Timing of implant-removal in late acute periprosthetic joint infection: A multicenter observational study


      • Patients with late acute PJI have a better outcome when treated with revision surgery instead of DAIR.
      • Patients with late acute PJI can be selected for revision surgery according to the preoperative risk of DAIR failure defined by the CRIME80 score.
      • The causative microorganism and its susceptibility to antibiotics should ideally be taken into account as well to decide for the best surgical approach.



      We evaluated the treatment outcome in late acute (LA) periprosthetic joint infections (PJI) treated with debridement and implant retention (DAIR) versus implant removal.


      In a large multicenter study, LA PJIs of the hip and knee were retrospectively evaluated. Failure was defined as: PJI related death, prosthesis removal or the need for suppressive antibiotic therapy. LA PJI was defined as acute symptoms <3 weeks in patients more than 3 months after the index surgery and with a history of normal joint function.


      445 patients were included, comprising 340 cases treated with DAIR and 105 cases treated with implant removal (19% one-stage revision (n = 20), 74.3% two-stage revision (n = 78) and 6.7% definitive implant removal (n = 7). Overall failure in patients treated with DAIR was 45.0% (153/340) compared to 24.8% (26/105) for implant removal (p < 0.001). Difference in failure rate remained after 1:1 propensity-score matching. A preoperative CRIME80-score ≥3 (OR 2.9), PJI caused by S. aureus (OR 1.8) and implant retention (OR 3.1) were independent predictors for failure in the multivariate analysis.


      DAIR is a viable surgical treatment for most patients with LA PJI, but implant removal should be considered in a subset of patients, especially in those with a CRIME80-score ≥3.


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        • Aboltins C.
        • Daffy J.
        • Choong P.
        • Stanley P.
        Current concepts in the management of prosthetic joint infection.
        Intern Med J. 2014; 44: 834-840
        • Ascione T.
        • Pagliano P.
        • Balato G.
        • Mariconda M.
        • Rotondo R.
        • Esposito S.
        Oral therapy, microbiological findings, and comorbidity influence the outcome of prosthetic joint infections undergoing 2-stage exchange.
        J Arthroplasty. 2017; 32: 2239-2243
        • Azzam K.A.
        • Seeley M.
        • Ghanem E.
        • Austin M.S.
        • Purtill J.J.
        • Parvizi J.
        Irrigation and debridement in the management of prosthetic joint infection: traditional indications revisited.
        J Arthroplasty. 2010; 25: 1022-1027
        • Boddapati V.
        • Fu M.C.
        • Mayman D.J.
        • Su E.P.
        • Sculco P.K.
        • McLawhorn A.S.
        Revision total knee arthroplasty for periprosthetic joint infection is associated with increased postoperative morbidity and mortality relative to non-infectious revisions.
        J Arthroplasty. 2018; 33: 521-526
        • Bozic K.J.
        • Ries M.D.
        The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization.
        J Bone Joint Surg Am. 2005; 87: 1746-1751
        • Brimmo O.
        • Ramanathan D.
        • Schiltz N.K.
        • Pillai A.L.
        • Klika A.K.
        • Barsoum W.K.
        Irrigation and debridement prior to a two-stage revision total knee arthroplasty does not increase risk of failure.
        J Arhroplasty. 2016; 31: 461-464
        • Dzaja I.
        • Howard J.
        • Somerville L.
        • Lanting B.
        Functional outcomes of acutely infected knee arthroplasty: a comparison of different surgical treatment options.
        Can J Surg. 2015; 58: 402-407
        • Fisman D.N.
        • Reilly D.T.
        • Karchmer A.W.
        • Goldie S.J.
        Clinical effectiveness and cost-effectiveness of 2 management strategies for infected total hip arthroplasty in the elderly.
        Clin Infect Dis. 2001; 32: 419-430
        • Gardner J.
        • Gioe T.J.
        • Tatman P.
        Can this prosthesis be saved?: implant salvage attempts in infected primary TKA.
        Clin Orthop Relat Res. 2011; 469: 970-976
        • Gehrke T.
        • Alijanipour P.
        • Parvizi J.
        The management of an infected total knee arthroplasty.
        Bone Joint J. 2015; 97: 20-29
        • Gundtoft P.H.
        • Pedersen A.B.
        • Varnum C.
        • Overgaard S.
        Increased mortality after prosthetic joint infection in primary THA.
        Clin Orthop Relat Res. 2017; 475: 2623-2631
        • Herman B.V.
        • Nyland M.
        • Somerville L.
        • MacDonald S.J.
        • Lanting B.A.
        • Howard J.L.
        Functional outcomes of infected hip arthroplasty: a comparison of different surgical treatment options.
        Hip Int. 2017; 27: 245-250
        • Lora-Tamayo J.
        • Murillo O.
        • Iribarren J.A.
        • Soriano A.
        • S nchez-Somolinos M.
        • Baraia-Etxaburu J.M.
        • et al.
        A large multicenter study of methicillin susceptible and methicillin-resistant staphylococcus aureus prosthetic joint infections managed with implant retention.
        Clin Infect Dis. 2013; 56: 182-194
        • Nodzo S.R.
        • Boyle K.K.
        • Nocon A.A.
        • Henry M.W.
        • Mayman D.J.
        • Westrich G.H.
        The influence of a failed irrigation and debridement on the outcomes of a subsequent 2-stage revision knee arthroplasty.
        J Arthroplasty. 2017; 32: 2508-2512
        • Osmon D.R.
        • Berbari E.F.
        • Berendt A.R.
        • Lew D.
        • Zimmerli W.
        • Steckelberg J.M.
        • et al.
        Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the infectious diseases society of America.
        Clin Infect Dis. 2013; 56: 1-25
        • Parvizi J.
        • Gehrke T.
        Definition of periprosthetic joint infection.
        J Arthroplasty. 2014; 29: 1331
        • Rodriguez D.
        • Pigrau C.
        • Euba G.
        • Cobo J.
        • García-Lechuz J.
        • Palomino J.
        • et al.
        Acute haematogenous prosthetic joint infection: prospective evaluation of medical and surgical management.
        Clin Microbiol Infect. 2010; 16: 1789-1795
        • Sherrel J.C.
        • Fehring T.K.
        • Odum S.
        • Hansen E.
        • Zmistowski B.
        • Dennos A.
        • et al.
        Fate of two-stage reimplantation after failed irrigation and debridement for periprosthetic knee infection.
        Clin Orthop Relat Res. 2011; 469: 18-25
        • Tande A.J.
        • Palrai B.R.
        • Osmon D.R.
        • Berbari E.F.
        • Baddour L.M.
        • Lohse C.M.
        • et al.
        Clinical presentation, risk factors, and outcomes of hematogenous prosthetic joint infection in patients with staphylococcus aureus bacteremia.
        Am J Med. 2016; 129: e11-e20
        • Vilchez F.
        • Martinez-Pastor J.C.
        • Garcia-Ramiro S.
        • Bori G.
        • Tornero E.
        • García E.
        • et al.
        Efficacy of debridement in hematogenous and early post-surgical prosthetic joint infections.
        Int J Artif Organs. 2011; 34: 863-869
        • Wouthuyzen-Bakker M.
        • Sebillotte M.
        • Lomas J.
        • Taylor A.
        • Palomares E.B.
        • Murillo O.
        • et al.
        Clinical outcome and risk factors for failure in late acute prosthetic joint infections treated with debridement and implant retention.
        J Infect. 2019; 78: 40-47
        • Zimmerli W.
        • Sendi P.
        Role of rifampin against staphylococcal biofilm infections in vitro, in animal models, and in orthopedic device related infections.
        Antimicrob Agents Chemother. 2019; 63 (, 1–10)e01746-18
        • Zimmerli W.
        • Widmer A.F.
        • Blatter M.
        • Frei R.
        • Ochsner P.E.
        • et al.
        Role of rifampin for treatment of orthopedic implant-related staphylococcal infections: a randomized controlled trial.
        JAMA. 1998; 279: 1537-1541