Akut periprostetik eklem enfeksiyonunda ultrason destekli debridmanın DAIR sonuçları üzerindeki etkisi

Abstract

Giriş: Periprostetik eklem enfeksiyonu (PJI) için tedavi seçenekleri arasında debridman, antibiyotik ve implantın korunması (DAIR) ile tek veya iki aşamalı revizyon yer almaktadır. DAIR tedavisi, daha uygun maliyetli olması ve daha az komplikasyona yol açması nedeniyle avantajlıdır. Amacımız, akut postoperatif PJI tanısı konulan ve DAIR tedavisi alan hastalarda, ultrason destekli yara debridmanı (UAWD) uygulanan hastalarda implant sağkalımı ve DAIR başarısını karşılaştırmaktır. Gereç ve Yöntem: Bu tek merkezli, retrospektif çalışmaya, Eylül 2022 ile Kasım 2024 tarihleri arasında akut postoperatif PJI tanısı konulan ve ameliyat sonrası ilk 6 hafta içinde DAIR tedavisi uygulanan 59 hasta (13 erkek, 46 kadın, ortalama yaş 66,9 ± 9,9) dahil edilmiştir. Çalışmaya dahil edilen hastalar iki gruba ayrıldı: DAIR tedavisine ek olarak UAWD uygulananlar ve uygulanmayanlar. Alt grup analizleri ayrıca kalça ve diz PJI'lı hastalar ile kültür negatif ve kültür pozitif PJI'lı hastalar için de yapıldı. Sonuçlar: 17 hastada (%28,8) enfeksiyon semptomları altı ay içinde düzelmedi ve protezin çıkarılması gerekti. İki grup arasında tedavi başarısı açısından anlamlı bir fark bulunmadı (p=0,526). DAIR + UAWD, 44 diz hastasından 18'ine ve 15 kalça hastasından 6'sına uygulandı. Her iki alt grupta da UAWD'nin ek başarısı açısından anlamlı bir fark görülmedi (diz için p=0,258 ve kalça için p=0,604). DAIR tedavisi, kültür pozitif PJI olan 29 hastanın 14'ünde (%48,3) ve kültür negatif PJI olan 30 hastanın 3'ünde (%10) başarısız oldu. Gruplar arasındaki farkın istatistiksel olarak anlamlı olduğu bulunmuştur (p=0,001). UAWD, kültür pozitif alt grupta 10 hastada ve kültür negatif alt grupta 14 hastada kullanılmıştır. UAWD alan hastalar ile almayan hastalar arasında başarı açısından istatistiksel bir fark bulunmamıştır (sırasıyla p=0,128 ve 1). Sonuç: Akut postoperatif diz ve kalça PJI'da, kültür negatif veya kültür pozitif durumuna bakılmaksızın, DAIR protokolüne ek olarak UAWD'nin implant sağkalımı üzerinde herhangi bir faydası gösterilememiştir.

Keywords

• Ultrasonik Debridman
• Periprostetik Eklem Enfeksiyonu
• Debridman- antibiyotik uygulaması - implant korunması

Effect of ultrasound-assisted debridement on DAIR outcomes in acute periprosthetic joint infection

Abstract

Aims: Treatment options for periprosthetic joint infection (PJI) include debridement, antibiotic and implant retention (DAIR), as well as one- or two-stage revision. DAIR treatment is advantageous because it is more cost-effective and has fewer complications. Our aim is to compare implant survival and DAIR success in patients diagnosed with acute postoperative PJI who received DAIR treatment, with and without ultrasound-assisted wound debridement (UAWD). Methods: This single-center, retrospective study included 59 patients (13 men, 46 women, mean age 66.9±9.9) who were diagnosed with acute postoperative PJI between September 2022 and November 2024 and underwent DAIR treatment within the first 6 weeks postoperatively. Patients included in the study were divided into two groups: those who received UAWD in addition to DAIR treatment and those who did not. Subgroup analyses were also performed for patients with hip and knee PJI and for patients with culture-negative and culture-positive PJI. Results: In 17 patients (28.8%), infection symptoms did not improve within six months, requiring prosthesis removal. No significant difference was found between the two groups in terms of treatment success (p=0.526). DAIR+UAWD was applied to 18 of 44 knee patients and 6 of 15 hip patients. Both subgroups did not reveal significant additional success of UAWD (p=0.258 for knee and p=0.604 for hip). DAIR treatment failed in 14 (48.3%) of the 29 patients with culture-positive PJI and in 3 (10%) of the 30 patients with culture-negative PJI. The difference between the groups was found to be statistically significant (p=0.001). UAWD was used in 10 patients in the culture-positive subgroup and in 14 patients in the culture-negative subgroup. No statistical difference in success was found between patients who received UAWD and those who did not (p=0.128 and 1, respectively). Conclusion: In acute postoperative knee and hip PJI, regardless of culture-negative or culture-positive status, no benefit of UAWD in addition to the DAIR protocol on implant survival was demonstrated.

Keywords

• Debridement-antibiotic-implant retention
• DAIR
• periprosthetic joint infection
• ultrasound-assisted wound debridement

References

1. Ayoade F, Li D, Mabrouk A, et al. Periprosthetic joint infection. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025.
2. Longo UG, De Salvatore S, Bandini B, et al. Debridement, antibiotics, and implant retention (DAIR) for the early prosthetic joint infection of total knee and hip arthroplasties: a systematic review. J ISAKOS. 2024; 9(1):62-70. doi:10.1016/j.jisako.2023.09.003
3. Koh CK, Zeng I, Ravi S, et al. Periprosthetic joint infection is the main cause of failure for modern knee arthroplasty: an analysis of 11,134 knees. Clin Orthop Relat Res. 2017;475(9):2194-2201. doi:10.1007/s 11999-017-5396-4
4. Kurtz SM, Lau EC, Son MS, et al. Are we winning or losing the battle with periprosthetic joint infection: trends in periprosthetic joint infection and mortality risk for the medicare population. J Arthroplasty. 2018;33(10):3238-3245. doi:10.1016/j.arth.2018.05.042
5. Kapadia BH, Banerjee S, Cherian JJ, et al. The economic impact of periprosthetic infections after total hip arthroplasty at a specialized tertiary-care center. J Arthroplasty. 2016;31(7):1422-1426. doi:10.1016/j.arth.2016.01.021
6. Koh IJ, Han SB, In Y, et al. Knee multicenter collaboration team. Open debridement and prosthesis retention is a viable treatment option for acute periprosthetic joint infection after total knee arthroplasty. Arch Orthop Trauma Surg. 2015;135(6):847-855. doi:10.1007/s00402-015-2237-3
7. Frear AJ, Shannon MF, Sadhwani S, et al. Type of acute periprosthetic joint infection may not affect failure of debridement, antibiotics, and implant retention after total knee arthroplasty. J Bone Jt Infect. 2025; 10(4):225-235. doi:10.5194/jbji-10-225-2025
8. Li K, Cuadra M, Scarola G, et al. Complications in the treatment of periprosthetic joint infection of the hip: when do they occur? J Bone Jt Infect. 2021;6(7):295-303. doi:10.5194/jbji-6-295-2021

9. Rajput V, Meek RMD, Haddad FS. Periprosthetic joint infection: what next? Bone Joint J. 2022;104-B(11):1193-1195. doi:10.1302/0301-620X. 104B11.BJJ-2022-0944
10. Deng W, Li R, Shao H, et al. Comparison of the success rate after debridement, antibiotics and implant retention (DAIR) for periprosthetic joint infection among patients with or without a sinus tract. BMC Musculoskelet Disord. 2021;22(1):895. doi:10.1186/s12891-021-04756-x
11. Leta TH, Lygre SHL, Schrama JC, et al. Outcome of revision surgery for infection after total knee arthroplasty: results of 3 surgical strategies. JBJS Rev. 2019;7(6):e4. doi:10.2106/JBJS.RVW.18.00084
12. Aboltins C, Dowsey M, Peel T, et al. Good quality of life outcomes after treatment of prosthetic joint infection with debridement and prosthesis retention. J Orthop Res. 2016;34(5):898-902. doi:10.1002/jor.23089
13. Herman BV, Nyland M, Somerville L, et al. Functional outcomes of infected hip arthroplasty: a comparison of different surgical treatment options. Hip Int. 2017;27(3):245-250. doi:10.5301/hipint.5000455
14. Puhto T, Puhto AP, Vielma M, et al. Infection triples the cost of a primary joint arthroplasty. Infect Dis (Lond). 2019;51(5):348-355. doi:10. 1080/23744235.2019.1572219
15. Abbaszadeh A, Yilmaz MK, Izadi N, et al. Efficacy of DAIR (debridement, antibiotics, and implant retention) in total hip and knee arthroplasty: a systematic review and meta-analysis. J Arthroplasty. 2025:S0883-5403 (25)00654-0. doi:10.1016/j.arth.2025.05.121
16. Gehrke T, Alijanipour P, Parvizi J. The management of an infected total knee arthroplasty. Bone Joint J. 2015;97-B(10 Suppl A):20-29. doi:10. 1302/0301-620X.97B10.36475
17. Yarets Y. Effective biofilm removal and changes in bacterial biofilm building capacity after wound debridement with low-frequency ultrasound as part of wound bed preparation before skin grafting. Chronic Wound Care Management Res. 2017;4:55-64. doi:10.2147/CWCMR. S127874
18. Ji BC, Aimaiti A, Wang F, Zheng JJ, Cao L. The short-term outcomes of non-contact low frequency ultrasonic debridement in treating periprosthetic joint infections: a prospective single-arm clinical study. Zhonghua Wai Ke Za Zhi [Chinese J Surg] 2023;61(2):129-137. doi:10. 3760/cma.j.cn112139-20220821-00363
19. Ashkenazi I, Longwell M, Byers B, et al. Nanoparticle ultrasonication: a promising approach for reducing bacterial biofilm in total joint infection-an in vivo rat model investigation. Arthroplasty. 2024;6(1):57. doi:10.1186/s42836-024-00279-7
20. Kamineni S, Huang C. The antibacterial effect of sonication and its potential medical application. SICOT J. 2019;5(19):1. doi:10.1051/sicotj/ 2019017
21. Crone S, Garde C, Bjarnsholt T, et al. A novel in vitro wound biofilm model used to evaluate low-frequency ultrasonic-assisted wound debridement. J Wound Care. 2015;24(2):64-66. doi:10.12968/jowc.2015. 24.2.64
22. Parvizi J, Tan TL, Goswami K, et al. The 2018 definition of periprosthetic hip and knee infection: an evidence-based and validated criteria. J Arthroplasty. 2018;33(5):1309-1314.e2. doi:10.1016/j.arth.2018.02.078
23. https://maveramedical.com.tr/syllable-ultrasonic-wound-debridement-system
24. Diaz-Ledezma C, Higuera CA, Parvizi J. Success after treatment of periprosthetic joint infection: a Delphi-based international multidisciplinary consensus. Clin Orthop Relat Res. 2013;471(7):2374-2382. doi:10.1007/s11999-013-2866-1
25. Kunutsor SK, Beswick AD, Whitehouse MR, et al. Debridement, antibiotics and implant retention for periprosthetic joint infections: a systematic review and meta-analysis of treatment outcomes. J Infect. 2018;77(6):479-488. doi:10.1016/j.jinf.2018.08.017
26. Parvizi J, Gehrke T, Chen AF. Proceedings of the international consensus on periprosthetic joint infection. Bone Joint J. 2013;95-B(11):1450-1452. doi:10.1302/0301-620X.95B11.33135
27. Yoon HK, Cho SH, Lee DY, et al. A review of the literature on culture-negative periprosthetic joint infection: epidemiology, diagnosis and treatment. Knee Surg Relat Res. 2017;29(3):155-164. doi:10.5792/ksrr.16.034
28. Awad F, Boktor J, Joseph V, et al. Debridement, antibiotics and implant retention (DAIR) following hip and knee arthroplasty: results and findings of a multidisciplinary approach from a non-specialist prosthetic infection centre. Ann R Coll Surg Engl. 2024;106(7):633-641. doi:10.1308/rcsann.2023.0076
29. Staats A, Li D, Sullivan AC, et al. Biofilm formation in periprosthetic joint infections. Ann Jt. 2021;6:43. doi:10.21037/aoj-20-85
30. Shoji MM, Chen AF. Biofilms in periprosthetic joint infections: a review of diagnostic modalities, current treatments, and future directions. J Knee Surg. 2020;33(2):119-131. doi:10.1055/s-0040-1701214
31. Yilmaz MK, Abbaszadeh A, Tarabichi S, Azboy I, Parvizi J. Diagnosis of periprosthetic joint infection: the utility of biomarkers in 2023. Antibiotics (Basel). 2023;12(6):1054. doi:10.3390/antibiotics12061054
32. Lu H, Wang W, Xu H, et al. Efficacy and safety of two-stage revision for patients with culture-negative versus culture-positive periprosthetic joint infection: a single-center retrospective study. BMC Musculoskelet Disord. 2024;25(1):160. doi:10.1186/s12891-024-07259-7
33. Soundarrajan D, Rajkumar N, Dhanasekararaja P, Rithika S, Rajasekaran S. A comparison of outcomes of culture positive and culture negative acute knee prosthetic joint infection following debridement, antibiotics and implant retention (DAIR). Eur J Orthop Surg Traumatol. 2023;33(6): 2375-2383. doi:10.1007/s00590-022-03445-2
34. van Eck J, Liu WY, Goosen JHM, et al. Higher 1-year risk of implant removal for culture-positive than for culture-negative DAIR patients following 359 primary hip or knee arthroplasties. J Bone Jt Infect. 2022; 7(4):143-149. doi:10.5194/jbji-7-143-2022