Debridement, antibiotics and implant retention in management of infected total knee arthroplasty: A systematic review

Accepted Manuscript

Debridement, Antibiotics and Implant Retention in Management of Infected Total Knee Arthroplasty; a systematic review S Horriat , S Ayyad , R Thakrar , F Haddad PII: DOI: Reference:

S1045-4527(19)30012-4 https://doi.org/10.1053/j.sart.2019.01.012 YSART 50836

To appear in:

Seminars in Arthroplasty

Please cite this article as: S Horriat , S Ayyad , R Thakrar , F Haddad , Debridement, Antibiotics and Implant Retention in Management of Infected Total Knee Arthroplasty; a systematic review, Seminars in Arthroplasty (2019), doi: https://doi.org/10.1053/j.sart.2019.01.012

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Debridement, Antibiotics and Implant Retention in Management of Infected Total Knee Arthroplasty; a systematic review Horriat S1, Ayyad S1, Thakrar R2, Haddad F3 1-Clinical Fellow, University College London Hospital NHSFT

3- Professor of Orthopaedic Surgery, University College London Hospital

Abstract

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2- Clinical Fellow, Hampshire Hospitals NHSFT

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Total knee arthroplasty is a life changing operation. Although a rare complication, periprosthetic joint infection (PJI) can be a devastating event for patient and can be a challenging experience for the treating department. Management of the PJI is generally operative combined with extensive antibiotic therapy. The primary aim of treatment is to restore a functioning joint, either with debridement and retaining the well-fixed implants or with revision of part or all of the components. Whilst two stage revision arthroplasty has been considered as optimal treatment for PJI by many surgeons, Debridement, Antibiotics and Implant Retention (DAIR) could be considered as an alternative option in a selected group of patients.

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In this study we review the recent literature to explore the efficacy and outcome of DAIR in PJI. We included all recent studies, which have used DAIR in PJI around total knee arthroplasty and assess for factors that would be either positive or negative towards the outcome. We particularly wanted to review role of timing of surgery and infecting organisms in outcomes of the treatment. We have also tried to identify whether patients have better functional outcome following DAIR in comparison to revision surgeries.

Introduction Total knee arthroplasty (TKA) is a life changing procedure, where demand is expected to rise by 673% to 3.48 million operations in the United States by 2030.1 Whilst 10 year failure rate of TKA is close to 5%, the most common causes of failure are aseptic loosening and infection (30% and 15% of failed operations respectively).2 The incidence of periprosthetic joint infection (PJI) after TKA is as high as 2% in the literature.3-5 However, up to 10% of failed TKA due to aseptic loosening could also have positive intra-operative cultures, indicative of a clinically occult infection.6 Due to the significance of PJI multiple studies focused on risk

ACCEPTED MANUSCRIPT factors for PJI,7-9 diagnostic tests and pathways to accurately diagnose the PJI10-12 and particularly investigating the factors influencing outcome results of treatments after PJI.13-16

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Management of PJI includes a combination of operative intervention and extended antibiotic therapy. The aim of operative treatment is to restore a functioning joint, either with debridement and retaining the well-fixed implants or with revising of part or all of the components. Debridement, antibiotics with implant retention (DAIR) carries less morbidity compared to revision surgery,17 with functional outcomes comparable to primary arthroplasty 18-19 and significantly better than two-stage revisions.19 During the procedure extensive soft tissue debridement is required in order to remove all necrotic and suspicious tissues to clear any source of infection; however preference is to retain all well fixed implants in place and only replace the modular components. Revision surgery, on the other hand, can either be a single or a multi-stage procedure, which requires removal of all components in order to eradicate infection before implanting a new prosthetic joint. 20-22

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The choice of surgery is dependent on multiple factors. Patient fitness for surgery and other co-morbidities are considered to be the most important factors for dictating the choice of intervention. It appears that the time since beginning of symptoms can also play an important role in the outcome results of the interventions. 13,23,24 DAIR is considered an alternative option to revision surgery particularly in the acute setting, where revision is more reliable option for PJI with symptoms that have lasted longer than a few weeks.19-24

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In this literature review we wanted to explore the efficacy and outcome of DAIR in PJI after TKA. We aim to include all recent studies, which have used DAIR in PJI around total knee arthroplasty and assess for factors that would be either positive or negative towards the outcome. We believe in doing so we can identify predictive factors in achieving better outcomes to choose the correct patient population for DAIR.

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Materials and Methods

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Our study is a systematic review using PRISMA checklists for protocol and report preparation. We aim to review the outcome of acute periprosthetic joint infection around total knee arthroplasty treated with debridement antibiotics and implant retention (DAIR). As per checklist recommendation participants were defined as patients with acute PJI (within 4 weeks of surgery or acute haematogenous infection) around their total knee arthroplasty. Debridement, antibiotics and implant retention was defined as intervention. We considered two stage revision as optimal treatment for PJI as comparison and outcome was infection eradication confirmed according to the clinicians assessment in their last follow up review. We included all prospective, retrospective, randomised and comparative studies in our review. However, we excluded review articles, expert opinions and case reports with less than 10 patients in their series. Other inclusion criteria for selected articles

ACCEPTED MANUSCRIPT were, acute infections in their cohort with intervention within 4 weeks of first presentation of symptoms (Type II and III according to classification of infection on the basis of the clinical presentation)25, studies with at least 10 PJIs around total knee arthroplasty in their series all treated with DAIR. Articles must have minimum of two years follow up of their patients and clear microbiology results of the infective organisms. We excluded non-English language articles, conference abstracts without access to the full presentation details and studies without clear definition of interventions, diagnosis or follow up arrangements.

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An electronic literature search has been performed in August 2018 using OVID-EMBASE and MEDLINE search engines, looking at acute PJI in total knee arthroplasty treated with DAIR, published in the English literature during the last 10 years. We also included search through the references of the selected articles to identify relevant and appropriate articles not already indexed in the electronic search. The preliminary literature search was performed using (knee arthroplasty) AND (infection) AND (Debridement) as search terms all in the Abstract and / or Title. Filters applied to limit the search to the articles published from 2008 onward. Title and abstracts of all hits in the preliminary search were reviewed independently by authors (SH and SA) and appropriate articles were selected for their full text to be examined against our study inclusion and exclusion criteria.

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Results

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Electronic literature search as described in the methodology was performed and narrowed down to 197 hits after removing the duplicate articles and non-English literature. By reading through the titles and abstracts 160 articles met the exclusion criteria set in the study method and have been excluded from the review. Authors selected the remaining 37 articles for a detailed review of their full texts. Further 18 articles were excluded from the review after their full texts were examined by authors. Seven articles have been excluded due to inadequate minimum follow up. The other 11 articles were excluded due to lack of required information set in the study method. Nineteen articles published between 2009 and 2018 have been selected for the review including 835 patients with acute PJI around their total knee arthroplasty with minimum of 2 years follow up. In total 285 patients had recurrence of infection with overall failure rate of the intervention 34.1%. There were 2 prospective and 17 retrospective studies mostly case series (level IV evidence)26. The highest infection control rate was reported by Wang et al 2015 with 100% infection control in early infection after primary total knee arthroplasty in a group of 10 patients, 3 infected with MRSA27. Three studies exclusively reviewed patients with periprosthetic Methicillin Resistant Staphylococcal infections around total knee arthroplasty (TKA) and showed poor infection control rates and recurrence of infection between 54-84%. Bradbury et al 2009 has reported failure of intervention to eradicate the infection in 84% of their patients (16 out of

ACCEPTED MANUSCRIPT 19 patients) with MRSA infection28. Also Siddiqui et al 2013 showed a recurrence rate of 66% with failure of procedure to eradicate infection in 8 out of 12 of their patients, once again with MRSA infection around their total knee arthroplasty.29 Parvizi et al 2009 had 54.5% recurrence of infection in 11 PJI (MRSA and MRSE) around TKA treated with debridement and retention of implant.30 However, Vilchez et al 2011 have only included patients with Staphylococcus aureus PJI in their study and report a 75% infection control in their patients but only 69% in knee PJI.31

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Two studies reviewed outcome results of DAIR in Haematogenous infections following TKA, and both showed almost 80% success in infection control in their follow up. Konigsberg et al 2014 had 42 infected knees and only 9 required further surgeries to control infection 32, whilst He et al 2016 in a smaller group of patients showed 81% success 33. Both studies report excellent success rates of better than 95% in non-Staphylococcal infections.

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Apart from Wang et al,27 which has reported 100% success in debridement of the early PJI and considered exchange of the polyethylene in all cases, five other studies specifically looked at the success rate after the debridement with exchange of the tibial modular component (polyethylene liner), with 61-88% eradication of infection during their follow up period 1,34-37. However, two studies with more than 80% success in PJI control had a significant number of patients with negative culture and no growth in their primary investigations.36,37

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We have identified only one study with arthroscopic debridement of acute knee PJI. Chung et al 2014 report 62% infection eradication in a selected group of knee PJI, with duration of symptoms less than 72 hours and no evidence of implant loosening. The main organisms identified in the recurrent cases were MSSA, Mycobacterium and Streptococcus.38 In their study group, patients with failed arthroscopic treatment had subsequent standard open debridement.

Discussion

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Successful infection control Whilst two stage revision arthroplasty still considered as the optimal treatment for PJI, single stage revision and DAIR are gaining popularity due to improving outcome results of these procedures.5 Historically expected success rate for DAIR was between 20-30%.39 Schoifet and Morrey in 1990 reported disappointing 23% success rate for DAIR in knee PJI in their group of patients, mostly acute PJI.40 However, Mont et al in 1997 showed better than 70% infection control with DAIR in knee PJIs in early post-operative and acute haematogenous patients.41 With better understanding of the factors influencing the success rate of DAIR, the average success rate of the intervention has improved by more than 20% during the last 15 years.13 Our review explored the recent published evidence around knee

ACCEPTED MANUSCRIPT PJI treated with DAIR and demonstrated more than 65% overall success rate of the this treatment (range between 16-100%).

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In this review, most studies report better than 60% infection control rate. Early postoperative31 and acute haematogenous infections33 (Tsukayama II and III), organisms sensitive to available antibiotics, selection of appropriate antibiotics targeting the high virulence organisms,35 and considering exchange of the modular component (polyethylene line)34 have been considered as important factors for better infection control rate in different studies in our review. Role of highly virulent organisms

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Gram positive organisms mainly Methicillin Sensitive Staphylococcus were the commonest organism identified in this review, however, there was significant attention to antimicrobial resistant organisms, particularly Methicillin Resistance Staphylococcus in some of the selected studies in this review. At least in 3 articles authors failed to show promising results for DAIR in specific group of patients infected with highly resistant or virulent organisms. Devastating failure rate of 60 to more than 80% has been reported particularly when MRSA was the main infective organism in the series.28,29 Parvizi et al 2009, also showed more than 50% failure rate of DAIR in a group of patients infected with Methicillin Resistant Staphylococcus.30 Koyonos et al 2011, had failure rate of 65% for PJI treated with debridement, and they have concluded Staphylococcal infection as the main risk factor for failure of the intervention.42 This might also reflect in the result of Matsumoto et al study in 2015, when concluded no difference in the outcome results of debridement in early postoperative or acute haematogenous infection with Methicillin Resistant or Methicillin Sensitive Staphylococcus, particularly as their overall success rate was still below 50% in both groups.43

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Akgun et al in 2017, reports significant failure of treatment in presence of Streptococcal infection with even up to 45% recurrence after two stage revision. However in the very same study failure of DAIR was only 33%.44 He et al in 2016 in their small group of patients had infection control in more than 80% of their PJIs all with streptococcal infection. All patients with Staphylococcal infection in this series had recurrence of infection. 33 Also FontVizcarra et al in 2012 report infection control in more than 80% in their cohort with more probability of recurrence in the patients with Staphylococcal infections. 45 On the other hand, Holmberg et al in 2015 in the only joint registry study in our review, report a success rate of 75% for DAIR and has showed that 60% of the knee PJIs were due to Staphylococcal organisms (37% Staphylococcus aureus and 23% Coagulase negative Staphylococcus). Whilst according to their results, type of organism did not have any effect on the outcome results of the DAIR procedure in knee PJIs, operations within 3 weeks of the beginning of symptoms were associated with better infection control rate.35

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Similar to the results from Holmberg et al, some of the studies in our review report excellent infection control in their small subgroup of highly selected patients without excluding MRSA or MRSE. Son et al in 2017 had 100% infection control in part of their selected cohort of patients with Tsukayama type II (early post-operative) knee PJI. In their study timing of the intervention has been considered the main reason for high success rate. The overall success rate in all patients in this study was 88%.37 Similarly, Wang et al in 2015 report 100% infection control in 10 patients with acute infection following primary TKA, including 3 MRSA positive patients. Successful infection control in this study has also been attributed to early debridement in acute infections around primary TKA.27 Functional outcome after DAIR

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Functional outcomes after revision TKA is rather poor. In a recently published study, of 30 patients in the working age, who had revision TKA, only one (3%) has returned to full-time work by one year.46 Unfortunately there are very limited studies in the recent literature, exploring functional outcomes after PJI treated with DAIR. Cury et al in 2015 reports 75% infection control in their group of PJIs treated DAIR compared to 100% in two stage revision. However, they showed better quality of life and functional outcome after DAIR in comparison to revisions, particularly as patients with DAIR do better than both single stage revision and two stage revision in their functional capacity, pain and general health status.47 Chung et al in 2014, reported considerable improvement in WOMAC and The Knee Society scores after successful infection control following acute knee PJI treated with arthroscopic wash out and debridement.38 A recently published clinical study has assessed the functional outcomes of patients, whom had DAIR compared to revision. They have considered functional outcome of primary arthroplasty patient as control. They have found that the functional scores were comparable between the primary and the DAIR group, but the revision group had worse score.19 On the other hand, Lizaur-Utrilla et al 2015, have compared functional outcomes of DAIR with 2 stage revision patients. In their study the final functional outcome score has improved in both groups however, it was significantly better in the revision group.48 As the supporting evidence is very limited we defer drawing any conclusion on this matter upon review of further studies in the literature assessing functional outcomes in PJI patient population treated with different surgical interventions. Socioeconomic burden There was no significant information on the socioeconomic advantage of the DAIR in our selected studies. However the socioeconomic burden of revision surgery for PJI remains an on-going issue, and we thought it needed to be included, particularly as some studies reporting costs in excess of 3 to 4 times that of primary arthroplasty surgery and twice that for revision in aseptic cases.49 Much of this cost constitutes significantly longer length of hospital stay 50 amongst other things such as number of operations, longer operative time and greater use of antibiotics. Garrido-Gómez J et al 2013 showed that surgical interventions for early PJI cost significantly less compared to late PJI. 51

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The economic effects of different surgical strategies in the approach to management of PJIs have been sparsely reported in the selected studies. Whilst exchange arthroplasty is well accepted by many studies it is likely to have a higher rate of surgical morbidity and is more expensive than debridement and retention.52 Due to higher success rate of revision arthroplasty it could appear to be more cost effective option, however with improving success rate of DAIR in selected patients, this option might also have adequate economic justification. Fisman et al,53 in their study based on a mathematical model, compared the effect of different treatment options on quality of life in infected THAs. Comparing implant retention vs. two stage revision (with median time to implantation of 2 months), patients undergoing debridement and retention were subject to a greater number of operations and also a higher infection recurrence rate. However, when age was taken into account (i.e. frail population over the age of 80), the quality adjusted life expectancy was superseded using the implant retention approach. In their study debridement and retention was shown to increase life expectancy by 2.2-2.6 quality adjusted life months and furthermore had a favourable cost-effectiveness ratio. On this basis it may be suggested that debridement and retention could also be a cost effective strategy for treatment of PJIs in the older population.

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Conclusion

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Most of the selected articles in this review were retrospective series. Due to lack of wellstructured clinical trials drawing a robust conclusion on the effect of infecting organisms and timing of the intervention on the clinical outcome of DAIR and success in infection control is difficult, however, majority of the retrieved articles suggested better outcomes with DAIR in early post-operative infections or acute haematogenous infection and less favourable outcomes of DAIR in the presence of staphylococcal infections particularly Methicillin resistant ones. The most interesting finding from reviewed articles was that in highly selected series of patients DAIR with less morbidity can have a plausible success rate close to more invasive revision surgeries with higher morbidity. Whilst further well-structured studies needed to clarify clear indications and predictive factors of successful DAIR in PJI, we recommend DAIR and exchange of modular component of prosthetic joint in highly selected patients including early post-operative infections (less than 4 weeks from the index operations) and acute haematogenous PJI.

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References: 1) Duque AF, Post ZD, Lutz RW, Orozco FR, Pulido SH, Ong AC. Is there still a role for irrigation

4)

5) 6)

7)

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3)

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2)

and debridement with liner exchange in acute periprosthetic total knee infection?. The Journal of arthroplasty. 2017 Apr 1;32(4):1280-4. Khan M, Osman K, Green G, Haddad FS. The epidemiology of failure in total knee arthroplasty: avoiding your next revision. The bone & joint journal. 2016 Jan;98(1_Supple_A):105-12. Bozic KJ, Kurtz SM, Lau E, et al. The epidemiology of revision total knee arthroplasty in the United States. Clin Orthop Relat Res. 2010. Jan;468(1):45-51. Doi:10.10pu/s11999-0090945x0 Parvizi J, Alijanipour P, Barbering EF, et al. Novel developments in the prevention diagnosis and treatment of periprostheic joint infections. J Am Acad Orthop Surgery. 2015 Apr;23 Suppl:S32-43. Thakrar R, Horriat S, Kayani B, et al. Indications for a single-stage exchange arthroplasty for chronic prosthetic joint infection. CCJR supplement to BJJ. 2018 Jacobs AM, Bénard M, Meis JF, van Hellemondt G, Goosen JH. The unsuspected prosthetic joint infection: incidence and consequences of positive intra-operative cultures in presumed aseptic knee and hip revisions. The bone & joint journal. 2017 Nov;99(11):1482-9. De Jong L, Klem TM, Kuijper TM, Roukema GR. Factors affecting the rate of surgical site infection in patients after hemiarthroplasty of the hip following a fracture of the neck of the femur. The bone & joint journal. 2017 Aug;99(8):1088-94.

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8) Hexter AT, Hislop SM, Blunn GW, Liddle AD. The effect of bearing surface on risk of periprosthetic joint infection in total hip arthroplasty: a systematic review and meta-analysis. The bone & joint journal. 2018 Feb;100(2):134-42. 9) Bloch BV, Shah A, Snape SE, Boswell TC, James PJ. Primary hip and knee arthroplasty in a temporary operating theatre is associated with a significant increase in deep periprosthetic infection. The bone & joint journal. 2017 Jul;99(7):917-20. 10) Dattilo J, Gittings M, Lee C, et al. ‘Hot Joint’ infection protocol reduces unnecessary post-

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operative re-admissions following total hip and knee arthroplasty. BJJ. 2017;99-B, issue 12. 11) Partridge DG, Winnard C, Townsend R, Cooper R, Stockley I. Joint aspiration, including culture of reaspirated saline after a ‘dry tap’, is sensitive and specific for the diagnosis of hip and knee prosthetic joint infection. Bone Joint J. 2018 Jun;100(6):749-54.

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12) Marson BA, Deshmukh SR, Grindlay DJ, Scammell BE. Alpha-defensin and the Synovasure lateral flow device for the diagnosis of prosthetic joint infection: a systematic review and meta-analysis. Bone Joint J. 2018 Jun;100(6):703-11. 13) Tsang SJ, Ting J, Simpson AH, Gaston P. Outcomes following debridement, antibiotics and implant retention in the management of periprosthetic infections of the hip: a review of cohort studies. The bone & joint journal. 2017 Nov;99(11):1458-66. 14) Akgün D, Trampuz A, Perka C, Renz N. High failure rates in treatment of streptococcal

periprosthetic joint infection: results from a seven-year retrospective cohort study. The bone & joint journal. 2017 May;99(5):653-9. 15) Lora-Tamayo J, Senneville É, Ribera A, Bernard L, Dupon M, Zeller V, Li HK, Arvieux C, Clauss M, Uçkay I, Vigante D. The not-so-good prognosis of streptococcal periprosthetic joint infection managed by implant retention: the results of a large multicenter study. Clinical infectious diseases. 2017 Jun 15;64(12):1742-52.

ACCEPTED MANUSCRIPT 16) Sendi P, Lötscher PO, Kessler B, Graber P, Zimmerli W, Clauss M. Debridement and implant

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retention in the management of hip periprosthetic joint infection: outcomes following guided and rapid treatment at a single centre. The bone & joint journal. 2017 Mar;99(3):3306. 17) Haddad, F. S. Even the winners are losers. The Bone & Joint Journal. 2017 99-B:5, 561-562. 18) Streubel PN, Simone JP, Morrey BF, Sanchez-Sotelo J, Morrey ME. Infection in total elbow arthroplasty with stable components: outcomes of a staged surgical protocol with retention of the components. The bone & joint journal. 2016 Jul;98(7):976-83. 19) Grammatopoulus G, Murray DW, Taylor AH, et al. Functional outcome of debridement, antibiotics and implant retention in periprosthetic joint infection involving the hip: a casecontrol study. Bone Joint J. 2017 May;99-B(5):614-622. Doi:10.1302/0301-620X.99B5.BJJ2016-0562-R2. 20) Whitehouse MR, Parry MC, Konan S, Duncan CP. Deep infection after hip arthroplasty: staying current with change. The bone & joint journal. 2016 Jan;98(1_Supple_A):27-30. 21) Parvizi J, Zmistowski B, Adeli B. Periprosthetic joint infection: treatment options.

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Orthopedics. 2010 Sep 1;33(9). 22) Blom AW, Brown J, Bannister, et al. Infection after total knee arthroplasty. BJJ. 2004;86-B, issue 5. 23) Kinckinger. Early Debridement as treatment for post-operative wound complications in total knee arthroplasty. In Orthopaedic Proceedings 2015 Dec (Vol. 97, No. SUPP_16, pp. 131131). The British Editorial Society of Bone & Joint Surgery. 24) Narayanan R, Anoushiravani AA, Schwarzkopf R, et al. Irrigation and Debridement for Early Periprosthetic Knee Infection: Is It Effective? J Arthroplasty. 2018 Jun;33(6):1872-1878. doi: 10.1016/j.arth.2017.12.039.

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25) Tsukayama DT, Goldberg VM, Kyle R. Diagnosis and management of infection after total knee arthroplasty. JBJS. 2003 Jan 1;85:75-80. 26) Phillips B, Ball C, Sackett D, et al. Oxford Centre for Evidence-based – Levels of Evidence

(March 2009). https://www.cebm.net/2009/06/oxford-centre-evidence-based-medicinelevels-evidence-march-2009/ (date last accessed 17 July 2018).

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27) Wang KH, Stephen WY, Iorio R, Marcantonio AJ, Kain MS. Long term treatment results for deep infections of total knee arthroplasty. The Journal of arthroplasty. 2015 Sep 1;30(9):16238. 28) Bradbury T, Fehring TK, Taunton M, Hanssen A, Azzam K, Parvizi J, Odum SM. The fate of

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acute methicillin-resistant Staphylococcus aureus periprosthetic knee infections treated by open debridement and retention of components. The Journal of arthroplasty. 2009 Sep 1;24(6):101-4. 29) Siddiqui MM, Lo NN, Ab Rahman S, Chin PL, Chia SL, Yeo SJ. Two-year outcome of early deep MRSA infections after primary total knee arthroplasty: a joint registry review. The Journal of arthroplasty. 2013 Jan 1;28(1):44-8. 30) Parvizi J, Azzam K, Ghanem E, Austin MS, Rothman RH. Periprosthetic infection due to resistant staphylococci: serious problems on the horizon. Clinical Orthopaedics and Related Research®. 2009 Jul 1;467(7):1732-9. 31) Vilchez F, Martínez‐Pastor JC, Garcia‐Ramiro S, Bori G, Maculé F, Sierra J, Font L, Mensa J, Soriano A. Outcome and predictors of treatment failure in early post‐surgical prosthetic joint infections due to Staphylococcus aureus treated with debridement. Clinical Microbiology and Infection. 2011 Mar 1;17(3):439-44.

ACCEPTED MANUSCRIPT 32) Konigsberg BS, Della Valle CJ, Ting NT, Qiu F, Sporer SM. Acute hematogenous infection

following total hip and knee arthroplasty. The Journal of arthroplasty. 2014 Mar 1;29(3):46972. 33) He R, Yang L, Guo L, Chen H, Zhang Y, Jiang DM. Management of Acute Hematogenous Infection Following Total Knee Arthroplasty: A Case Series of 11 Patients. Orthopaedic surgery. 2016 Nov;8(4):475-82. 34) Zhang C, Yan CH, Chan PK, Ng FY, Chiu KY. Polyethylene insert exchange is crucial in debridement for acute periprosthetic infections following total knee arthroplasty. The journal of knee surgery. 2017 Jan;30(01):36-41. 35) Holmberg A, Thórhallsdóttir VG, Robertsson O, W-Dahl A, Stefánsdóttir A. 75% success rate

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after open debridement, exchange of tibial insert, and antibiotics in knee prosthetic joint infections: Report on 145 cases from the Swedish Knee Arthroplasty Register. Acta orthopaedica. 2015 Jul 4;86(4):457-62. 36) Klare CM, Fortney TA, Kahng PW, Cox AP, Keeney BJ, Moschetti WE. Prognostic Factors for Success After Irrigation and Debridement With Modular Component Exchange for Infected Total Knee Arthroplasty. The Journal of arthroplasty. 2018 Jul 1;33(7):2240-5. 37) Son WS, Shon OJ, Lee DC, Park SJ, Yang HS. Efficacy of open debridement and polyethylene exchange in strictly selected patients with infection after total knee arthroplasty. Knee surgery & related research. 2017 Sep;29(3):172. 38) Chung JY, Ha CW, Park YB, Song YJ, Yu KS. Arthroscopic debridement for acutely infected prosthetic knee: any role for infection control and prosthesis salvage?. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2014 May 1;30(5):599-606. 39) Kalore NV, Gioe TJ, Singh JA. Diagnosis and management of infected total knee arthroplasty.

42)

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43)

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41)

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40)

The open orthopaedics journal. 2011;5:86. Schoifet SD, Morrey BF. Treatment of infection after total knee arthroplasty by débridement with retention of the components. The Journal of bone and joint surgery. American volume. 1990 Oct;72(9):1383-90. Mont MA, Waldman B, Banerjee C, Pacheco IH, Hungerford DS. Multiple irrigation, debridement, and retention of components in infected total knee arthroplasty. The Journal of arthroplasty. 1997 Jun 1;12(4):426-33. Koyonos L, Zmistowski B, Della Valle CJ, Parvizi J. Infection control rate of irrigation and debridement for periprosthetic joint infection. Clinical Orthopaedics and Related Research®. 2011 Nov 1;469(11):3043. Matsumoto T, Ishida K, Tsumura N, Nagai K, Muratsu H, Hida Y, Hiranaka T, Kuroda R, Kurosaka M. Treatment of 50 deep infections after total knee arthroplasty. Orthopedics. 2015 Jun 12;38(6):e529-35.

44) Akgün D, Trampuz A, Perka C, Renz N. High failure rates in treatment of streptococcal periprosthetic joint infection: results from a seven-year retrospective cohort study. The bone & joint journal. 2017 May;99(5):653-9. 45) Font-Vizcarra L, García S, Bori G, Martinez-Pastor JC, Zumbado A, Morata L, Mensa J,

Soriano A. Long-term results of acute prosthetic joint infection treated with debridement and prosthesis retention: a case-control study. The International journal of artificial organs. 2012 Oct;35(10):908-12. 46) Scott CE, Turnbull GS, Powell-Bowns MF, MacDonald DJ, Breusch SJ. Activity levels and return to work after revision total hip and knee arthroplasty in patients under 65 years of age. Bone Joint J. 2018 Aug;100(8):1043-53.

ACCEPTED MANUSCRIPT 47) Cury RD, Cinagawa EH, Camargo OP, Honda EK, Klautau GB, Salles MJ. Treatment of

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51)

52)

53)

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49)

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48)

infection after total knee arthroplasty. Acta ortopedica brasileira. 2015 Oct;23(5):239-43. Lizaur-Utrilla A, Gonzalez-Parreño S, Lopez-Prats FA, et al. Debridement with prosthesis retention and antibiotherapy vs. two-stage revision for periprosthetic knee infection within 3 months after arthroplasty: a case–control study. Clin Microbiol Infect. 2015 Sep;21(9):851.e11-7. doi: 10.1016/j.cmi.2015.05.028. Hebert CK, Williams RE, Levy RS, Barrack RL. Cost of treating an infected total knee replacement. Clinical Orthopaedics and Related Research®. 1996 Oct 1;331:140-5. Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infection Control & Hospital Epidemiology. 1999 Nov;20(11):725-30. Garrido-Gómez J, Arrabel-Polo MA, Parra-Ruiz J, et al. Descriptive analysis of the economic costs of periprosthetic joint infection of the knee for the public health system of Andalusia. J Arthroplasty. 2013 Aug;28(7):1057-1060. Hernández-Vaquero D, Fernández-Fairen M, Torres A, Menzie AM, Fernández-Carreira JM, Murcia-Mazon A, Guerado E, Merzthal L. Treatment of periprosthetic infections: an economic analysis. The Scientific World Journal. 2013;2013. Fisman DN, Reilly DT, Karchmer AW, Goldie SJ. Clinical effectiveness and cost-effectiveness of 2 management strategies for infected total hip arthroplasty in the elderly. Clinical Infectious Diseases. 2001 Feb 1;32(3):419-30.

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54) Kim JG, Bae JH, Lee SY, Cho WT, Lim HC. The parameters affecting the success of irrigation and debridement with component retention in the treatment of acutely infected total knee arthroplasty. Clinics in orthopedic surgery. 2015 Mar 1;7(1):69-76. 55) Kim YH, Park JW, Kim JS, Kim DJ. The outcome of infected total knee arthroplasty: culturepositive versus culture-negative. Archives of orthopaedic and trauma surgery. 2015 Oct 1;135(10):1459-67. 56) Koh IJ, Han SB, In Y, Oh KJ, Lee DH, Kim TK. Open debridement and prosthesis retention is a viable treatment option for acute periprosthetic joint infection after total knee arthroplasty. Archives of orthopaedic and trauma surgery. 2015 Jun 1;135(6):847-55. 57) Stryker LS, Abdel MP, Hanssen AD. Predictive value of inflammatory markers for irrigation and debridement of acute TKA infection. Orthopedics. 2013 Jun 1;36(6):765-70.

AC

Table 1.

Study

Duque He

1

33

Holmberg 35

Year

No. of patients included in review (Knees)

Mean F/U in years

2016

67

4

2016

11

5

2015

129

3

organisms SA 24, MRSA 5, strep 4, entro 3, psuedo 3 SA 1, CNS 1, Strep 7 SA 53, CNS 33, Strep 7, poly mic 30

No. of Level of Reinfection evidence percentage 21(31%)

IV R

2(18%)

IV R

29(22.4%)

IV R

ACCEPTED MANUSCRIPT

Kim

55

Klare Koh

36

56

Konigsberg 32

Matsumoto 43

30

Parvizi

Siddiqui Son

29

37

7

GP 14, GN 21

6(17%)

III

2009

19

4

35 (25 P - 10 R)

4

16(84%) 24(14 P10R)(68%)

IV R

2017 2014

16 Arthroscopic

3

6(37.5%)

IV R

2015

28

4

11(39%)

IV R

2015

101

9

44(44%)

IV R

2018

99

2

2015

52

3

MRSA SA 14, MRSA 4, CNS 5 SA 4, SBH 5, MH 2,MRSA 1, CNS 1 MRS 11, Neg cult. 8, SA 2, other staph 3 SA 30, CNS 26,Gram neg 38, strep 14 Staph 32, Strep 19, MRSA 11 SA 11, CNS 19, MRS 19, Strep 7

2014

22

2

Staphylococus

2015

50

4

2009

11

2013

12

2017

25

57

2013

72

Vilchez

31

2011

35

2015

16

AC

CE

PT

Wang

27

2 3

ED

Stryker

2

4 2 5

IV R

CR IP T

Jae Gyoon 54 Kim

35

SA 25, CAN 10, Strep 4 MRSA, MRSE, PA, Proteus, Entrobacter MRSA Neg Growth 12, SA 2 MRSE 2, MRSA 1, Strep 5 SA 12, CNS 7, Strep 7 SA MRSA 6, SA 4,CNS 3

AN US

38

Chung

2012

M

Font31 Vizcarra 28 Bradbury Chaofan 34 Zhang

35(35%)

IV R

15(28.8%)

IV R

5(22.7%)

IV R

22(44%)

IV R

6(54%)

IV

8(66%)

IV R

3(12%)

IV R

20(27%)

IV R

11(31%)

IV P

0

IV P