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.

Currently two-stage resection arthroplasty is the preferred method for surgical treatment of periprosthetic infection in North America. However, the success of this treatment strategy has varied from 54% to 98% based on previous reports. The exact reason for this variation in outcome is not known. The purpose of this study was to determine the efficacy of this treatment modality and delineate patient risk factors that result in recurrent infection and failure.

During the period of this study (2000–2005) 77 patients with an infected THA were treated at our institution. Fifty-four patients underwent two-stage exchange arthroplasty while the remaining 22 failed to have the second stage reimplantation due to ill health. The latter 22 were excluded from the analysis. All patients were followed up prospectively for at least two years after reimplantation. Detailed data including demographics, comorbidities, surgical history, and medication intake was collected. Intraoperative data, organism profile, and complications were also documented. Failure was defined as patient requiring additional surgical procedure for control of infection or loosening.

Two-stage exchange arthroplasty successfully eradicated infection in 36 patients (67%) without need for further treatment. Seven patients (13%) had recurrent infection that necessitated resection arthroplasty. Eleven (20%) patients required irrigation and debridement for postoperative purulent drainage which successfully treated infection in 8 of the cases. The remaining 3 patients failed and required resection arthroplasty. Three additional patients had early loosening of components and required revision arthroplasty. The exact cause of loosening in these patients could not be determined and despite lack of isolation of organisms infection was suspected. Multivariate analysis identified previous medical comorbidity and postoperative allogenic transfusion as risk factors for failure.

Current strategies to treat periprosthetic infection remain imperfect. Two-stage exchange arthroplasty with all its inherent problems and inconveniences imparted a modest success in treatment of PPI at our high volume specialized center. With the increase in the number of virulent and resistant organisms, and the rise in arthroplasties being performed in infirm patients with medical comorbidities the success of this procedure is likely to be jeopardized. Novel treatment modalities to combat this dreaded condition is needed.

Debridement of an infected total joint arthroplasty with retention of mechanically stable components is often performed for acute cases of periprosthetic infection (PPI). However, the reported success of such a procedure to fully eradicate infection has varied widely. The objective of this study was to elucidate the efficacy of debridement in both infected THA and TKA and attempt to identify risk factors responsible for failure.

During the years 2000–2005, 71 TKA and 69 THA underwent irrigation and debridement for acute PPI (< 4 weeks). All patients were followed up prospectively for at least two years. Detailed data including demographics, comorbidities, surgical history, and medication intake was collected. Intraoperative data, organism profile, and complications were also documented. Failure was defined as patient requiring additional surgical procedure for control of infection or loosening.

Of the 140 patients, 24% required repeat irrigation and debridement for postoperative drainage, hema-toma formation, or systemic symptoms. One third of these revision debridement patients underwent multiple consecutive debridements. Two-stage resection arthroplasty was required in 65 patients (46%) of the entire cohort. Fifty-eight percent of the patients with resection required revision of their cement spacer block due to continuous drainage and systemic symptoms indicative of persistent infection. We noted a total of 86 failures (61%) that required either an additional debridement or resection arthroplasty after the first debridement procedure. The failure rates of THA (62%) and TKA (55%) individually were similar (p=0.253).

Although the concept of conservative management of PPI with debridement and retention of components is an attractive alternative to resection arthroplasty, we have found that 60% of patients undergoing this procedure will inevitably undergo two-stage arthroplasty. Furthermore, more than half of the patients that required resection arthroplasty developed infection of their spacer that entailed revision of the cement block. Therefore, we can conclude that this procedure has a high failure rate and should be implemented in only a select group of patients.

Background/objective: Although several prospective trials have shown the efficacy of sequential intravenous followed by oral antimicrobial regimen in treatment of bone and joint infections, considerable uncertainty exists about ideal antibiotic regimen and optimal duration of antibiotic therapy.

The aim of this study was to demonstrate that short course antibiotic therapy combined with surgical drainage and followed by oral antibiotic therapy is quite adequate and suggested a scoring system as a comfortable and reliable tool to adjust the route of drug administration.

Methods: Thirty-three cases of acute hematogenous bone or joint infection were randomly treated with short term (7 days for joint infection, l0 days for bone infection) or a long-term (14 days and 21 days, respectively) intravenous antibiotics after surgical drainage. The treatment outcome was measured through a detailed scoring system that included the ability to eradicate infection, the functional status of the limb, and the radiological appearance of the bone and joint.

Criteria for discontinuation of parenteral antibiotic Scoring criteriapoints

Clinical evaluation

A: improved active motion of the joint: l

B: Painless active motion of the joint: 2

C: improvement in A & B:3

Radiological findings

A: progressive osteolysis ormultifocal involvement: 0

B: absence of the above findings*: 1

Laboratory evaluation

A: drop of 50.00/mm3 in WBC count or return to normal range (5.000–10.000 /mni3): 0.5

B: drop in ESR of 30 mm/hr or return to level of 30 mm/hr or less: 0.5

Total score: 5

*Pure periosteal elevation received a score of 1.

Patients with a score > or equal to 4 would be switched to oral antibiotic.

Results: The average follow up was 19 months. The scoring system had the following results: Infection was eradicated in both groups. Radiological scoring for septic arthritis was full for both groups and had a non-significant difference P> 0.05 between the 2 groups for osteomyelitis.

The mean functional scoring between the short-term group and long-term group were similar P> 0.05.

Overall, excellent or good results were achieved in both groups. No fair or poor results were observed. The average hospital cost for a patient in long-term group was twice that of a patient in short-term group.

Conclusion: It is concluded that for bone or joint infection in children who have received appropriate and early surgical treatment, intravenous antibiotics given for 7 days in joint infections and 10 days in bone infections, followed by 4 weeks of oral antibiotics, is an adequate treatment.

A decision on prolonging the duration of parenteral antibiotics should be based on a combination of clear clinical, laboratory, and radiographic criteria, such us the scoring system presented in this article.