Abstract
Introduction: A 2-stage approach is often employed to treat infected TJA. Success rates have been reported between 85–100%. Other authors favor multiple routine debridements (I& D) to lower the infection rate. This study compares the relative effectiveness of 2-, 3- and 4 stage treatment approaches.
Methods: Between 1988 and 1998, all infected TJA at our institution were treated with a 2-, 3- or 4 stage approach. In the 2-stage approach, prosthesis removal was followed by 6 weeks of IV antibiotics and reimplantation. In the 3-stage approach, an additional I& D was added 5–7 days after prosthesis removal. In the 4-stage protocol, a third I& D was performed after completion of antibiotics. Negative cultures led to reimplantation. Positive cultures led to an additional 6-week course of antibiotics, and then repeat 3rd and 4th stages. Patients retained their components if free of infection, on chronic antibiotic suppression or after additional I& D. Patients were free of infection if no more treatment was needed.
Results: 83 patients with infected TJA were treated. Average follow-up was 25 months. Of the 2 stage patients, 9/10 (90%) retained their components, and 7/10 (70%) was free of infection. Of the 3 stage patients, 32/37 (86%) retained their components, and 28/37 (76%) was free of infection. Of the 4 stage patients, 34/36 (94%) retained their prosthesis, and 30/36 (83%) was free of infection. Seventeen additional patients in the 4-stage group had positive cultures at the third stage. After additional treatment 13/17 (76%) retained their components and 12/17 (71%) was free of infection. No correlation was found between infection severity (gram positive vs. negative organisms; single vs multiple organisms) or initial diagnosis.
Discussion. Our ten-year experience with infected THA suggests that multiple I& D are required for successful treatment. Repeat I& D assures a sterile wound, as tissue culture is more sensitive than aspiration. Importantly, persistent infection after three I& D and appropriate antibiotics led to poorer results, suggesting that other host factors may preclude these patients from reimplantation. Given the exorbitant costs of treating failed reimplantations, an additional routine I& D may in fact be cost-effective across an entire population of infected TJA patients. Further analysis will focus upon cemented versus cementless implants, cost-benefit ratios of multiple debridements, nutritional parameters, functional assessments of patients at latest follow-up, cost analysis, and the value of preoperative.
Conclusion: We recommend a 4-stage approach to the treatment of infected THA.
The abstracts were prepared by Nico Verdonschot. Correspondence should be addressed to him at Orthopaedic Research Laboratory, University Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
