Total hip arthroplasty for destructive septic arthritis of the hip using a two-stage protocol without spacer placement

Diagnosis and surgical treatment of chronic destructive septic hip arthritis

Septic hip arthritis (SHA) is a relatively rare but hazardous disease. Much controversy exists regarding the definition, diagnosis and treatment of chronic destructive SHAs. This review aims to provide an overview of the diagnostic and therapeutic approaches for chronic, destructive SHA and suggest possible research directions for this disease's future diagnosis and treatment. There is no unified naming or classification standard for SHAs. Chronic destructive SHA still requires a comprehensive diagnosis combining history, signs, bacterial culture, histopathological examination, inflammation and other indicators, of which metagenomic next-generation sequencing is a promising diagnostic tool. Previous treatment options for this disease include debridement, debridement + Girdlestone femoral head and neck resection, and debridement + Girdlestone femoral head and neck resection + two-stage arthroplasty. Among them, one-stage spacer implantation + two-stage arthroplasty is the current standard surgical option with a high success rate and low reinfection rate, while one-stage arthroplasty is a new treatment option proposed in recent years with unique advantages but limitations in terms of surgical indications. In the future, more high-quality studies are needed to provide the latest evidence to support clinical decision-making.

One and a Half-stage Total Hip Arthroplasty with Custom-Made Articulating Spacers (CUMARS) for Management of Bilateral Destructive Hip Septic Arthritis - A Case Report

INTRODUCTION

Prompt diagnosis and management of septic arthritis are pivotal for early infection eradication, joint preservation, and prevention of quality-of-life impact consequences. Total hip arthroplasty has been introduced for the management of severe destructive septic arthritis with the aims to eradicate infection while preserving hip function. Few case studies have been done on two-stage exchange total hip arthroplasty for treatment of native hip septic arthritis using prosthesis with antibiotic-loaded acrylic cement articulating spacer with generally good outcomes. However, a small percentage of patients electively chose not to proceed with the second-stage exchange arthroplasty. Therefore, 1.5-stage total hip arthroplasty was considered a viable option; however, it has only been established in periprosthetic infection management, but not in native hip septic arthritis. Custom-made articulating spacers are considered an ideal option as has no constraints, are more readily available, and were designed to be a functional single-stage spacer that can remain permanent yet not preclude the possibility of a second-stage exchange surgery if required. Overall, this led to the consideration of 1.5-stage total hip arthroplasty using custom-made articulating spacers for the management of chronic destructive hip septic arthritis.

CASE REPORT

We report a 67-year-old patient with functional decline from fully independent without aids to chairbound over 8 months. Work-up revealed raised inflammatory markers and bilateral destructive hip septic arthritis. He underwent bilateral 1.5-stage total hip arthroplasty with antibiotic-loaded custom-made articulating spacers. One-year post-operation, he remains infection-free and is progressing well with rehabilitation - ambulating independently with walking frame.

CONCLUSION

Management of septic arthritis varies largely depending on infection duration, activity level, and extent of joint destruction. In significantly destructed hip septic arthritis, 1.5-stage total hip arthroplasty using antibiotic-loaded custom-made articulating spacer is a viable option with the benefits of effective infection eradication, good functional outcomes, cost-effectiveness, reduced physical and psychological burden in avoiding a second operation, all whilst not precluding the possibility of a second-stage exchange arthroplasty if required with ease.

C-reactive protein of ≥ 20 mg/L and ultrasound finding of an effusion ≥ 7 mm has a high specificity and sensitivity in diagnosing paediatric hip septic arthritis

PURPOSE

Differentiating septic arthritis (SA) from transient synovitis (TS) in children remains a diagnostic challenge. Several algorithms have been developed to diagnose SA including Kocher's criteria and its subsequent modifications, but reports show variable efficacy. This study aims to examine the diagnostic utility of a novel method only using C-reactive protein (CRP) and ultrasound (US) findings of effusion in differentiating SA from TS, determine the optimal values for these predictors and validate this method against existing clinical predictors.

METHODS

A 5-year retrospective study was performed including all paediatric patients with acute, non-traumatic hip pain with a suspicion of SA. All patients were evaluated using Kocher's criteria, Caird's criteria, and the novel method. Multivariate logistic regression was performed to identify independent clinical predictors of SA. The degree of agreement between the various methods were assessed using Cohen's kappa (k). Receiver operating characteristics (ROC) curves were used to examine the diagnostic accuracy of this novel method as well as to determine optimal cut-offs for US effusion and CRP in diagnosing SA.

RESULTS

Hundred and one patients were recruited. CRP and effusion on US were found to be independent predictors of SA. Both Kocher's and Caird's method showed good specificity (98.9%) but extremely poor sensitivity for SA (0%). When Kocher's four clinical predictors were present, probability of SA was only 59.16%. The k for both Kocher's and Caird's methods, was -0.017 indicating poor agreement. However the k in the novel method was 0.641, indicating good agreement.

CONCLUSION

Our study showed that the novel method using CRP (≥ 20 mg/L) and US finding of effusion (≥ 7 mm) has a high specificity (97%) and sensitivity (71%) in diagnosing SA.

Should treatment decisions in septic arthritis of the native hip joint be based on the route of infection?

Background: Surgical management of septic arthritis (SA) of the hip aims at treating the infection by either preserving, resecting or replacing the joint. In some cases, joint preservation should be attempted, whereas other cases would benefit from immediate joint resection or replacement. Prognostic factors have been proposed to guide decision-making. We hypothesized that most of these factors can be simplified to three subgroups based on the route of infection: contiguous spreading, direct inoculation or hematogenous seeding. Methods: A total of 41 patients have been treated surgically for SA of the native hip at our tertiary hospital during the last 16 years. Medical records were studied, and various patient and disease characteristics were collated. Results: Significant differences between (1) level of fitness, (2) condition of the hip joint, (3) micro-organisms and (4) chance of femoral head preservation were found for patients with SA of the native hip resulting from the three aforementioned subgroups. Femoral head resection was necessary at one point in 85 % of patients. Patients with hematogenous infections of undamaged hips had a reasonable chance (53 %) of avoiding joint resection or replacement. Hip arthroplasty was performed on 46.3 % of patients, with an infection rate of 10.5 %. Conclusion: Patients with SA of the native hip resulting from contiguous spreading, hematogenous seeding or direct inoculation differ significantly and should be considered distinct clinical entities. Route of infection is directly related to the chance of femoral head preservation and should, therefore, guide decision-making. Only patients with hematogenous infection to a previously healthy hip had the possibility of femoral head preservation.

Outcomes of single- vs two-stage primary joint arthroplasty for septic arthritis: a systematic review and meta-analysis

Purpose

Septic arthritis (SA) is an intra-articular infection caused by purulent bacteria and the only effective method is surgical intervention. Two-stage arthroplasty is considered the gold standard treatment for SA, but recent studies have found that single-stage arthroplasty can achieve the same efficacy as two-stage arthroplasty. This study aimed to compare the efficacy of single- vs two-stage arthroplasty in the treatment of (acute or quiescent) SA.

Methods

The review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched the PubMed, EMBASE, Medline, and Cochrane Library databases to identify all literature on the treatment of SA using single- and two-stage arthroplasty from the date of database inception to November 10, 2022. Data on reinfection rates were expressed as odds ratios and 95% CIs.

Results

Seven retrospective studies with a total of 413 patients were included. Pooled analysis showed no difference in the reinfection rate between single- and two-stage arthroplasty. Subgroup analysis found no difference between the single- and two-stage arthroplasty groups in the incidence of purulent infection of the hip and knee. Cumulative meta-analysis showed gradual stabilization of outcomes.

Conclusions

Based on our meta-analysis of available retrospective studies, we found no significant difference in reinfection rates between single- and two-stage arthroplasty for SA. Further prospective cohort studies are needed to confirm our results, although our meta-analysis provides important insights into the current literature on this topic.

Mechanical complications of hip spacers: a systematic review of the literature

INTRODUCTION

Temporary spacers used in the staged revision of a hip prosthetic joint infection (PJI) have been associated with several mechanical complications with very variable reported general complications rates up to 73%. The aim of this systematic review was to assess the mechanical complications associated with hip antibiotic-loaded spacers when treating periprosthetic hip PJI.

METHODS

Through an electronic systematic search of PubMed, articles reporting mechanical complications of spacers used in the treatment of hip PJI were reviewed. Dislocations, spacer fracture, femoral fractures, and acetabular lysis rates were evaluated.

RESULTS

Forty studies were included. Standardized molded spacers had a significantly higher weighted mean of total mechanical complication rates (37.2%) when compared to standardized preformed spacers (13.8%, p = 0.039), while no significant difference was found between molded spacers and manually shaped spacers. Spacer dislocation was the most frequent complication. No significant difference in mechanical complication rate was found between spacers with and without any metallic component.

CONCLUSIONS

Spacer placement in chronic PJI of the hip with bone and soft-tissue defects is challenging and bears a high risk of mechanical failures and progressive bone loss during the interim period. A careful patient selection for spacer implantation is mandatory.