Ayushmita De, Brian P Chalmers, Bryan D Springer, James A Browne, David G Lewallen, Jeffrey B Stambough
{"title":"在 AJRR 群体中,清创、抗生素和植入物保留(DAIR)治疗假体周围关节感染的发生率和效果如何?","authors":"Ayushmita De, Brian P Chalmers, Bryan D Springer, James A Browne, David G Lewallen, Jeffrey B Stambough","doi":"10.1097/CORR.0000000000003138","DOIUrl":null,"url":null,"abstract":"<p><strong>Background: </strong>Debridement, antibiotics, and implant retention (DAIR) is used to manage acute periprosthetic joint infections (PJIs) after total joint arthroplasty (TJA). Given the uncertain success of single or multiple DAIR attempts and possible long-term deleterious effects this treatment can create when trying to treat persistent infection, it is important to understand the frequency with which surgeons in the United States are attempting multiple debridements for PJI and whether those procedures are achieving the desired goal.</p><p><strong>Question/purposes: </strong>In the context of the American Joint Replacement Registry (AJRR), we asked: (1) What proportion of patients who undergo DAIR have only one DAIR, and what percentage of those patients have more than one? (2) Of the patients who undergo one or more DAIR procedures, what is the proportion who progress to additional surgical procedures? (3) What is the cumulative incidence of medical or surgical endpoints related to infection on the affected leg (other than additional DAIR procedures)?</p><p><strong>Methods: </strong>DAIR procedures to treat PJI, defined by ICD-9/10 and CPT (Current Procedural Technology) codes, reported to the AJRR from 2012 to 2020 were merged with Centers for Medicare and Medicaid Services (CMS) data from 2012 to 2020 to determine the incidence of patients aged 65 and older who underwent additional PJI-related procedures on the same joint. Linking to CMS ensures no loss to follow-up or patient migration to a non-AJRR site. As of 2021, the AJRR captures roughly 35% of all arthroplasty procedures performed in the United States. Of the total 2.2 million procedures in the AJRR, only 0.2% of the procedures were eligible based on our inclusion criteria. Additionally, 61% of the total population is Medicare eligible, and thus, these patients are linked to CMS. Of the 5029 DAIR attempts after a TKA, 46% (2318) were performed in female patients. Similarly, there were a total of 798 DAIR attempts after a THA, and 50% (398) were performed in female patients. For the purposes of decreasing confounding factors, bilateral THAs and TKAs were excluded from the study population. When querying for eligible procedures from 2012 to 2020, the patient population was limited to those 65 years and older, and a subsequent reoperation for infection had to be reported after a primary TJA. This limited the patient population as most infections reported to AJRR resulted in a revision, and we were searching for DAIRs. Although 5827 TJAs were identified as a primary TJA with a subsequent infectious event, more than 65% (3788) of that population did not have a reported event. The following conditions were queried as secondary outcomes after the first DAIR: sepsis, cellulitis, postoperative infection, endocarditis, amputation, knee fusion, resection, drainage, arthrotomy, and debridement. To answer our first and second study questions, we used frequency testing from the available AJRR data. Because of competing risks and issues with incomplete data, we used the cumulative incidence function to evaluate the outcomes specific to study question 3.</p><p><strong>Results: </strong>Of the patients who underwent DAIR, 93% (5406 of 5827) had one DAIR and 8% (421 of 5827) had more than one. Among the DAIR population, at least 35% of TKAs and 38% of THAs were identified as having experienced an additional PJI-related event (an additional surgical procedure on the same joint, sustained an infectious endpoint in the linked CMS-AJRR dataset, or they had died). The cumulative incidence of developing a further medical or surgical condition related to the joint that had the initial DAIR were as follows: 48% (95% CI 42% to 54%) at 8 years after a DAIR following a TKA and 42% (95% CI 37% to 46%) at 4 years after a DAIR following a THA. The timepoints for TKA and THA are different because there are more longitudinal procedure data available for TKAs regarding DAIR procedures than for THAs.</p><p><strong>Conclusion: </strong>In this study, we used data from the AJRR to assess the incidences of single and multiple DAIR attempts and additional surgical- and infection-related sequalae. Continued investigation is required to determine the fate of infected joints that undergo DAIR with regard to ultimate patient outcome. Future cross-sectional studies using large datasets are necessary to assess functional outcomes and determine the risk of persistent infection after DAIR more precisely.</p><p><strong>Level of evidence: </strong>Level III, therapeutic study.</p>","PeriodicalId":10404,"journal":{"name":"Clinical Orthopaedics and Related Research®","volume":null,"pages":null},"PeriodicalIF":4.2000,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11469890/pdf/","citationCount":"0","resultStr":"{\"title\":\"What Is the Incidence of and Outcomes After Debridement, Antibiotics, and Implant Retention (DAIR) for the Treatment of Periprosthetic Joint Infections in the AJRR Population?\",\"authors\":\"Ayushmita De, Brian P Chalmers, Bryan D Springer, James A Browne, David G Lewallen, Jeffrey B Stambough\",\"doi\":\"10.1097/CORR.0000000000003138\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><strong>Background: </strong>Debridement, antibiotics, and implant retention (DAIR) is used to manage acute periprosthetic joint infections (PJIs) after total joint arthroplasty (TJA). Given the uncertain success of single or multiple DAIR attempts and possible long-term deleterious effects this treatment can create when trying to treat persistent infection, it is important to understand the frequency with which surgeons in the United States are attempting multiple debridements for PJI and whether those procedures are achieving the desired goal.</p><p><strong>Question/purposes: </strong>In the context of the American Joint Replacement Registry (AJRR), we asked: (1) What proportion of patients who undergo DAIR have only one DAIR, and what percentage of those patients have more than one? (2) Of the patients who undergo one or more DAIR procedures, what is the proportion who progress to additional surgical procedures? (3) What is the cumulative incidence of medical or surgical endpoints related to infection on the affected leg (other than additional DAIR procedures)?</p><p><strong>Methods: </strong>DAIR procedures to treat PJI, defined by ICD-9/10 and CPT (Current Procedural Technology) codes, reported to the AJRR from 2012 to 2020 were merged with Centers for Medicare and Medicaid Services (CMS) data from 2012 to 2020 to determine the incidence of patients aged 65 and older who underwent additional PJI-related procedures on the same joint. Linking to CMS ensures no loss to follow-up or patient migration to a non-AJRR site. As of 2021, the AJRR captures roughly 35% of all arthroplasty procedures performed in the United States. Of the total 2.2 million procedures in the AJRR, only 0.2% of the procedures were eligible based on our inclusion criteria. Additionally, 61% of the total population is Medicare eligible, and thus, these patients are linked to CMS. Of the 5029 DAIR attempts after a TKA, 46% (2318) were performed in female patients. Similarly, there were a total of 798 DAIR attempts after a THA, and 50% (398) were performed in female patients. For the purposes of decreasing confounding factors, bilateral THAs and TKAs were excluded from the study population. When querying for eligible procedures from 2012 to 2020, the patient population was limited to those 65 years and older, and a subsequent reoperation for infection had to be reported after a primary TJA. This limited the patient population as most infections reported to AJRR resulted in a revision, and we were searching for DAIRs. Although 5827 TJAs were identified as a primary TJA with a subsequent infectious event, more than 65% (3788) of that population did not have a reported event. The following conditions were queried as secondary outcomes after the first DAIR: sepsis, cellulitis, postoperative infection, endocarditis, amputation, knee fusion, resection, drainage, arthrotomy, and debridement. To answer our first and second study questions, we used frequency testing from the available AJRR data. Because of competing risks and issues with incomplete data, we used the cumulative incidence function to evaluate the outcomes specific to study question 3.</p><p><strong>Results: </strong>Of the patients who underwent DAIR, 93% (5406 of 5827) had one DAIR and 8% (421 of 5827) had more than one. Among the DAIR population, at least 35% of TKAs and 38% of THAs were identified as having experienced an additional PJI-related event (an additional surgical procedure on the same joint, sustained an infectious endpoint in the linked CMS-AJRR dataset, or they had died). The cumulative incidence of developing a further medical or surgical condition related to the joint that had the initial DAIR were as follows: 48% (95% CI 42% to 54%) at 8 years after a DAIR following a TKA and 42% (95% CI 37% to 46%) at 4 years after a DAIR following a THA. The timepoints for TKA and THA are different because there are more longitudinal procedure data available for TKAs regarding DAIR procedures than for THAs.</p><p><strong>Conclusion: </strong>In this study, we used data from the AJRR to assess the incidences of single and multiple DAIR attempts and additional surgical- and infection-related sequalae. Continued investigation is required to determine the fate of infected joints that undergo DAIR with regard to ultimate patient outcome. 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引用次数: 0
摘要
背景:清创、抗生素和植入物留置(DAIR)用于处理全关节成形术(TJA)后的急性假体周围关节感染(PJI)。鉴于单次或多次尝试 DAIR 的成功率不确定,以及这种治疗方法在试图治疗持续感染时可能产生的长期有害影响,了解美国外科医生尝试多次清创治疗 PJI 的频率以及这些手术是否达到了预期目标非常重要:在美国关节置换登记处(AJRR)的背景下,我们提出了以下问题:(1)接受 DAIR 的患者中只有一次 DAIR 的比例是多少?(2) 在接受一次或多次 DAIR 手术的患者中,进展到其他外科手术的比例是多少?(3) 与患腿感染相关的医疗或手术终点(额外的 DAIR 手术除外)的累积发生率是多少?将 2012 年至 2020 年向 AJRR 报告的用于治疗 PJI 的 DAIR 手术(以 ICD-9/10 和 CPT(现行手术技术)代码定义)与美国医疗保险与医疗补助服务中心(CMS)2012 年至 2020 年的数据合并,以确定 65 岁及以上患者在同一关节上接受其他 PJI 相关手术的发生率。与 CMS 的链接可确保患者不会失去随访或转移到非 AJRR 站点。截至 2021 年,AJRR 记录了美国约 35% 的关节成形术。在 AJRR 的 220 万例手术中,只有 0.2% 的手术符合我们的纳入标准。此外,61% 的总人口符合医疗保险资格,因此这些患者与 CMS 有关联。在 5029 例 TKA 术后 DAIR 尝试中,46%(2318 例)为女性患者。同样,THA 后共进行了 798 次 DAIR 尝试,其中 50%(398 次)为女性患者。为了减少混杂因素,双侧 THA 和 TKAs 均未纳入研究人群。在查询 2012 年至 2020 年期间符合条件的手术时,患者人群仅限于 65 岁及以上的患者,并且必须报告初次 TJA 后因感染而进行的后续再手术。这就限制了患者人群,因为向 AJRR 报告的大多数感染都导致了翻修,而我们正在搜索 DAIR。虽然有 5827 例 TJA 被确定为初诊 TJA 后发生感染事件,但其中超过 65% 的患者(3788 例)没有报告感染事件。在第一次 DAIR 之后,我们将以下情况作为次要结果进行了查询:败血症、蜂窝组织炎、术后感染、心内膜炎、截肢、膝关节融合术、切除术、引流术、关节切开术和清创术。为了回答第一个和第二个研究问题,我们利用现有的 AJRR 数据进行了频率测试。由于存在竞争风险和数据不完整的问题,我们使用累积发生率函数来评估研究问题 3 的具体结果:在接受 DAIR 的患者中,93%(5827 例中的 5406 例)接受过一次 DAIR,8%(5827 例中的 421 例)接受过一次以上 DAIR。在接受 DAIR 的人群中,至少有 35% 的 TKAs 和 38% 的 THAs 被确定为发生过额外的 PJI 相关事件(在同一关节上进行了额外的外科手术、在关联的 CMS-AJRR 数据集中出现了感染终点,或者他们已经死亡)。与最初发生 DAIR 的关节相关的其他内科或外科疾病的累积发生率如下:TKA发生DAIR后8年的累计发生率为48%(95% CI为42%至54%),THA发生DAIR后4年的累计发生率为42%(95% CI为37%至46%)。TKA和THA的时间点不同,因为TKA的DAIR手术纵向数据比THA的多:在这项研究中,我们利用 AJRR 的数据评估了单次和多次 DAIR 尝试的发生率以及其他手术和感染相关后遗症的发生率。我们需要继续调查,以确定接受DAIR的感染关节的最终结局。未来有必要使用大型数据集进行横断面研究,以评估功能预后,并更准确地确定DAIR后持续感染的风险:证据等级:III级,治疗性研究。
What Is the Incidence of and Outcomes After Debridement, Antibiotics, and Implant Retention (DAIR) for the Treatment of Periprosthetic Joint Infections in the AJRR Population?
Background: Debridement, antibiotics, and implant retention (DAIR) is used to manage acute periprosthetic joint infections (PJIs) after total joint arthroplasty (TJA). Given the uncertain success of single or multiple DAIR attempts and possible long-term deleterious effects this treatment can create when trying to treat persistent infection, it is important to understand the frequency with which surgeons in the United States are attempting multiple debridements for PJI and whether those procedures are achieving the desired goal.
Question/purposes: In the context of the American Joint Replacement Registry (AJRR), we asked: (1) What proportion of patients who undergo DAIR have only one DAIR, and what percentage of those patients have more than one? (2) Of the patients who undergo one or more DAIR procedures, what is the proportion who progress to additional surgical procedures? (3) What is the cumulative incidence of medical or surgical endpoints related to infection on the affected leg (other than additional DAIR procedures)?
Methods: DAIR procedures to treat PJI, defined by ICD-9/10 and CPT (Current Procedural Technology) codes, reported to the AJRR from 2012 to 2020 were merged with Centers for Medicare and Medicaid Services (CMS) data from 2012 to 2020 to determine the incidence of patients aged 65 and older who underwent additional PJI-related procedures on the same joint. Linking to CMS ensures no loss to follow-up or patient migration to a non-AJRR site. As of 2021, the AJRR captures roughly 35% of all arthroplasty procedures performed in the United States. Of the total 2.2 million procedures in the AJRR, only 0.2% of the procedures were eligible based on our inclusion criteria. Additionally, 61% of the total population is Medicare eligible, and thus, these patients are linked to CMS. Of the 5029 DAIR attempts after a TKA, 46% (2318) were performed in female patients. Similarly, there were a total of 798 DAIR attempts after a THA, and 50% (398) were performed in female patients. For the purposes of decreasing confounding factors, bilateral THAs and TKAs were excluded from the study population. When querying for eligible procedures from 2012 to 2020, the patient population was limited to those 65 years and older, and a subsequent reoperation for infection had to be reported after a primary TJA. This limited the patient population as most infections reported to AJRR resulted in a revision, and we were searching for DAIRs. Although 5827 TJAs were identified as a primary TJA with a subsequent infectious event, more than 65% (3788) of that population did not have a reported event. The following conditions were queried as secondary outcomes after the first DAIR: sepsis, cellulitis, postoperative infection, endocarditis, amputation, knee fusion, resection, drainage, arthrotomy, and debridement. To answer our first and second study questions, we used frequency testing from the available AJRR data. Because of competing risks and issues with incomplete data, we used the cumulative incidence function to evaluate the outcomes specific to study question 3.
Results: Of the patients who underwent DAIR, 93% (5406 of 5827) had one DAIR and 8% (421 of 5827) had more than one. Among the DAIR population, at least 35% of TKAs and 38% of THAs were identified as having experienced an additional PJI-related event (an additional surgical procedure on the same joint, sustained an infectious endpoint in the linked CMS-AJRR dataset, or they had died). The cumulative incidence of developing a further medical or surgical condition related to the joint that had the initial DAIR were as follows: 48% (95% CI 42% to 54%) at 8 years after a DAIR following a TKA and 42% (95% CI 37% to 46%) at 4 years after a DAIR following a THA. The timepoints for TKA and THA are different because there are more longitudinal procedure data available for TKAs regarding DAIR procedures than for THAs.
Conclusion: In this study, we used data from the AJRR to assess the incidences of single and multiple DAIR attempts and additional surgical- and infection-related sequalae. Continued investigation is required to determine the fate of infected joints that undergo DAIR with regard to ultimate patient outcome. Future cross-sectional studies using large datasets are necessary to assess functional outcomes and determine the risk of persistent infection after DAIR more precisely.
期刊介绍:
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