitracin (50,000 U).

As the final solution is being utilized, new “sterile” environment is prepared. New draping is applied, all personnel change their gloves, suction tip is exchanged, and all instruments are removed and placed in back table. Upon completion of irrigation, the wound is closed meticulously with monofilament sutures while minimal handling of soft tissues. We apply a compressive dressing on the wound and maintain this for 48 hours. Although we do not utilize surgical drains routinely, this patient population is perhaps the most appropriate group for the use of drain to minimize collection of fluid in intra-articular space and allow for bacterial growth.

Additional steps

Here are some additional steps:

  1. Administer weight-based combined antibiotics (cephalosporin and vancomycin) at least 30 minutes prior to surgical incision and start of I&D.
  2. For an infected total knee, we often avoid using a tourniquet to allow assessing infected tissue and reach bleeding tissues.
  3. The incisional edges should be “freshened up”/sharply debrided to allow for a better closure.
  4. It is imperative to obtain between three and five tissue cultures from various parts of the infected joint. It is critically important that each sample be removed with a separate, clean instrument and placed directly into a tissue specimen container. All samples are sent to the microbiology culture for standard culture and sensitivity analysis. If there is any concern that the infecting microbe may be an atypical organism (e.g., immunosuppressed patient, etc.), then we will ask the lab to hold the specimens for a minimum of 2 weeks and also use special plating techniques with various enriched media for isolation of fungi and atypical bacteria.
  5. Until final culture data is available, we keep patients on a weight adjusted dose of IV vancomycin as our institution has a high percentage of MRSA infections. In collaboration with our infectious disease colleagues, an ultimate plan for a minimum of 2 weeks of IV antibiotics is determined.

By performing a systematic and methodical I&D, the potential for eradication of infection and retention of components can be optimized.

References

  • Azzam KA, Seeley M, Ghanem E, et al. Irrigation and debridement in the management of prosthetic joint infection: traditional indications revisited. J Arthroplasty. 2010;25:1022-1027.
  • Bedair H, Ting N, Jacovides C, et al. The Mark Coventry Award: Diagnosis of early postoperative TKA infection using synovial fluid analysis. Clin Orthop Relat Res. 2011;469:34-40.
  • Ghanem E, Parvizi J, Clohisy J, et al. Perioperative antibiotics should not be withheld in proven cases of periprosthetic infection. Clin Orthop Relat Res. 2007;461:44-47.
  • Odum SM, Fehring TK, Lombardi AV, et al. Irrigation and debridement for periprosthetic infections: Does the organism matter? J Arthroplasty. 2011; 26:114-118.
  • Parvizi J, Jacovides C, Antoci V, Ghanem E. Diagnosis of periprosthetic joint infection: The utility of a simple yet unappreciated enzyme. J Bone Joint Surg Am. 2011;93:2242-2248.
  • Sherrell JC, Fehring TK, Odum S, et al. The Chitranjan Ranawat Award: Fate of two-stage reimplantation after failed irrigation and debridement for periprosthetic knee infection. Clin Orthop Relat Res. 2011;469:18-25.

For more information:

  • Javad Parvizi, MD, FRCS, editor of Infection Watch, can be reached at the Rothman Institute, 925 Chestnut St., 5th Floor, Philadelphia, PA 19107; 267-339-3617; email: parvj@aol.com.
  • Disclosures: Parvizi is a consultant to Stryker. Hansen has no relevant financial disclosure.