Encouraging outcomes of staged, uncemented arthroplasty with short-term antibiotic therapy for treatment of recalcitrant septic arthritis of the native hip

Two-stage total joint replacement for hip or knee septic arthritis: post-traumatic etiology and difficult-to-treat infections predict poor outcomes

PURPOSE

Septic arthritis (SA) is a rare but significant clinical challenge in orthopedics that can impact patients' quality of life. This study aims to examine the clinical outcomes of patients undergoing two-stage total joint replacement (TJR) in hip and knee SA and analyze potential predictors of treatment failure.

METHODS

A retrospective analysis was conducted using data from a prospectively collected institutional arthroplasty registry from January 1st, 2012, to January 1st, 2019. Patients with hip or knee SA who underwent a two-stage TJR and had at least two years of follow-up were included. Demographic characteristics, surgical variables, and outcomes were collected and analyzed from clinical and surgical data. Statistical analysis was performed using IBM SPSS Statistics, with statistical significance at p < 0.05.

RESULTS

One hundred and fourteen patients (61 with hip SA, 53 with knee SA) were included in the study. The mean follow-up was 72.8 months. Postoperatively, both clinical and functional outcomes significantly improved, as indicated by the Hip Society Score (HHS) and Knee Society Score (KSS). The overall success rate of the two-stage protocol was 89.5%. Complications that did not require revision occurred in 21% of cases. The most identified pathogen was methicillin-sensitive Staphylococcus aureus (MSSA). Difficult-to-treat (DTT) infections and post-traumatic etiology were identified as predictors of treatment failure in patients undergoing two-stage TJR for hip and knee SA.

CONCLUSIONS

Two-stage TJR in hip and knee SA demonstrated favorable clinical outcomes at mid-term follow-up. The procedure significantly improved functional scores and achieved a high success rate, while DTT infections and post-traumatic etiology were associated with a higher risk of treatment failure.

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.

ACUTE DESTRUCTIVE HIP SEPTIC ARTHRITIS IN A YOUNG ADULT PATIENT: CASE REPORT (v2)

The Authors describe a case of rapid right hip destructive septic arthritis in a 50-year-old male patient with no previous noteworthy medical history. Patient arrived to our attention following a one week history of right hip pain. Laboratory markers and imaging at presentation were negative. However, on a follow-up examination significant joint effusion was noted and joint tap was performed. Despite wide spectrum antibiotic therapy institution, significant joint damage was observed. This required surgical femoral head excision with antibiotic loaded spacer, followed by hip arthroplasty surgery 12 weeks afterwards. Complete healing of the infection and recovery of pain-free joint motion was noted at 1 year follow-up.

Management of septic arthritis of the hip joint in adults. A systematic review of the literature

BACKGROUND

The septic arthritis of the hip is a complex condition characterized by a variety of clinical presentations, a challenging diagnosis and different surgical treatment options, including arthroscopy, resection arthroplasty and one and two-stage total hip replacement. Each technique reports variable results in terms of infection eradication rate. The aim of this systematic review is to compare the most relevant studies available in current literature and to assess if a better treatment outcome can be predicted based on the microbiology, history, and type of infection (active vs quiescent) of each case.

METHODS

A systematic review of the literature was performed in accordance with the PRISMA guidelines, including the studies dealing with the treatment of hip septic arthritis in adult patients. Electronic databases, namely the MEDLINE, Scopus, and Web of Science, were reviewed using a combination of following keywords "septic arthritis" AND "hip joint" OR "hip" AND "adult".

RESULTS

The total number of patients included in this review was 1236 (45% of which females), for 1238 hips. The most common pathogen isolated was Staphylococcus aureus in its Methicillin-sensitive variant ranging from 2 to 37% of cases. Negative cultures were the second most common finding. It was also differentiated the type of infection of the hip, 809 and 417 patients with active and quiescent hip infection, respectively, were analyzed. Eradication rates for two-stage revision arthroplasty ranged between 85 and 100%, for one-stage approach between 94 and 100%, while for arthroscopic debridement/lavage between 89 and 100%.

CONCLUSION

Staphylococcus aureus is the most common microorganism isolated followed by culture negative infections. Arthroscopic, one and two stage procedures can be effective in the treatment of hip septic arthritis when the indication is consistent with the type of infection retrieved.

LEVEL OF EVIDENCE

IV, therapeutic study.

Two-stage arthroplasty for septic arthritis of the hip and knee: A systematic review on infection control and clinical functional outcomes

INTRODUCTION

Septic arthritis of the native hip and knee joint poses particular challenges to orthopedic surgeons. Patients often suffer from several comorbidities, and it could be challenging to find a balance between infection control and adequate function. Two-stage arthroplasty has been addressed as a reliable solution, however the literature on the topic is composed of case series with small sample size. This systematic review aimed to analyze data on infection control and clinical functional outcomes of patients who underwent two-stage arthroplasty for septic arthritis of the hip and knee.

METHODS

An electronic search of studies published from January 1st, 2000, to June 1st, 2021, was conducted using eight different databases. Following the Cochrane Handbook of Systematic Reviews of Interventions and Preferred Reporting Items for Systematic Revies and Meta-analysis two authors reviewed the available literature and reference lists to identify papers eligible for inclusion.

RESULTS

A total of 21 studies were included, involving 435 procedures. The mean age was 57.3 ± 6.2 (45.8-71.8) years. The mean follow-up was 53.7 ± 18.6 (12-86.7) months. The mean infection eradication was 93.3 ± 6.4%. Mean Harris Hip Score improved from 32.1 ± 10.6 (11.5-42.9) to 87.5 ± 5.7 (80.6-97.8). Mean Knee Society Score improved from 42.9 ± 7.6 (35.9-58.0) to 86.1 ± 5.4 (80.1-96.0).

CONCLUSIONS

Two-stage arthroplasty for hip and knee septic arthritis provided high infection control rate and excellent function. Further high-quality studies should be oriented on providing a validated algorithm for diagnosis and treatment of this condition.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Clinical outcomes and survivorship of two-stage total hip or knee arthroplasty in septic arthritis: a retrospective analysis with a minimum five-year follow-up

Purpose

Septic arthritis of the native joint is challenging for orthopedic surgeons because it may lead to wide bone defects and severe impairment of joint function. This study aimed to analyze clinical functional outcomes, the rate of infection eradication, and survival of implants of patients who underwent two-stage arthroplasty for septic arthritis of the hip and knee.

Methods

A retrospective single-centre analysis was conducted of patients treated for septic arthritis of the hip and knee joints through a two-stage surgery between 2012 and 2015. Clinical and radiological records were gathered from the prospectively collected Institutional Arthroplasty Registry. Patients’ pre-operative Harris hip scores and Knee Society scores were compared with those obtained at the latest follow-up. Kaplan–Meier curves were generated to assess survival of implants.

Results

Forty-seven patients were included. The mean follow-up was 85.2 ± 15.4 months. The Harris hip score improved from 39.4 ± 9.9 to 84.5 ± 10.8 points (p < 0.001). The Knee Society score improved from 40.7 ± 8.4 to 86.0 ± 7.8 points (p < 0.001). Knee Society score-function increased from 25.7 ± 14.2 to 85.4 ± 23.4 points (p < 0.001). The infection eradication rates were 92.0% and 90.9% in patients who underwent hip and knee operation, respectively (p = 0.891). Overall survivorship of implants after the second stage was 93.6%.

Conclusions

Two-stage arthroplasty provides good to excellent clinical outcomes in cases of active septic arthritis of the hip and the knee, high rates of infection control, and implant survival.

Active septic arthritis of the hip in adults: what's new in the treatment? A systematic review

Treatment of bacterial septic arthritis in the native adult hip joint can be challenging. Prompt diagnosis and treatment decisions can reduce the associated morbidity and mortality.

For this systematic review of the literature, we asked: (1) What are the treatment options? (2) What are the success rates and the outcomes after treatment? (3) Which antibiotic and duration of therapy are optimal?

We searched the electronic databases PubMed, Scopus, and Embase using the search terms “hip” or “native hip” and “septic arthritis” or “coxitis”. Studies were included if they reported on: (1) bacterial infection of the hip, (2) treatment, (3) success rate/outcomes, (4) follow-up. The final review included 19 studies. The quality of study reporting was evaluated with the Methodological Index for Non-randomized Studies (MINORS) questionnaire.

Three treatment options are: arthroscopy, single open surgery, and two-stage total hip arthroplasty (THA). A high success rate in infection eradication was reported for all three. Intravenous antibiotic therapy should be promptly initiated to eradicate septic arthritis and minimize potential sequelae and complications.

Arthroscopy, single open or two-stage THA were reported to be effective in treating bacterial septic arthritis of the native hip. The key to optimal outcome is early diagnosis and timely treatment.

Cite this article: EFORT Open Rev 2021;6:164-172. DOI: 10.1302/2058-5241.6.200082

Outcomes and predictors of treatment failure following two-stage total joint arthroplasty with articulating spacers for evolutive septic arthritis

Background

The treatment strategy for evolutive septic arthritis (SA) with coexistent degenerative joint disease is not well established. The purposes of this study were to 1) investigate treatment outcome and potential risk factors of treatment failure in patients with evolutive SA following two-stage procedure, including insertion of an antibiotic-loaded spacer at the first stage and subsequent implantation of a new prosthesis; and 2) determine the performance of serum erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and Interleukin-6 (IL-6) in predicting persisting infection at second-stage procedure.

Methods

We retrospectively reviewed 74 patients with evolutive SA of hips and knees who underwent a two-stage TJA between 2008 and 2015. The treatment success was defined according to the modified Delphi criteria and Kaplan-Meier survivorship curves were constructed to determine treatment success. A Cox regression model was performed to identify risk factors for treatment failure. Receiver operating characteristic (ROC) curves were generated to determine the prognostic value of ESR, CRP, and IL-6 in predicting persistent infection before second-stage prostheses implantation.

Results

Overall, the treatment success rate was 93% for hips and 100% for knees after the first-stage surgery. The treatment success rate was 89% for hips and 84% for knees after second-stage prosthesis implantation with a mean follow-up of 4.7 (range, 2.2 to 10.8) years. Older age (Hazard ratio [HR] [per 10-year increase], 1.20; 95% confidential interval [CI], 1.11 to 1.62), higher preoperative CRP level (HR [per 1-mg/dL increase], 1.15; 95% CI, 1.04 to 1.28) and resistant organism (HR, 13.96; 95% CI, 3.29 to 19.20) were associated with an increased risk of treatment failure. All serologic tests presented limited values in predicting persisting infection, with the area under ROC curve of ESR, CRP, IL-6 and combination of the three markers was 57.8, 61.6, 60.3, and 62.1%, respectively.

Conclusions

Two-stage TJA is an adequate management of infection control in patients with evolutive SA. The three potential risk factors (old age, high preoperative CRP, and resistant organism profile) may predict treatment failure following a two-stage procedure for evolutive SA. Additionally, serum ESR, CRP, and IL-6 had no benefit in predicting persisting infection before second-stage prostheses implantation. These findings may be useful when treating patients with evolutive SA.

Comparison of efficacy and complications between two types of staging arthroplasty in treating chronic septic hip arthritis: A retrospective clinical study

Septic hip arthritis is a rare but serious disease, which is often persistent, able to transform into a chronic infection, and difficult to cure. The present study aimed to compare the midterm outcomes between the staging of a total hip arthroplasty via the Girdlestone surgery (a resection of the head and neck) and the Girdlestone combined with a cement spacer in treating chronic septic hip arthritis, as well as to compare the postsurgery efficacy and complications between the two groups. A total of 13 patients (14 total hip joints) were enrolled and retrospectively analyzed. For the stage I surgery, four patients (five hips) underwent the resection of the head and neck, and nine patients (nine hips) underwent the resection of the head and neck combined with the implantation of a bone cement spacer. After the infection was fully controlled, the patients in both groups underwent cementless total hip arthroplasties as stage II surgeries. The mean follow-up period was 24.2 months. The curative effects and complications of the patients were recorded and compared. It was found that the application of the staging arthroplasty for treating a chronic septic hip was conducive to the complete clearance of lesions. Notably, the implantation of a bone cement spacer containing antibiotics in the stage I surgery prevented joint contracture caused by a head and neck resection, reducing the risk of infection recurrence between the two stages of the operation. This effectively maintained the length of the lower limbs, simplified the stage II complete hip arthroplasty and reduced operative hemorrhage, thus achieving improved recovery of joint function after the stage II arthroplasty. The results suggested that the implantation of a cement spacer at the stage I surgery was more effective in treating chronic septic hip arthritis.

Two-stage revision surgery with preformed spacers and cementless implants for septic hip arthritis: a prospective, non-randomized cohort study

Background

Outcome data on two-stage revision surgery for deep infection after septic hip arthritis are limited and inconsistent. This study presents the medium-term results of a new, standardized two-stage arthroplasty with preformed hip spacers and cementless implants in a consecutive series of adult patients with septic arthritis of the hip treated according to a same protocol.

Methods

Nineteen patients (20 hips) were enrolled in this prospective, non-randomized cohort study between 2000 and 2008. The first stage comprised femoral head resection, debridement, and insertion of a preformed, commercially available, antibiotic-loaded cement hip spacer. After eradication of infection, a cementless total hip arthroplasty was implanted in the second stage. Patients were assessed for infection recurrence, pain (visual analog scale [VAS]) and hip joint function (Harris Hip score).

Results

The mean time between first diagnosis of infection and revision surgery was 5.8 ± 9.0 months; the average duration of follow up was 56.6 (range, 24 - 104) months; all 20 hips were successfully converted to prosthesis an average 22 ± 5.1 weeks after spacer implantation. Reinfection after total hip joint replacement occurred in 1 patient. The mean VAS pain score improved from 48 (range, 35 - 84) pre-operatively to 18 (range, 0 - 38) prior to spacer removal and to 8 (range, 0 - 15) at the last follow-up assessment after prosthesis implantation. The average Harris Hip score improved from 27.5 before surgery to 61.8 between the two stages to 92.3 at the final follow-up assessment.

Conclusions

Satisfactory outcomes can be obtained with two-stage revision hip arthroplasty using preformed spacers and cementless implants for prosthetic hip joint infections of various etiologies.