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Sotiriou D, Stigbrand H, Ullmark G. Is two-stage revision surgery for infected hip arthroplasty worth the suffering, resources and results compared to one-stage? Hip Int 2022; 32:205-212. [PMID: 32777947 DOI: 10.1177/1120700020949162] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Periprosthetic joint infection (PJI) is the most serious complication of total hip arthroplasty. The treatment is usually revision in either 1 or 2 stages. This study analyses revision with impaction bone grafting for periprosthetic joint infection of the hip and compares 1- and 2-stage strategies. PATIENTS AND METHODS We reviewed 55 consecutive cases (54 patients) of revision arthroplasty for PJI carried out at our hospital between 2002 and 2016. Of these, 46 were 2-stage procedures. 21 had vancomycin mixed in with the bone graft, and all had gentamycin-containing bone cement. The total perioperative blood loss, duration of operation, and length of hospital stay were recorded. Clinical and radiological results were analysed for 48 hips at 2-16 years follow-up. RESULTS No PJI remained at follow-up. 3 patients (6%) had undergone revision for all causes. 1 had radiological signs of mechanical loosening but was not revised. 2-stage procedures had a significantly longer operating time (409 vs. 238 min) and hospital stay (34 vs. 13 days), greater blood loss (2764 vs. 1638 ml), and lower mean functional hip score (15.9 vs. 17.5) at follow-up than the one-stage procedures. INTERPRETATION Revision total hip arthroplasty for PJI with vancomycin-loaded impaction bone grafting is a safe method that achieves both the restoration of bone stock and resolution of the infection. This single-stage procedure could therefore be the new gold standard for treatment of non-complicated PJI in the hip.
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Affiliation(s)
- Dimitrios Sotiriou
- Department of Orthopaedics, Gävle Hospital and Centre for Research and Development Uppsala University/County Council of Gävleborg, Sweden
| | - Hampus Stigbrand
- Department of Orthopaedics, Gävle Hospital and Centre for Research and Development Uppsala University/County Council of Gävleborg, Sweden
| | - Gösta Ullmark
- Department of Orthopaedics, Gävle Hospital and Centre for Research and Development Uppsala University/County Council of Gävleborg, Sweden
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Unfried RI, Krause LMF, Cezimbra HM, Pacheco LS, Larangeira JA, Ribeiro TA. A Retrospective Observational Cohort Study of Periprosthetic Hip Infection Treated by one-stage Method Including Cases With Bone Graft Reconstruction. CLINICAL MEDICINE INSIGHTS: ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2022; 15:11795441221090344. [PMID: 35547099 PMCID: PMC9081729 DOI: 10.1177/11795441221090344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 03/03/2022] [Indexed: 11/17/2022]
Abstract
Purpose: Prosthetic joint infection (PJI) is a devastating complication that can affect hip arthroplasty. Its treatment is extremely difficult, and issues regarding the optimal treatment remain unanswered. This study intended to show the effectiveness of the one-stage treatment of PJI. Materials and Methods: A retrospective observational cohort study performed from July 2014- August 2018. All patients with suspected PJI were included. Major and minor criteria developed by the International Consensus on Periprosthetic Joint Infection (ICPJI) was used to define infection. Laboratory tests and image exams were performed, and all patients were followed for at least 2 years. Outcomes: Success rate (2018 ICPJI definition to success) in treatment of PJI using one-stage revision method. Clinical and functional outcomes defined by Harris Hip Score (HHS). Results: Thirty-one patients were screened and 18 analyzed. 69.85 ± 9.76 years was the mean age. Mean follow-up time was 63.84 ± 18.55 months. Ten patients had acetabular defects and required bone graft reconstruction. Sixteen patients were classified as Tier 1, 1 as Tier 3D, and as 1 Tier 3E. Almost 90% of patients submitted to one-stage revision with acetabulum graft reconstruction were free of infection. The overall infection survival rate was 78.31±6.34 months. Candida albicans and sinus tract were statistically significant in univariate Cox’s analysis. The predictor of one-stage revision surgery failure that remained final Cox’s regression model was C. albicans (hazard ratio [HR]: 4.47). Conclusion: Treatment through one-stage revision surgery associated with 6 months of antimicrobial is a viable option with acceptable results even when bone graft reconstruction is necessary. C. albicans was a strong predictor of failure in this cohort.
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Affiliation(s)
- Ricardo Issler Unfried
- Department of and Traumatology, University Hospital of Santa Maria (SOT-HUSM), Federal University of Santa Maria (UFSM), Santa Maria, Brazil
- Master’s Course in Health and Life Sciences, Universidade Franciscana (UFN), Santa Maria, Brazil
| | | | - Helen Minussi Cezimbra
- Department of Infectious Diseases, University Hospital of Santa Maria, Federal University of Santa Maria (UFSM), Santa Maria, Brazil
| | - Liliane Souto Pacheco
- Medicine School, Hospital São Francisco de Assis (HSFA), Universidade Franciscana (UFN), Santa Maria, Brazil
- Department of Infectious Diseases, University Hospital of Santa Maria, Federal University of Santa Maria (UFSM), Santa Maria, Brazil
| | - João Alberto Larangeira
- Department of and Traumatology, University Hospital of Santa Maria (SOT-HUSM), Federal University of Santa Maria (UFSM), Santa Maria, Brazil
| | - Tiango Aguiar Ribeiro
- Department of and Traumatology, University Hospital of Santa Maria (SOT-HUSM), Federal University of Santa Maria (UFSM), Santa Maria, Brazil
- Master’s Course in Health and Life Sciences, Universidade Franciscana (UFN), Santa Maria, Brazil
- Medicine School, Hospital São Francisco de Assis (HSFA), Universidade Franciscana (UFN), Santa Maria, Brazil
- Postgraduate Program of Health Science, Federal University of Santa Maria (UFSM), Santa Maria, Brazil
- Department of Surgery in Orthopaedic, Medicine School, Federal University of Santa Maria (UFSM), Santa Maria, Brazil
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Wolff M, Lausmann C, Gehrke T, Zahar A, Ohlmeier M, Citak M. Results at 10-24 years after single-stage revision arthroplasty of infected total hip arthroplasty in patients under 45 years of age. Hip Int 2021; 31:237-241. [PMID: 31766882 DOI: 10.1177/1120700019888877] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The management of periprosthetic joint infection (PJI) of the hip is a challenging procedure. One-stage exchange is carried out in specialist centres with comparable infection free survival rates. However, there is a paucity of long-term results of this approach in young patients. METHODS All patients undergoing one-stage exchange due to PJI with a known causative organism ⩽45 years of age with a minimum of 10-year follow-up (mean 15 years; range 10-24 years) were enrolled in this retrospective study. Patients older than 45 years of age or patients with a two-stage procedure were excluded from the study. The primary outcome measure was failure rate with special focus on reinfection at latest follow-up. Failure was defined as revision surgery for infection. Furthermore, functional outcome using the Harris Hip Score was determined initially and at latest follow-up. 26 patients fulfilled the inclusion criteria and were available for final follow-up. RESULTS The study cohort consists of 16 male and 10 female patients with a mean age of 36.8 years (range 20-45 years) and a mean BMI of 29.8 kg/m2 (range 20.7-40.6 kg/m2). Prior to the single-stage procedure, the patients underwent an average of 3.1 previous surgical interventions (range 1-9). The mean hospital stay after septic revision was 19.7 days (11-33 days). Most infections were caused by Staphylococcus epidermidis (n = 8, 30.8%), followed by Staph. aureus (n = 7, 26.9%) and Propionibacterium acnes (n = 6, 23.1%). At latest follow-up, the overall survival rate was 76.9 %, while infection control could be achieved in 96.2%. At final examination, the mean Harris Hip Score improved from 46.2 to 78.9 (range 18.0-99; SD, 22.6). CONCLUSIONS Single-stage revision surgery for the management of PJI in patients ⩽45 years is a successful treatment option with high infection control, even after long-term follow-up.
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Affiliation(s)
- Matthias Wolff
- Prosthetic Joint Infection Centre, Helios ENDO-Klinik, Hamburg, Germany
| | | | - Thorsten Gehrke
- Prosthetic Joint Infection Centre, Helios ENDO-Klinik, Hamburg, Germany
| | - Akos Zahar
- Prosthetic Joint Infection Centre, Helios ENDO-Klinik, Hamburg, Germany
| | - Malte Ohlmeier
- Prosthetic Joint Infection Centre, Helios ENDO-Klinik, Hamburg, Germany
| | - Mustafa Citak
- Prosthetic Joint Infection Centre, Helios ENDO-Klinik, Hamburg, Germany
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Lum ZC, Holland CT, Meehan JP. Systematic review of single stage revision for prosthetic joint infection. World J Orthop 2020; 11:559-572. [PMID: 33362992 PMCID: PMC7745489 DOI: 10.5312/wjo.v11.i12.559] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/20/2020] [Accepted: 11/29/2020] [Indexed: 02/06/2023] Open
Abstract
While advanced technology, increased medical knowledge and improved surgical technique has improved patient outcomes in total joint arthroplasty, prosthetic joint infection still remains one of the leading causes of increased healthcare costs, medical resources and societal burdens in orthopaedic care. Two stage arthroplasty revision remains the gold standard for treatment of prosthetic joint infection. Proponents of single stage revision arthroplasty for infection argue that it results in lower healthcare costs while improving patient reported functional outcomes and with equivalent success rates. Here we review the history of single stage revision arthroplasty, discuss the key principles, highlight the indications and contraindications, and review the reported outcomes with a focus on future developments of single stage revision arthroplasty for hip and knee periprosthetic joint infections.
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Affiliation(s)
- Zachary C Lum
- Department of Orthopaedic Surgery, Davis Medical Center, University of California, Sacramento, CA 95817, United States
| | - Christopher Thomas Holland
- Department of Orthopaedics, University of California, Davis Medical Center, Sacramento, CA 95817, United States
| | - John P Meehan
- Department of Orthopaedics, University of California, Davis Medical Center, Sacramento, CA 95817, United States
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Marmor S, Kerroumi Y, Meyssonnier V, Lhotellier L, Mouton A, Graff W, Zeller V. One-Stage Exchange Arthroplasty for Fistulizing Periprosthetic Joint Infection of the Hip: An Effective Strategy. Front Med (Lausanne) 2020; 7:540929. [PMID: 33178708 PMCID: PMC7596676 DOI: 10.3389/fmed.2020.540929] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 09/08/2020] [Indexed: 01/03/2023] Open
Abstract
Background: Prosthetic hip infection (PHI) is a disastrous scenario after an arthroplasty. International guidelines contraindicate one-stage exchange arthroplasty for fistulizing chronic prosthetic hip infection (FCPHI), nevertheless few surgical teams, mostly from Europe, support one stage procedure for this indication. Questions/Purposes: Analysis of infection recurrence and implant failure of a series of FCPHIs treated with one stage arthroplasty. Patients and Methods: Sixty-six FCPHIs treated with one-stage exchange arthroplasty were prospectively followed up at least 2 years. Clinical, radiological and bacteriological signs suggestive of reinfection were sought, as well as implant failures and PHI related deaths. Results: Thirty-four females and thirty-two males with median age of 69.5 years [61–77] and BMI of 26 kg/m2 [22-31] were included. Fistulae were productive in 50 patients (76%). Staphylococcus was responsible for 45% of PHI and 21% were polymicrobial. Twenty-nine patients (44%) received preoperative antibiotic therapy. After a median 60-month follow-up [35–82], 3 patients (4.5%) presented reinfection (two new infections, one relapse) and 3 patients experienced implant failure (1 femoral fracture, 1 stem breakage, 1 recurrent dislocation). One death was related to PHI. After a minimum of 2 years, the infection control rate was of 95.3% (±0.02). Conclusion: One-stage exchange arthroplasty for FCPHIs showed a good infection control rate similar to that of non-fistulizing PHI. Systematic preoperative microbiological documentation with joint aspiration and, in some specific cases, the use of preoperative antibiotic therapy are among the optimizations accounting for the success of the one-stage arthroplasty. In light of these results, and those of other studies, international recommendations could evolve. Level of Evidence: Descriptive therapeutic prospective cohort study. Level of evidence: IV.
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Affiliation(s)
- Simon Marmor
- Department of Orthopedic Surgery, Diaconesses Croix Saint-Simon Hospital, Paris, France.,Referral Center for Osteoarticular Infections, Diaconesses Croix Saint-Simon Hospital, Paris, France
| | - Younes Kerroumi
- Department of Orthopedic Surgery, Diaconesses Croix Saint-Simon Hospital, Paris, France.,Referral Center for Osteoarticular Infections, Diaconesses Croix Saint-Simon Hospital, Paris, France
| | - Vanina Meyssonnier
- Referral Center for Osteoarticular Infections, Diaconesses Croix Saint-Simon Hospital, Paris, France
| | - Luc Lhotellier
- Department of Orthopedic Surgery, Diaconesses Croix Saint-Simon Hospital, Paris, France.,Referral Center for Osteoarticular Infections, Diaconesses Croix Saint-Simon Hospital, Paris, France
| | - Antoine Mouton
- Department of Orthopedic Surgery, Diaconesses Croix Saint-Simon Hospital, Paris, France.,Referral Center for Osteoarticular Infections, Diaconesses Croix Saint-Simon Hospital, Paris, France
| | - Wilfrid Graff
- Department of Orthopedic Surgery, Diaconesses Croix Saint-Simon Hospital, Paris, France.,Referral Center for Osteoarticular Infections, Diaconesses Croix Saint-Simon Hospital, Paris, France
| | - Valérie Zeller
- Referral Center for Osteoarticular Infections, Diaconesses Croix Saint-Simon Hospital, Paris, France
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Kuiper JW, Rustenburg CM, Willems JH, Verberne SJ, Peters EJ, Saouti R. Results and Patient Reported Outcome Measures (PROMs) after One-Stage Revision for Periprosthetic Joint Infection of the Hip: A Single-centre Retrospective Study. J Bone Jt Infect 2018; 3:143-149. [PMID: 30013896 PMCID: PMC6043468 DOI: 10.7150/jbji.24366] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 06/13/2018] [Indexed: 12/21/2022] Open
Abstract
Background: Little is known about functional outcome and quality of life (QoL) after one-stage revision for periprosthetic joint infection (PJI) of the hip. Methods: a cohort of 30 subjects treated with one-stage revision between 2011 and 2015 was identified, and questionnaires on functional outcome and QoL were distributed. Results: 28 subjects were successfully treated (93%). Most subjects were referred from other hospitals. Coagulase-negative Staphylococcus was found in 50% of the cases, and 40% of all cultured bacteria were multidrug-resistant. 25% had subsequent revision surgery, unrelated to PJI. Functional outcome was good and QoL scores were high, comparable to prosthetic joint revision surgery in general. Conclusion: Although the cohort was small and statistical analysis was not performed, this study showed that excellent results can be obtained with one-stage revision for hip PJI. Functional outcome and QoL was comparable to prosthetic joint revision surgery in general.
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Affiliation(s)
- Jesse W.P. Kuiper
- Department of Orthopaedic Surgery, VU University Medical Centre, Amsterdam, the Netherlands
- Department of Orthopaedic Surgery, Noord-West Ziekenhuisgroep, Alkmaar, the Netherlands
| | | | - Jore H. Willems
- Department of Orthopaedic Surgery, Noord-West Ziekenhuisgroep, Alkmaar, the Netherlands
- Department of Orthopaedic Surgery, Spaarne Gasthuis, Hoofddorp, the Netherlands
| | - Steven J. Verberne
- Department of Orthopaedic Surgery, Noord-West Ziekenhuisgroep, Alkmaar, the Netherlands
| | - Edgar J.G. Peters
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, the Netherlands
- Amsterdam Infection and Immunity Institute, Amsterdam, the Netherlands
| | - Rachid Saouti
- Department of Orthopaedic Surgery, VU University Medical Centre, Amsterdam, the Netherlands
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Parisi TJ, Konopka JF, Bedair HS. What is the Long-term Economic Societal Effect of Periprosthetic Infections After THA? A Markov Analysis. Clin Orthop Relat Res 2017; 475:1891-1900. [PMID: 28389865 PMCID: PMC5449335 DOI: 10.1007/s11999-017-5333-6] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 03/22/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Current estimates for the direct costs of a single episode of care for periprosthetic joint infection (PJI) after THA are approximately USD 100,000. These estimates do not account for the costs of failed treatments and do not include indirect costs such as lost wages. QUESTIONS/PURPOSES The goal of this study was to estimate the long-term economic effect to society (direct and indirect costs) of a PJI after THA treated with contemporary standards of care in a hypothetical patient of working age (three scenarios, age 55, 60, and 65 years). METHODS We created a state-transition Markov model with health states defined by surgical treatment options including irrigation and débridement with modular exchange, single-stage revision, and two-stage revision. Reoperation rates attributable to septic and aseptic failure modes and indirect and direct costs were calculated estimates garnered via multiple systematic reviews of peer-reviewed orthopaedic and infectious disease journals and Medicare reimbursement data. We conducted an analysis over a hypothetical patient's lifetime from the societal perspective with costs discounted by 3% annually. We conducted sensitivity analysis to delineate the effects of uncertainty attributable to input variables. RESULTS The model found a base case cost of USD 390,806 per 65-year-old patient with an infected THA. One-way sensitivity analysis gives a range of USD 389,307 (65-year-old with a 3% reinfection rate) and USD 474,004 (55-year-old with a 12% reinfection rate). Indirect costs such as lost wages make up a considerable portion of the costs and increase considerably as age at the time of infection decreases. CONCLUSIONS The results of this study show that the overall treatment of a periprosthetic infection after a THA is markedly more expensive to society than previously estimated when accounting for the considerable failure rates of current treatment options and including indirect costs. These overall costs, combined with a large projected increase in THAs and a steady state of septic failures, should be taken into account when considering the total cost of THA. Further research is needed to adequately compare the clinical and economic effectiveness of alternative treatment pathways. LEVEL OF EVIDENCE Level II, economic and decision analysis.
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Affiliation(s)
- Thomas J. Parisi
- Department of Orthopaedics, Massachusetts General Hospital, 55 Fruit Street, Yawkey Building 3B, Boston, MA 02114 USA
| | - Joseph F. Konopka
- Department of Orthopaedics, Massachusetts General Hospital, 55 Fruit Street, Yawkey Building 3B, Boston, MA 02114 USA
| | - Hany S. Bedair
- Department of Orthopaedics, Massachusetts General Hospital, 55 Fruit Street, Yawkey Building 3B, Boston, MA 02114 USA
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Nguyen M, Sukeik M, Zahar A, Nizam I, Haddad FS. One-stage Exchange Arthroplasty for Periprosthetic Hip and Knee Joint Infections. Open Orthop J 2016; 10:646-653. [PMID: 28144374 PMCID: PMC5220180 DOI: 10.2174/1874325001610010646] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 06/22/2016] [Accepted: 07/15/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is a devastating complication of joint replacement surgery. In an aging population of the developed world, the increasing numbers of hip and knee replacements will inevitably lead to increasing incidence of PJI, carrying with (it) significant patient morbidity and cost to the health care system. Two-stage exchange arthroplasty is currently the gold standard but it is associated with multiple operations, prolonged hospitalization and impaired functionality. One-stage exchange arthroplasty is similar to the two-stage procedure but the interval between removal of the prosthesis and reimplantation of a new one is only a few minutes. It has the theoretical benefits of a single anesthetic, shorter hospitalization, less cost and improved function. METHODS We reviewed the current literature regarding the outcomes of one-stage exchange arthroplasties focusing on re-infection rates and functional outcomes. RESULTS Current themes around the one-stage exchange procedure include the indications for the procedure, definition of re-infection, surgical techniques used to provide fixation and differences in approach for hip and knee replacements. CONCLUSION The current literature on one-stage exchange procedure is promising, with comparable results to two-stage revisions for hips and knees in selected patients. However, there is a great need for a large multi-centred randomized control trial, focusing on re-infection rates and functional scores postoperatively, to provide concrete guidelines in managing this complex condition.
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Affiliation(s)
- Manny Nguyen
- Ozorthopaedics, Hospital in Malvern, 1356 High Street Malvern, VIC 3144, Australia
| | - Mohamed Sukeik
- Department of Trauma and Orthopaedics, The Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom
| | - Akos Zahar
- Center for Septic Surgery, Helios ENDO Klinik, Holstenstr. 2, 22767 Hamburg, Germany
| | - Ikram Nizam
- Ozorthopaedics, Hospital in Malvern, 1356 High Street Malvern, VIC 3144, Australia
| | - Fares Sami Haddad
- Department of Trauma and Orthopaedics, University College London Hospital, 235 Euston Road, NW1 2BU, London, United Kingdom
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9
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Abstract
Exchange arthroplasty remains the gold standard of treatment of established prosthetic joint infection. This can be achieved using a one or two stage approach. The ENDO-Klinik, in Hamburg, has pioneered the one-stage technique since 1970 utilising antibiotic loaded acrylic cement (ALAC). This editorial discusses the relevant literature and describes the indications and surgical technique employed by the ENDO-Klinik Hamburg.
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Beswick AD, Elvers KT, Smith AJ, Gooberman-Hill R, Lovering A, Blom AW. What is the evidence base to guide surgical treatment of infected hip prostheses? systematic review of longitudinal studies in unselected patients. BMC Med 2012; 10:18. [PMID: 22340795 PMCID: PMC3364856 DOI: 10.1186/1741-7015-10-18] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Accepted: 02/16/2012] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Prosthetic joint infection is an uncommon but serious complication of hip replacement. There are two main surgical treatment options, with the choice largely based on the preference of the surgeon. Evidence is required regarding the comparative effectiveness of one-stage and two-stage revision to prevent reinfection after prosthetic joint infection. METHODS We conducted a systematic review to identify randomised controlled trials, systematic reviews and longitudinal studies in unselected patients with infection treated exclusively by one- or two-stage methods or by any method. The Embase, MEDLINE and Cochrane databases were searched up to March 2011. Reference lists were checked, and citations of key articles were identified by using the ISI Web of Science portal. Classification of studies and data extraction were performed independently by two reviewers. The outcome measure studied was reinfection within 2 years. Data were combined to produce pooled random-effects estimates using the Freeman-Tukey arc-sine transformation. RESULTS We identified 62 relevant studies comprising 4,197 patients. Regardless of treatment, the overall rate of reinfection after any treatment was 10.1% (95% CI = 8.2 to 12.0). In 11 studies comprising 1,225 patients with infected hip prostheses who underwent exclusively one-stage revision, the rate of reinfection was 8.6% (95% CI = 4.5 to 13.9). After two-stage revision exclusively in 28 studies comprising 1,188 patients, the rate of reinfection was 10.2% (95% CI = 7.7 to 12.9). CONCLUSION Evidence of the relative effectiveness of one- and two-stage revision in preventing reinfection of hip prostheses is largely based on interpretation of longitudinal studies. There is no suggestion in the published studies that one- or two stage methods have different reinfection outcomes. Randomised trials are needed to establish optimum management strategies.
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Affiliation(s)
- Andrew D Beswick
- School of Clinical Sciences, University of Bristol, Musculoskeletal Research Unit, Southmead Hospital, Southmead Road, Bristol, BS10 5NB, UK.
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11
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Seghrouchni K, van Delden C, Dominguez D, Benkabouche M, Bernard L, Assal M, Hoffmeyer P, Uçkay I. Remission after treatment of osteoarticular infections due to Pseudomonas aeruginosa versus Staphylococcus aureus: a case-controlled study. INTERNATIONAL ORTHOPAEDICS 2011; 36:1065-71. [PMID: 21983903 DOI: 10.1007/s00264-011-1366-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2011] [Accepted: 09/11/2011] [Indexed: 11/30/2022]
Abstract
PURPOSE Osteoarticular infections due to methicillin-susceptible Staphylococcus aureus (MSSA) or its methicillin-resistant variant (MRSA) are feared due to treatment failures. According to clinical experience, Pseudomonas aeruginosa may reveal less long-term remission than S. aureus. METHODS A case-controlled study comparing outcomes of osteoarticular infections due to P. aeruginosa vs S. aureus was performed at Geneva University Hospitals. RESULTS A total of 111 S. aureus (including 37 MRSA) and 20 P. aeruginosa osteoarticular infections were analysed in 131 patients: arthroplasties (n = 38), fracture fixation devices (n = 56), native joint arthritis (n = 7) and osteomyelitis without implant (n = 30). The median active follow-up time was 4 years. The patients underwent a median number of two surgical interventions for P. aeruginosa infections compared to two for S. aureus (two for MRSA), while the median duration of antibiotic treatment was 87 days for P. aeruginosa and 46 days for S. aureus infections (58 days for MRSA) (all p > 0.05). Overall, Pseudomonas-infected patients tended towards a lower remission rate than those infected with S. aureus (12/20 vs 88/111; p = 0.06). This was similar when P. aeruginosa was compared with MRSA alone (12/20 vs 30/37; p = 0.08). In multivariate logistic regression analyses adjusting for case mix, odds ratios (OR) for remission were as follows: P. aeruginosa vs S. aureus [OR 0.4, 95% confidence interval (CI) 0.1-1.2], number of surgical interventions (OR 0.6, 95% CI 0.5-1.0) and duration of antibiotic treatment (OR 1.0, 95% CI 1.0-1.0). CONCLUSIONS Despite a similar number of surgical interventions and longer antibiotic treatment, osteoarticular infections due to P. aeruginosa tended towards a lower remission rate than infections due to S. aureus in general or MRSA in particular.
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Affiliation(s)
- Khalid Seghrouchni
- Orthopedic Surgery Service, Geneva University Hospitals, 4, Rue Gabrielle Perret-Gentil, 1211, Geneva 14, Switzerland
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12
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Kamath AF, Anakwenze O, Lee GC, Nelson CL. Staged custom, intramedullary antibiotic spacers for severe segmental bone loss in infected total hip arthroplasty. Adv Orthop 2011; 2011:398954. [PMID: 21991412 PMCID: PMC3170761 DOI: 10.4061/2011/398954] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Accepted: 06/30/2011] [Indexed: 01/29/2023] Open
Abstract
Introduction. Total hip arthroplasty (THA) infections with severe bone loss pose significant reconstructive challenges. We present our experience with two-stage hip reimplantation using an intramedullary, antibiotic-impregnated nail. Methods. Three patients with infected THA with severe proximal femoral bone loss (Mallory type IIIB or greater) were treated using a custom antibiotic spacer. Clinical outcomes and any complications were recorded. Average followup was 49 months from final reimplantation. Results. Mean age at spacer placement (stage 1) was 53 years. The mean Harris Hip Score at final followup was 80. Two patients had asymptomatic heterotopic ossification, and one patient had a 2 cm leg-length discrepancy. Conclusions. A custom intramedullary nail antibiotic spacer is a reliable option in the staged management of the infected THA with severe proximal femoral bone loss. Benefits of this technique include limb salvage with maintenance of leg length, soft tissue tension, and functional status.
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Affiliation(s)
- Atul F. Kamath
- Department of Orthopaedic Surgery, University of Pennsylvania, 3400 Spruce Street, 2 Silverstein, Philadelphia, PA 19104, USA
| | - Okechukwu Anakwenze
- Department of Orthopaedic Surgery, University of Pennsylvania, 3400 Spruce Street, 2 Silverstein, Philadelphia, PA 19104, USA
| | - Gwo-Chin Lee
- Department of Orthopaedic Surgery, Penn Presbyterian Medical Center, Cupp 1, 39th and Market Streets, Philadelphia, PA 19104, USA
| | - Charles L. Nelson
- Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA 17822, USA
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Rudelli S, Uip D, Honda E, Lima ALLM. One-stage revision of infected total hip arthroplasty with bone graft. J Arthroplasty 2008; 23:1165-77. [PMID: 18534510 DOI: 10.1016/j.arth.2007.08.010] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2006] [Accepted: 08/08/2007] [Indexed: 02/01/2023] Open
Abstract
There are many different opinions in the literature regarding the best procedure for revision of infected hip arthroplasty and hence in achieving long-term stabilization of a new implant. Thirty-two patients with 32 loose and infected total hip arthroplasties underwent revision with a bone graft in a 1-stage procedure. The bone graft was used in the acetabulum and femur in 25 patients, in the acetabulum alone in 4 patients and in the femur alone in 3 patients. A metal mesh was necessary in 15 patients to contain the morselized bone graft. At the time of surgical revision, 9 patients had a draining sinus, 6 had a closed sinus, and 17 had never had sinuses in the surgical wound. Antibiotic therapy was administered intravenously and orally for 6 months. Mean follow-up was 103 months (range, 63-183 months), and infection recurred in 2 (6.2%) cases. Further studies are necessary, and continuation of this method is justified.
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Affiliation(s)
- Sergio Rudelli
- Department of Orthopaedic Surgery, Santa Casa Medical School, São Paulo, Brazil
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One-stage cementless revision arthroplasty for infected hip replacements. INTERNATIONAL ORTHOPAEDICS 2008; 33:1195-201. [PMID: 18704412 DOI: 10.1007/s00264-008-0640-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Accepted: 07/03/2008] [Indexed: 12/28/2022]
Abstract
We hypothesised that one-stage cementless revision hip arthroplasty may have advantages and a role in the treatment of selected patients with an infected hip replacement. We retrospectively reviewed all patients with an infected hip replacement treated with one-stage revision using cementless implants. Twelve patients were reviewed and followed up for at least three years (average: 7.2 years, range: 3.3-11.3 years) postoperatively. One recurrence of infection and one aseptic stem loosening were detected during follow-up. Grafted bone, which was used in eight patients, appeared to have united to host bone in all patients. The success rate of treatment was 83.3% when infection recurrence or component loosening were regarded as failure. One-stage revision hip arthroplasty using cementless implants appears to have a role in the treatment of carefully selected patients with an infected hip replacement if meticulous débridement is performed and appropriate antibiotics are properly used.
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Cabrita HB, Croci AT, Camargo OPD, Lima ALLMD. Prospective study of the treatment of infected hip arthroplasties with or without the use of an antibiotic-loaded cement spacer. Clinics (Sao Paulo) 2007; 62:99-108. [PMID: 17505692 DOI: 10.1590/s1807-59322007000200002] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2007] [Accepted: 02/26/2007] [Indexed: 11/22/2022] Open
Abstract
PURPOSE Our purpose was to compare 2 methods of treatment of chronic infection in hip arthroplasties--with or without an antibiotic-loaded cement spacer. METHODS In a prospective study, we treated 68 infected hip arthroplasties with discharging sinuses and bone loss, comparing 30 patients treated in 2 stages without the use of a spacer (control group) and 38 patients treated with a vancomycin-loaded spacer (study group). The average follow-up was 4 years (2-8.5 years). One patient died of unrelated causes 4 months after first-stage surgery and was excluded from the study. RESULTS The 2-stage surgery without spacer controlled the infection in 66.7% of patients, and the 2-stage surgery using the spacer controlled it in 89.1% (P < 0.05). At last follow-up, the average Harris Hip Score increased from 19.3 to 69.0 in the control group versus 19.7 to 75.2 in the study group (P > 0.05). The average leg length discrepancy was 2.6 cm in the control group and 1.5 cm in the study group (P < 0.05). The patients treated with a spacer had better clinical results (81.5% of patients with good results against 60.0% for the control group). CONCLUSION The use of an antibiotic-loaded spacer in the 2-stage treatment of infected hip arthroplasties provides better infection control with good functional results and is superior to treatment in 2 stages without a spacer. LEVEL OF EVIDENCE Therapeutic study, Level I-1.
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Windhager R, Leithner A, Hochegger M. Wechsel von Tumorendoprothesen des Kniegelenks. DER ORTHOPADE 2006; 35:176-83. [PMID: 16369846 DOI: 10.1007/s00132-005-0913-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Revision of tumour endoprostheses around the knee joint is mainly caused by aseptic loosening and deep infection. Mechanical complications have been significantly reduced by improvements in prosthetic design. The rate of aseptic loosening after distal femur or proximal tibia replacement ranges from 10% to 45% depending on the time of follow-up and prosthetic design; the success rate after revision averages 75% at midterm follow-up. The rate of infection reported in the literature varies between 2.9% and 12%. One stage revision may be considered after acute infection without signs of loosening, after which a success rate of 77.8% can be expected. Two stage revision is mainly indicated in multi-resistant microorganisms as well as septic loosening, with a success rate of 75% after 5 years. Deep infection represents the most serious complication in long-term follow-up, often leading to amputation due to soft tissue problems after tumour resection. The authors were able to confirm the minimal decrease in MSTS score despite the large number of operations (15 patients: nine females, six males; median MSTS score 84%; mean 81%).
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Affiliation(s)
- R Windhager
- Klinik für Orthopädie, Medizinische Universität, Graz, Osterreich.
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Abstract
Selection of the suitable treatment method for an infected hip arthroplasty requires careful assessment of patient-related variables and expected treatment goals. The basic treatment options include antibiotic suppression, open debridement, resection arthroplasty, arthrodesis, reimplantation of another prosthesis, and amputation. Successful treatment of infection requires complete debridement of all infected and foreign material and appropriate antimicrobial therapy. When possible, the preferred treatment approach is insertion of another prosthesis with a delayed reconstructive treatment technique. Patients now are presenting with an increasing incidence of resistant organisms and severe bone loss, which increases the difficulty of treatment.
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Affiliation(s)
- Arlen D Hanssen
- Department of Orthopedics, Mayo Clinic and Mayo Foundation, 200 First Street Southwest, Rochester, MN 55906, USA.
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Nijhof MW, Fleer A, Hardus K, Vogely HC, Schouls LM, Verbout AJ, Dhert WJ. Tobramycin-containing bone cement and systemic cefazolin in a one-stage revision. Treatment of infection in a rabbit model. JOURNAL OF BIOMEDICAL MATERIALS RESEARCH 2002; 58:747-53. [PMID: 11745530 DOI: 10.1002/jbm.1073] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The efficacy of tobramycin-containing bone cement with that of systemic cefazolin for treatment of infection in a one-stage revision model is compared. In addition, the value of detecting bacterial DNA after antibiotic treatment was investigated. An implant was inserted into the right tibia of rabbits after inoculation with Staphylococcus aureus. At 28 days, the implant was removed. Subsequently, either plain bone cement with or without systemic administration of cefazolin, or tobramycin-containing bone cement was injected into the medullary canal. The tibiae were cultured 14 days after revision (Day 42), and showed a significant decrease in bacterial counts for both antibiotic groups compared with the control group (p</=0.05). The rate of infection in the tobramycin-cement group was slightly higher (2/9) than in the cefazolin group (0/8), although the difference was not significant. Persistence of bacterial DNA after antibiotic treatment may be the result of delayed clearance of DNA and not a sign of active infection. This animal model shows that in a one-stage revision tobramycin-containing bone cement can reduce size and rate of infection, although systemic cefazolin may be more efficacious. Therefore, the use of antibiotic-containing bone cement combined with systemic antibiotic might provide optimal treatment.
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Affiliation(s)
- M W Nijhof
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, The Netherlands
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HANSSEN ARLEND, RAND JAMESA. Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Evaluation and Treatment of Infection at the Site of a Total Hip or Knee Arthroplasty*†. J Bone Joint Surg Am 1998. [DOI: 10.2106/00004623-199806000-00016] [Citation(s) in RCA: 94] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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Abstract
Between 1976 and 1992, reinfection developed in 34 patients treated for an infected total hip arthroplasty with removal of the prosthesis and implantation of another prosthesis. These patients included 15 men and 19 women with a mean age of 62 years. Infection recurred an average of 2.2 years after reimplantation of the new prosthesis. Followup after the diagnosis of reinfection averaged 5.1 years. Reinfection after an attempt at reimplantation total hip arthroplasty was seldom compatible with a good functional outcome. Resection arthroplasty was reliable in eradicating reinfection but led to poor function and was associated with persistent pain. Although reimplantation of a third prosthesis allowed 3 patients to achieve an excellent result, the 8 hips that failed a third reimplantation attempt had the worst functional results in this study. The results from the present series suggest that reinfection after an attempt at reimplantation is a contraindication to further attempts at a 1-stage reimplantation of another prosthesis. Those patients in whom the same single microorganism has been identified from the failed primary total hip and from the failed first reimplantation, however, may be reasonable candidates for an attempt at a 2-stage reimplantation of a third prosthesis, particularly when a deficiency in prior antibiotic therapy or surgical technique can be identified.
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Affiliation(s)
- M W Pagnano
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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Affiliation(s)
- K L Garvin
- Department of Orthopaedic Surgery, University of Nebraska Medical Center, Omaha 68198-1080, USA
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