Another Option in the Armamentarium: Understanding the Role of Irrigation and Debridement to Treat Hip Periprosthetic Joint Infection

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The role of irrigation and debridement in the treatment of periprosthetic joint infection after total hip arthroplasty has been described in the past1,2. However, the overall poor outcomes reported in such series are less than inviting. The alternative treatment that includes removal of potentially well-fixed components and revision in 1 or 2 stages has shown increased morbidity and mortality, especially in elderly individuals when extensive exposure and often osseous osteotomies are needed3. With the advancements in the understanding of extensive irrigation and debridement, improvements in surgical technique, and the use of chronic suppression antibiotics, the current role of irrigation and debridement with the retention of components in certain well-defined circumstances may be of benefit in such difficult cases. In their study, Bryan et al. elucidated the contemporary role of such an intervention, explaining the indications and potential predictors of failure.
The current article describes a retrospective cohort of 90 patients who underwent irrigation and debridement with or without change of modular components and retention of well-fixed prostheses. The mean follow-up was 6 years. Bryan et al. reported an overall failure rate of 17%, including reoperation and periprosthetic joint infection-related mortality. They described the characteristics of the patients who underwent failed treatment, grouping them using the McPherson criteria4. There was a clear difference (p = 0.006) in terms of treatment failure in the patients who had ≥1 compromising factors (60%) compared with the patients who had none (8%). Likewise, the chances of treatment failure were higher when there was a hematogenous infection (21%) compared with an acute early postoperative infection (15%), but the difference was not significant (p = 0.7). Finally, it is important to understand the protective effect of chronic suppression antibiotics, in which the patients who had such therapy had less chance of treatment failure compared with the patients who did not have it, despite the lack of significance.
This study illustrates that there is room for irrigation and debridement with component retention in addition to chronic suppression antibiotics in appropriate cases including patients without major comorbidities. The overall morbidity and mortality rates in such patients are less than the rates in patients undergoing a 1-stage or 2-stage revision. There are many questions that still need to be answered, including the role of local antibiotic delivery techniques and the impact of resistant bacteria in the overall outcomes of such a technique. Also, the impact of a prior irrigation and debridement in the control and eradication of the infection, when an additional surgical procedure is needed, is still debatable.
Despite the limitations of this study, the information provided in the Discussion may aid in the process of deciding what the best intervention is in such difficult cases.
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