Role of irrigation and Debridement in PJI S.M Kazemi associate professor, orthopedic surgeon SBM University Tehran Iran
M Kazemi associate professor, orthopedic surgeon SBM University Tehran Iran Role of irrigation and Debridement in PJI
Available classification inadequate in guiding a surgeon in selecting the appropriate surgical intervention for management of early PJI
early PJI classification for surgical guide Start time Duration time Both Host & micro organism
selection of surgical treatment Tsukayama classification : _ Early infection within one month of index surgery - Any infection beyond this point as late. - Acute hematogenous infection is also included
Zimmerli/Trampuz classification: for pathogenesis Early infection within 3 months of surgery 3 to 24 months are delayed infections >24 months after index arthroplasty are late. Early infections seeding during surgery, Late infections are hematogenous
Senneville et al : Duration of symptoms, less emphasis on the timing of index arthroplasty. acute infection is one with less than one month of symptoms any infection with greater than one month of symptoms is late. -McPherson : considers criteria other than timing, host factors micro-organism factors, periods of less than 3 weeks
Decision to perform an I&D Host type, Virulence of the infecting organism Status of the soft tissues. Biofilm is the key factor for success or failure using irrigation and debridement.
1 - for early PJI that occur within 3 months of index primary arthroplasty with less than 3 weeks of symptoms. I&D indications :
I&D indications : 2 - for patients with late hematogenous infection that occurred within 3 weeks of an inciting event or with symptoms not longer than 3 weeks.
prior surgical incision is opened Irrigation Debridement of any necrotic or infected soft tissue Removal of any encountered hematoma Evacuation of any purulence surrounding the prosthesis. Debridement must be thorough and complete in order for treatment strategy to succeed
Irrigation Ringer 6-9 L NaCl 6-9 L Bacitracin Polymyxin B
Absolute contraindications FOR I&D and retention of the prosthesis. Inability to close a wound presence of a sinus tract presence of loose prostheses.
I&D for hematoma after TKA The fascia/arthrotomy should always be opened in patients with total knee arthroplasty (TKA) and hematoma formation
Modular part All modular components should be removed and exchanged, if possible, during I&D.
Optimization I&D is not an emergency procedure in a patient without generalized sepsis. All efforts should be made to optimize the patients prior to surgical intervention.
Arthroscopy Arthroscopy has no role in I&D of an infected prosthetic joint.
one I&D Following failure of one I&D, the surgeon should give consideration to implant removal.
culture samples Representative tissue and fluid samples, between 3 and 6, from the periprosthetic region should be taken during I&D.
extended antibiotic for patients following I&D only be administered to patients that meet the criteria for PJ
intra-articular local antibiotic after I&D There is inadequate evidence to support administration of continuous intra-articular antibiotics for the treatment of PJI.
Role for the use of resorbable antibiotic impregnated pellets after I &D no conclusive evidence that the use of antibiotic-impregnated resorbable material improves the outcome of surgical intervention for I&D.
Antibiotic dilution
Inclusion criteria Fewer than 3 weeks of symptoms, No immunologic compromise, Intact soft tissue sleeve, and Well-fixed components.
Recommended protocol
Conclusion I&D/L treatment of PJI in TKA patients is successful in the majority of patients who met strict criteria. Strong consideration should be given to 2- stage resection in patients with previously identified MRSA or Pseudomonas
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