[Two-stage procedure to exchange septic total hip arthroplasties with late periprosthetic infection. Early results after implantation of a reverse modular hybrid endoprosthesis]

Two-stage revision of an infected total hip arthroplasty: a follow-up of 136 patients

BACKGROUND AND PURPOSE

Periprosthetic infection of a total hip arthroplasty (THA) is commonly treated with a two-stage revision procedure. After resection of the infected THA and placement of a cement spacer loaded with antibiotics, a THA is inserted at a second procedure to restore hip function and mobility. Revision surgery carries a significant risk of complications. This study focuses on hip function, rate of complications and reinfection after two-stage revision surgery for an infected THA.

PATIENTS AND METHODS

From January 1996 to April 2010, 136 patients underwent revision surgery after removal of an infected THA. Follow-up ranged from 2 years to more than 15 years. Hip function was evaluated using the modified Harris Hip Score (mHHS) and the Hip disability and Osteoarthritis Outcome Score (HOOS). Visual Analogue Scale (VAS) measured pain. Annual follow-up included radiographs of the affected hip and blood sampling for inflammatory parameters.

RESULTS

After revision surgery, average mHHS was 63% and average HOOS was 54%. VAS pain averaged 26.8 on a 100-point scale and 40% of patients had no pain. Prosthesis-related complications unrelated to sepsis occurred in 32%. Most common were periprosthetic fractures, leg length discrepancy and dislocation. Reinfection occurred in 13% of these patients and Coagulase Negative Staphylococcus (CNS) was isolated in 67%.

CONCLUSION

Two-stage evision surgery is an accepted treatment for infected THAs. However, complications are common and hip function afterwards is modest. As previous studies have shown, CNS is an important microorganism in reinfection.

Partial two-stage exchange for infected total hip arthroplasty: a preliminary report

BACKGROUND

One common approach to the infected total hip arthroplasty (THA) calls for a staged revision, including removal of all components. However, removal of well-fixed femoral components can result in bone loss and compromised fixation; it is not known whether it is effective to leave a well-fixed femoral component in situ, remove only the acetabular component, débride thoroughly, place a spacer, and delay reimplantation.

QUESTIONS/PURPOSES

The purposes of this study were to determine (1) the frequency of infection recurrence; (2) the frequency of death; and (3) the Harris hip scores of patients treated with a "two-stage partial exchange" approach.

METHODS

A retrospective analysis from 2000 through January 2011 revealed 19 patients with infected THA treated with partial two-stage exchange including complete acetabular component removal, aggressive soft tissue débridement, retention of the well-fixed femoral stem, placement of an antibiotic-laden cement femoral head on the trunnion of the retained stem, postoperative course of antibiotics, and delayed reimplantation. Indications for this treatment included those patients whose femoral component was determined to be well fixed and its removal would result in significant femoral bone loss and compromise of future fixation. During the study period, this represented 7% (19 of 262) of the patients whom we treated for a chronically infected THA. Minimum followup was 2 years (mean, 4 years; range, 2-11 years). None of the 19 patients in this series were lost to followup. We defined failure as recurrence of infection in the same hip or the use of long-term suppressive antibiotics.

RESULTS

Two patients (11%), both with prior failure of two-staged treatment of infection, failed secondary to recurrence of infection at an average of 3.3 years. There were no patient deaths within 90 days. The mean Harris hip score was 68 (range, 31-100; best score is 100).

CONCLUSIONS

Insofar as 89% of patients in this series were clinically free of infection at a minimum of 2 years, we believe partial two-stage exchange may represent an acceptable option for patients with infected THA when femoral component removal would result in significant bone loss and compromise of reconstruction. Further study is required on this approach.

Chronic infections in hip arthroplasties: comparing risk of reinfection following one-stage and two-stage revision: a systematic review and meta-analysis

BACKGROUND

Two-stage revision is regarded by many as the best treatment of chronic infection in hip arthroplasties. Some international reports, however, have advocated one-stage revision. No systematic review or meta-analysis has ever compared the risk of reinfection following one-stage and two-stage revisions for chronic infection in hip arthroplasties.

METHODS

The review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Relevant studies were identified using PubMed and Embase. We assessed studies that included patients with a chronic infection of a hip arthroplasty treated with either one-stage or two-stage revision and with available data on occurrence of reinfections. We performed a meta-analysis estimating absolute risk of reinfection using a random-effects model.

RESULTS

We identified 36 studies eligible for inclusion. None were randomized controlled trials or comparative studies. The patients in these studies had received either one-stage revision (n = 375) or two-stage revision (n = 929). Reinfection occurred with an estimated absolute risk of 13.1% (95% confidence interval: 10.0%-17.1%) in the one-stage cohort and 10.4% (95% confidence interval: 8.5%-12.7%) in the two-stage cohort. The methodological quality of most included studies was considered low, with insufficient data to evaluate confounding factors.

CONCLUSIONS

Our results may indicate three additional reinfections per 100 reimplanted patients when performing a one-stage versus two-stage revision. However, the risk estimates were statistically imprecise and the quality of underlying data low, demonstrating the lack of clear evidence that two-stage revision is superior to one-stage revision among patients with chronically infected hip arthroplasties. This systematic review underscores the need for improvement in reporting and collection of high-quality data and for large comparative prospective studies on this issue.

Two-stage revision of implant-associated infections after total hip and knee arthroplasty

Septic loosening of total hip and knee endoprostheses gains an increasing proportion of revision arthroplasties. Operative revisions of infected endoprostheses are mentally and physically wearing for the patient, challenging for the surgeon and a significant economic burden for healthcare systems. In cases of early infection within the first three weeks after implantation a one-stage revision with leaving the implant in place is widely accepted. The recommendations for the management of late infections vary by far. One-stage revisions as well as two-stage or multiple revision schedules have been reported to be successful in over 90% of all cases for certain patient collectives. But implant associated infection still remains a severe complication. Moreover, the management of late endoprosthetic infection requires specific logistics, sufficient and standardized treatment protocol, qualified manpower as well as an efficient quality management. With regard to the literature and experience of specialized orthopaedic surgeons from several university and regional hospitals we modified a commonly used treatment protocol for two-stage revision of infected total hip and knee endoprostheses. In addition to the achievement of maximum survival rate of the revision implants an optimisation of the functional outcome of the affected artificial joint is aimed for.

Treatment of post-operative infections following proximal femoral fractures: our institutional experience

Proximal femoral fractures (PFFs) are a major health concern in the elderly population. Improvements made in implants and surgical techniques resulted in faster rehabilitation and shorter length of hospital stay. Despite this, the reduced physiological reserve, associated co-morbidities and polypharmacy intake of the elderly population put them at high risk of postoperative complications particularly of infectious origin. Out of 10061 patients with proximal femoral fractures 105 (1.05%) developed surgical site infection; 76 (72%) infections occurred in patients who had sustained intracapsular (IC) fractures with the remaining 29 (28%) infections occurring in patients with extracapsular (EC) neck of femur fractures. The median number of additional surgical debridements was 2 (range 1-7). MRSA was isolated in 49 (47%) of the cases; 38 patients (36%) ultimately underwent a Girdlestone's excisional arthroplasty. Mortality at 30 days and 3 months was 10% and 31%, respectively. It was noted that post-operative hip infection predisposed to a prolonged length of stay in the acute unit and subsequently to a more dependent destination after discharge.