In this literature review, 30 reports provided outcome data on 37 direct exchange arthroplasties, 530 open debridements, and 23 arthroscopic debridements. The average followup was approximately 4 years, but the range was broad (range, 0.02-14 years). Infection was controlled in 33 of the 37 infected total knee arthroplasties (89.2%) treated by direct exchange arthroplasty, in only 173 of the 530 infected total knee arthroplasties (32.6%) treated by open debridement and retention of the prosthetic components, and in 12 of the 23 infected total knee arthroplastics (52.2%) treated by arthroscopic debridement. There was wide variability in associated antibiotic therapy. Factors associated with successful direct exchange included infections by gram-positive organisms, absence of sinus formation, use of antibiotic-impregnated bone cement for the new prosthesis, and 12 weeks of antibiotic therapy. Direct exchange arthroplasty failed in four of 37 knees; two were in patients with rheumatoid arthritis who were taking corticosteroids. Factors associated with successful debridements included those done within 4 months of the index procedure, or in patients with less than 4 weeks of symptoms, antibiotic sensitive gram-positive organisms, well-fixed components with no radiologic evidence of osteitis, and in young healthy patients. Factors associated with the failed debridements included postoperative drainage for more than 2 weeks, sinus tracts present at the time of the debridement, a hinged prosthesis, and an immunocompromised host. Direct exchange can be successful with a sensitive organism in a healthy host with prolonged antibiotic therapy. Debridement can be successful in early infections in a healthy host.
