HOW MUCH DELAY IS ACCEPTABLE IN INCISION AND DRAINAGE OF AN INFECTED ARTHROPLASTY? ‘SEVEN DAY RULE’

Abstract

Introduction: Ignoring the consequences of wound problem and persistent surgical drainage after joint arthroplasty often leads to denial and procrastination when prompt surgery is indicated hoping to save the joint. A wide range for definition of “early surgery” from as early as 2 days up to 30 days has been proposed in the literature, but the “Golden time” is yet undefined. The purpose of this study was to identify the predisposing factors for poor outcome after incision and drainage (I& D) of an infected arthroplasty.

Methods and subjects: A consecutive series of 7153 total joint arthroplasties performed between 2000 to 2006 at our institution were collected in this study. There were 83 cases with persistent drainage of more than 48 hours postoperatively which underwent I& D.

Patients’, surgical and pharmacological related factors studied extensively. Univariate analysis compared the different variables of the two groups of success who retained a functional joint despite periprosthetic infection and those who ended to failure, including patients with excisional arthroplasty, continuous antibiotic suppression therapy, repeated revisions for infection or infection induced loosening.

Results: There were 64 cases in the success group and 19 patients in failure group. Incision and drainage in the failure group resulted in eradication of infection and achieving functional joint after further staged revision in 73% of this group. Five patients (27%) remained in girdlestone status. This study identified a delay of diagnosis of more than 7 days (p=0.03) and malnutrition (p=0.002) as the determinant of success versus failure. Age, BMI, maximal and mean INR, hematological profile, ASA, estimated blood loss, postoperative transfusion NINS, methicillin resistant organism and type of the infected arthroplasty being primary or revision were not the predictors of outcome.

Conclusion: The study has identified delay of more than 7 days in the treatment of infected TJA presenting with > 48 hours post surgical treatment as an important predictor of failure of periprosthetic infection treatment. Malnutrition, as in other studies to be an important risk factor. In this study the cut-off value of delay in treatment is much less than the proposed 2 weeks or in some studies up to 30 days to retain the components and achieve a functional arthroplasty. High alertness to presence of infection and prompt action even if the infection can not be proved, is an intelligent strategy that can survive joint arthroplasty and avoid catastrophic result for the patient and the care providers.