Débridement with Component Retention

Open débridement is indicated for acute postoperative infections or acute hematogenous infections in previously well functioning joints. Criteria for this procedure include a short duration of symptoms, ideally less than 2 to 3 weeks, implants that are well fixed and well positioned, and surrounding soft tissues that are in good condition with minimal scarring from previous procedures. Open débridement is contraindicated in patients with prolonged symptoms (>1 month), in patients with a poor soft-tissue envelope, or in situations in which revision is required because of loose or poorly positioned implants.

Although numerous variables affect the overall outcome of débridement, it is often difficult to isolate the importance of one single variable because they are often codependent, and studies are limited by small sample size. However, one variable, well supported in the literature, is duration of symptoms.² There is an inverse relationship between the duration of symptoms and the success of débridement. The cutoff point at which débridement is less likely to be successful is not clearly established. However, some reports indicate that symptoms of >2 weeks are associated with failed treatment.² It is likely, but not proven, that as the duration of symptoms increases, other variables, such as patient comorbidities, the status of the local soft tissues, and the virulence of the organism, play an increasingly important role in determining outcome. Therefore it is likely that a patient with 3 weeks of symptoms who is otherwise healthy, has good soft tissues, and is infected with a less-virulent organism (e.g., Streptococcus species) will have a higher chance for a successful outcome than a patient with 10 days of symptoms who has multiple medical comorbidities, has significant periarticular scarring, or is infected with a more-virulent organism (e.g., Staphylococcus aureus). All these factors must be taken into consideration when deciding what treatment option is best for the patient.

Two-Stage Exchange

Removal followed by delayed reimplantation of implants is the procedure of choice for the management of most chronic deep infections. Overall success rate for eradication of infection is higher than with a one-stage (direct) exchange but lower than with permanent resection arthroplasty. Reimplantation of the prosthesis has the obvious advantage over salvage procedures, in that it allows the best chance for maintaining a functional joint.

Two-stage reconstruction is indicated for the management of chronic deep infection. It is also indicated in the rare situation of an acute infection where the implants are loose or would otherwise need revising because of malposition, wear, or osteolysis. It is unlikely that large osteolytic defects that become acutely infected can be salvaged with débridement and implant retention alone, as it is difficult to thoroughly débride these areas; removal and reimplantation would be a better choice in these rare cases. Generally accepted contraindications include severe local tissue damage, systemic conditions that predispose toward reinfection (e.g., extensive noncompliant soft tissues with scarring secondary to radiation, or active intravenous drug abuse), and medical conditions that prevent multiple reconstructive procedures.

One-Stage (Direct) Exchange

One-stage exchange is appealing because if successful it involves only one surgical procedure and thereby less patient morbidity and overall cost. Whereas some series report favorable results for curing infection, near or equal to those of two-stage exchange, most series show results inferior to those achieved with two-stage exchange.^3,4 One common variable of successful outcomes was the use antibiotic-loaded cement directed toward the infecting organism. Hence, if a one-stage exchange is chosen, the reconstruction must be suitable for a cemented femoral component. The requirement of a cemented femoral reconstruction makes it less suitable for the majority of revision procedures.

One-stage reconstruction can be considered in patients who are of reasonably good general health but who have limited life expectancy, where a cemented reconstruction is appropriate (low demand with limited life expectancy and sufficient bone quality to support a cemented implant). Additional criteria for a one-stage exchange include an organism that is sensitive to the antibiotics used in the cement and to well-tolerated oral antibiotics, because prolonged antibiotic treatment or life-long suppression may be required.

Acute Postoperative Infections

Patients with infection in the acute postoperative period usually have signs and symptoms of infection, and the diagnosis is clinically evident. Such patients are febrile, usually show leukocytosis, and have pain. Wound problems may be evident with persistent drainage, erythema, and swelling. Occasionally the only wound finding is greater than expected warmth. Elevated inflammatories markers (erythrocyte sedimentation rate [ESR] and C-reactive protein) may be difficult to interpret, as they may still be elevated as a result of the recent surgery. However, a markedly high C-reactive protein level should raise the suspicion for infection, as this value usually returns to normal by approximately 3 weeks after surgery. Less commonly, the only symptom is pain. Patients who have pain that initially seemed well managed but increases postoperatively more than is expected should be investigated for infection.

Related posts:

The Cementless Tapered Stem Femoroacetabular Osteoplasty Reconstruction of Acetabular Bone Deficiencies Using the Antiprotrusio Cage The Cemented Stem Revision Total Hip Replacement The Cemented Stem

Stay updated, free articles. Join our Telegram channel

Join