Enough is enough: salvage procedures in severe periprosthetic joint infection

Abstract

Background: In severe cases of periprosthetic joint infection involving negative host-dependent factors, individual-based decisions between a curative therapy vs. salvage procedure are necessary. We aimed to review salvage procedures in severe periprosthetic joint infection cases, where a gold standard of a curative two-stage exchange can no longer be achieved. The options of knee arthrodesis, amputation, persistent fistula (stable drainage), or a debridement, antibiotics, and implant retention procedure in late-onset cases are discussed, including lifelong antibiotic suppression alone.

Methods: We focused on known salvage procedures for severe periprosthetic joint infection of the hip and knee, such as amputation, arthrodesis, antibiotic suppression, persistent fistula, and debridement, antibiotics, and implant retention in late-stage infections, and the role of local antibiotics. The current literature regarding indications and outcomes was reviewed.

Results: Whereas a successful single-stage above-knee amputation can be a curative effort in younger patients, this is associated with limited outcome in older patients, as the proportion who receive an exoprosthesis leading to independent mobility is low. Therefore, arthrodesis using an intramedullary modular nail is an option for limb salvage, pain reduction, and preservation of quality of life and everyday life mobility, when revision total knee arthroplasty is not an option. Carrying out a persistent fistula using a stable drainage system, as well as a lifelong antibiotic suppression therapy, can be an option, in cases where no other surgery is possible. Active clinical surveillance should then be carried out. A debridement, antibiotics, and implant retention procedure in combination with local degradable antibiotics can be used and is an encouraging new option, but should not been carried out twice.

Conclusion: Whereas the gold standard in periprosthetic joint infection treatment of late infections remains the exchange of the prosthesis, salvage procedures should be considered in the cases of reduced life expectancy, several recurrences of the infection, patients having preference and negative host factors. In these cases, the appropriate salvage procedure can temporarily lead to remission of the infection and the possibility to maintain mobility.

Keywords: Amputation; Antibiotic suppression; Arthrodesis; Debridement, antibiotics, implant retention; Periprosthetic joint infection; Salvage procedure.

Fig. 1

Flow diagram of decisions to perform a salvage procedure. The decision to perform a salvage procedure in the cases of PJI depends on the conditions of patients, who may be subjected to a curative operation (OP) or antibiotic therapy (ABs). If the patient does not fulfill the requirements for the gold-standard or curative treatment options, salvage-procedures should be considered

Fig. 2

a X-rays of a patient with a hinged cemented total knee arthroplasty. b X-rays after prosthesis explantation, various revision stages and debridements, which led to extensor insufficiency and bone loss, as well as patellectomized with fixed spacer. c The joint reconstruction is carried out by implanting a distance arthrodesis prosthesis (Knee Arthrodesis Module, Brehm, Germany)

Fig. 3

Images of a patient who underwent a curative arthrodesis of the left knee. a This was after multiple septic debridements and plastic surgery using a free flap. b After six years, a chronic infection in line with cutaneous fistula is present. c Accordingly, a persistent fistula using a 16 CH drainage tube was performed. d Patients regularly have to undergo maintenance of the drainage system

Fig. 4

Bead application. a Application of the OSTEOSET (Wright Medical, USA) bead kit (admixed 3,000 mg of vancomycin per 30 beads). b, c Surgical single-stage application of beads in a periprosthetic joint infection of total hip arthroplasty during a debridement, systemic antibiotics, and implant retention (DAIR) procedure. d X-ray after one year shows degradation of the beads