Managing uncertainty - a qualitative study of surgeons' decision-making for one-stage and two-stage revision surgery for prosthetic hip joint infection

Development of evidence-based guidelines for the treatment and management of periprosthetic hip infection

Aims

Periprosthetic hip-joint infection is a multifaceted and highly detrimental outcome for patients and clinicians. The incidence of prosthetic joint infection reported within two years of primary hip arthroplasty ranges from 0.8% to 2.1%. Costs of treatment are over five-times greater in people with periprosthetic hip joint infection than in those with no infection. Currently, there are no national evidence-based guidelines for treatment and management of this condition to guide clinical practice or to inform clinical study design. The aim of this study is to develop guidelines based on evidence from the six-year INFection and ORthopaedic Management (INFORM) research programme.

Methods

We used a consensus process consisting of an evidence review to generate items for the guidelines and online consensus questionnaire and virtual face-to-face consensus meeting to draft the guidelines.

Results

The consensus panel comprised 21 clinical experts in orthopaedics, primary care, rehabilitation, and healthcare commissioning. The final output from the consensus process was a 14-item guideline. The guidelines make recommendations regarding increased vigilance and monitoring of those at increased risk of infection; diagnosis including strategies to ensure the early recognition of prosthetic infection and referral to orthopaedic teams; treatment, including early use of DAIR and revision strategies; and postoperative management including appropriate physical and psychological support and antibiotic strategies.

Conclusion

We believe the implementation of the INFORM guidelines will inform treatment protocols and clinical pathways to improve the treatment and management of periprosthetic hip infection.

Cite this article: Bone Jt Open 2023;4(4):226–233.

Routine Pathologic Examination of the Femoral Head in Total Hip Arthroplasty: A Survey Study of the American Association of Hip and Knee Surgeons

Background

Current literature does not provide conclusive evidence on whether routine pathologic examination of femoral heads from total hip arthroplasty is indicated or cost-effective. As a result, there is substantial variation in opinion among surgeons related to this issue. Our study aim was to determine factors that impact surgeon propensity to order pathologic examination of femoral heads.

Methods

A 12-question survey was created to evaluate surgeon practices, indications, and patient care implications surrounding routine pathologic examination of femoral heads. The email survey was distributed to all members of the American Association of Hip and Knee Surgeons (n = 2598).

Results

There were 572 survey respondents. Out of all respondents, 28.4% always send femoral heads to pathology, and 27.6% reported an institutional requirement to do so. Of the 572 surgeons, 73.6% report femoral head pathology has never resulted in a change in patient disease course. Factors that increase the likelihood of surgeons ordering femoral head pathologic examination include institutional requirements, medicolegal concern, and prior experience with femoral head pathologic examination changing patients' disease course (P < .001). Cost concern decreases the likelihood of surgeons ordering femoral head pathologic examination (P = .0012).

Conclusions

A minority of surgeons routinely send femoral heads from total hip arthroplasty for pathologic examination, mostly because of institutional requirement. The majority of surgeons feel that femoral head pathologic examination never changes patient management, although others have infrequently detected malignancy and infection. Institutional policy, concern for litigation, and prior experience with discordant pathologic diagnoses increase femoral head pathologic examinations, while cost concern decreases them.

Infection after total joint replacement of the hip and knee: research programme including the INFORM RCT

Background

People with severe osteoarthritis, other joint conditions or injury may have joint replacement to reduce pain and disability. In the UK in 2019, over 200,000 hip and knee replacements were performed. About 1 in 100 replacements becomes infected, and most people with infected replacements require further surgery.

Objectives

To investigate why some patients are predisposed to joint infections and how this affects patients and the NHS, and to evaluate treatments.

Design

Systematic reviews, joint registry analyses, qualitative interviews, a randomised controlled trial, health economic analyses and a discrete choice questionnaire.

Setting

Our studies are relevant to the NHS, to the Swedish health system and internationally.

Participants

People with prosthetic joint infection after hip or knee replacement and surgeons.

Interventions

Revision of hip prosthetic joint infection with a single- or two-stage procedure.

Main outcome measures

Long-term patient-reported outcomes and reinfection. Cost-effectiveness of revision strategies over 18 months from two perspectives: health-care provider and Personal Social Services, and societal.

Data sources

National Joint Registry; literature databases; published cohort studies; interviews with 67 patients and 35 surgeons; a patient discrete choice questionnaire; and the INFORM (INFection ORthopaedic Management) randomised trial.

Review methods

Systematic reviews of studies reporting risk factors, diagnosis, treatment outcomes and cost comparisons. Individual patient data meta-analysis.

Results

In registry analyses, about 0.62% and 0.75% of patients with hip and knee replacement, respectively, had joint infection requiring surgery. Rates were four times greater after aseptic revision. The costs of inpatient and day-case admissions in people with hip prosthetic joint infection were about five times higher than those in people with no infection, an additional cost of > £30,000. People described devastating effects of hip and knee prosthetic joint infection and treatment. In the treatment of hip prosthetic joint infection, a two-stage procedure with or without a cement spacer had a greater negative impact on patient well-being than a single- or two-stage procedure with a custom-made articulating spacer. Surgeons described the significant emotional impact of hip and knee prosthetic joint infection and the importance of a supportive multidisciplinary team. In systematic reviews and registry analyses, the risk factors for hip and knee prosthetic joint infection included male sex, diagnoses other than osteoarthritis, high body mass index, poor physical status, diabetes, dementia and liver disease. Evidence linking health-care setting and surgeon experience with prosthetic joint infection was inconsistent. Uncemented fixation, posterior approach and ceramic bearings were associated with lower infection risk after hip replacement. In our systematic review, synovial fluid alpha-defensin and leucocyte esterase showed high diagnostic accuracy for prosthetic joint infection. Systematic reviews and individual patient data meta-analysis showed similar reinfection outcomes in patients with hip or knee prosthetic joint infection treated with single- and two-stage revision. In registry analysis, there was a higher rate of early rerevision after single-stage revision for hip prosthetic joint infection, but, overall, 40% fewer operations are required as part of a single-stage procedure than as part of a two-stage procedure. The treatment of hip or knee prosthetic joint infection with early debridement and implant retention may be effective in > 60% of cases. In the INFORM randomised controlled trial, 140 patients with hip prosthetic joint infection were randomised to single- or two-stage revision. Eighteen months after randomisation, pain, function and stiffness were similar between the randomised groups (p = 0.98), and there were no differences in reinfection rates. Patient outcomes improved earlier in the single-stage than in the two-stage group. Participants randomised to a single-stage procedure had lower costs (mean difference –£10,055, 95% confidence interval –£19,568 to –£542) and higher quality-adjusted life-years (mean difference 0.06, 95% confidence interval –0.07 to 0.18) than those randomised to a two-stage procedure. Single-stage was the more cost-effective option, with an incremental net monetary benefit at a threshold of £20,000 per quality-adjusted life-year of £11,167 (95% confidence interval £638 to £21,696). In a discrete choice questionnaire completed by 57 patients 18 months after surgery to treat hip prosthetic joint infection, the most valued characteristics in decisions about revision were the ability to engage in valued activities and a quick return to normal activity.

Limitations

Some research was specific to people with hip prosthetic joint infection. Study populations in meta-analyses and registry analyses may have been selected for joint replacement and specific treatments. The INFORM trial was not powered to study reinfection and was limited to 18 months’ follow-up. The qualitative study subgroups were small.

Conclusions

We identified risk factors, diagnostic biomarkers, effective treatments and patient preferences for the treatment of hip and knee prosthetic joint infection. The risk factors include male sex, diagnoses other than osteoarthritis, specific comorbidities and surgical factors. Synovial fluid alpha-defensin and leucocyte esterase showed high diagnostic accuracy. Infection is devastating for patients and surgeons, both of whom describe the need for support during treatment. Debridement and implant retention is effective, particularly if performed early. For infected hip replacements, single- and two-stage revision appear equally efficacious, but single-stage has better early results, is cost-effective at 18-month follow-up and is increasingly used. Patients prefer treatments that allow full functional return within 3–9 months.

Future work

For people with infection, develop information, counselling, peer support and care pathways. Develop supportive care and information for patients and health-care professionals to enable the early recognition of infections. Compare alternative and new treatment strategies in hip and knee prosthetic joint infection. Assess diagnostic methods and establish NHS diagnostic criteria.

Study registration

The INFORM randomised controlled trial is registered as ISRCTN10956306. All systematic reviews were registered in PROSPERO (as CRD42017069526, CRD42015023485, CRD42018106503, CRD42018114592, CRD42015023704, CRD42017057513, CRD42015016559, CRD42015017327 and CRD42015016664).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 10. See the NIHR Journals Library website for further project information.

Clinical and cost effectiveness of single stage compared with two stage revision for hip prosthetic joint infection (INFORM): pragmatic, parallel group, open label, randomised controlled trial

OBJECTIVES

To determine whether patient reported outcomes improve after single stage versus two stage revision surgery for prosthetic joint infection of the hip, and to determine the cost effectiveness of these procedures.

DESIGN

Pragmatic, parallel group, open label, randomised controlled trial.

SETTING

High volume tertiary referral centres or orthopaedic units in the UK (n=12) and in Sweden (n=3), recruiting from 1 March 2015 to 19 December 2018.

PARTICIPANTS

140 adults (aged ≥18 years) with a prosthetic joint infection of the hip who required revision (65 randomly assigned to single stage and 75 to two stage revision).

INTERVENTIONS

A computer generated 1:1 randomisation list stratified by hospital was used to allocate participants with prosthetic joint infection of the hip to a single stage or a two stage revision procedure.

MAIN OUTCOME MEASURES

The primary intention-to-treat outcome was pain, stiffness, and functional limitations 18 months after randomisation, measured by the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC) score. Secondary outcomes included surgical complications and joint infection. The economic evaluation (only assessed in UK participants) compared quality adjusted life years and costs between the randomised groups.

RESULTS

The mean age of participants was 71 years (standard deviation 9) and 51 (36%) were women. WOMAC scores did not differ between groups at 18 months (mean difference 0.13 (95% confidence interval -8.20 to 8.46), P=0.98); however, the single stage procedure was better at three months (11.53 (3.89 to 19.17), P=0.003), but not from six months onwards. Intraoperative events occurred in five (8%) participants in the single stage group and 20 (27%) in the two stage group (P=0.01). At 18 months, nine (14%) participants in the single stage group and eight (11%) in the two stage group had at least one marker of possible ongoing infection (P=0.62). From the perspective of healthcare providers and personal social services, single stage revision was cost effective with an incremental net monetary benefit of £11 167 (95% confidence interval £638 to £21 696) at a £20 000 per quality adjusted life years threshold (£1.0; $1.1; €1.4).

CONCLUSIONS

At 18 months, single stage revision compared with two stage revision for prosthetic joint infection of the hip showed no superiority by patient reported outcome. Single stage revision had a better outcome at three months, fewer intraoperative complications, and was cost effective. Patients prefer early restoration of function, therefore, when deciding treatment, surgeons should consider patient preferences and the cost effectiveness of single stage surgery.

TRIAL REGISTRATION

ISRCTN registry ISRCTN10956306.

Managing periprosthetic joint infection-a qualitative analysis of nursing staffs' experiences

Background

Periprosthetic joint infection represents a major complication in orthopaedics and trauma surgery. For an ideal management approach, it is important to understand the distinct challenges for all persons involved in the treatment. Therefore, it was aimed at investigating (1) the impact of periprosthetic joint infection (PJI) on the well-being of nursing staff to (2) identify challenges, which could be improved facilitating the management of PJI.

Methods

This is a qualitative interview study. In total, 20 nurses of a German university orthopedic trauma center specialized on infectious complications were recruited using a purposive sampling strategy. Content analysis was performed on transcripts of individual in-person interviews conducted between March 2021 and June 2021.

Results

Three major themes could be extracted including (i) feelings associated with the management of PJI and the need for emotional support, illustrating the negative emotional impact on nurses, whereby receiving collegial support was perceived as an important coping strategy, (ii) patients’ psychological burden, highlighting the nurses’ lack of time to address mental issues adequately and, (iii) realization of the severity of PJI and compliance problems.

Conclusion

Identified facilitating factors for PJI management include strengthening of mental care in the treatment of PJI, providing opportunities for exchange among multidisciplinary team members and implementing compliance-enhancing strategies. The findings of this study can be beneficial for improving professionals’ satisfaction, optimising the work environment, creating organizational structures which enhance opportunities for exchange and preventing mental health issues among the nursing team.

External validation study of hip peri-prosthetic joint infection with cemented custom-made articulating spacer (CUMARS)

INTRODUCTION

Peri-prosthetic joint infection (PJI) is a devastating complication after total hip arthroplasty (THA). The use of custom-made articulating spacers (CUMARS) has been described for use in the first of 2-stage treatment. We report our outcomes of managing PJI using CUMARS.

METHODS

Patients undergoing 1st-stage revision using the Exeter standard stem, all-polyethylene acetabulum and antibiotic-loaded cement were identified. Medical records were assessed for demographics, microbiological and operative treatment, complications, eradication of infection and reoperations. No postoperative restrictions were enforced. 2nd-stage revision was undertaken in the presence of pain or subsidence.

RESULTS

53 patients underwent 1st-stage revision using this technique. The average follow-up was 3.9 (range 0.5-7.2) years. Infection was eradicated in 47 (88.7%) patients. 2 patients had chronic infection managed with suppressive antibiotics, 2 patients died before eradication confirmed, 1 patient had raised inflammatory markers but no positive aspiration cultures, 1 patient was lost to follow-up. Complications occurred in 5 (9.4%) patients - 4 dislocations and 1 infected haematoma. 4 patients required a repeated 1st stage. 2nd-stage revision was performed in 19 patients (35%).

CONCLUSIONS

The CUMARS technique is an effective way of eradicating PJI after THA. It maintains function by providing a stable construct that permits weight-bearing. It delays or negates the need for 2nd-stage revision. Furthermore, it allows surgeons to choose between managing patients prospectively as a single-stage revision with the option of reverting to a 2nd stage.

Risk factors for mortality following one-stage septic hip arthroplasty - a case-control study

PURPOSE

Despite good clinical outcomes and a high success rate, there is a comparatively high mortality after one stage septic exchange of total hip arthroplasty. The aim of this study was to identify risk factors for mortality in the hospitalization period after one-stage septic exchange of THA.

METHODS

We retrospectively analyzed in our database all patients who had a one-stage septic exchange for periprosthetic infection of THA and died during hospitalization (n = 33). The control group was matched semi-randomly by surgical procedure (n = 121) who did not die during hospitalization. The two groups were analyzed for risk factors such as age, Charlson Comorbidity Index (CCI), and high-/low-virulence bacteria.

RESULTS

In the deceased group, 16 patients were female and 17 were male with a mean age at surgery of 73.2 years. In the control group, there were 55 females and 66 males with an average age at surgery of 68.2 years. Comparing the two groups, the deceased group had a significantly higher proportion of liver disease as well as higher rate of pulmonary embolism, apoplexy, and/or myocardial infarction, an increased CCI with an average of 6.5 and advanced age. Further demographic and surgery-related parameters especially high- or low-virulent germs were not identified as risk factors for mortality during the hospitalization period. The binominal logistic regression analysis showed that the probability of an inpatient death following one-stage septic exchange of THA increases by a factor of 3.079, with each additional point of the CCI.

CONCLUSION

In conclusion, advanced age and high CCI are the main risk factors for mortality after single-stage septic change of THA. However, high-virulence bacteria have no influence on the mortality during the hospitalization period after one-stage septic exchange of THA.

Exchange of Modular Components Improves Success of Debridement, Antibiotics, and Implant Retention: An Observational Study of 575 Patients with Infection After Primary Total Hip Arthroplasty

Debridement, antibiotics, and implant retention (DAIR) is a surgical treatment for periprosthetic joint infection (PJI). DAIR is a desirable treatment option from an economic and patient perspective, if successful. The aim of this observational study was to compare the rates of success, defined as no additional reoperations due to PJI, between DAIR with exchange of modular components and DAIR without exchange in patients who had first-time PJI after primary total hip arthroplasty (THA).

METHODS

Patients with PJI at the site of a primary THA who were treated with DAIR in Sweden between January 1, 2009, and December 31, 2016, were identified in the Swedish Hip Arthroplasty Register. Supplementary questionnaires were sent to orthopaedic departments for additional variables of interest related to PJI. The primary end point was another reoperation due to PJI within 2 years after the first-time DAIR. DAIR with exchange was compared with DAIR without exchange using Kaplan-Meier survival analysis and Cox regression analysis.

RESULTS

A total of 575 patients treated with DAIR for a first-time PJI at the site of a primary THA were analyzed; 364 underwent component exchange and 211 did not. The exchange of components was associated with a lower rate of reoperations due to PJI after DAIR (28.0%) compared with non-exchange (44.1%). The Kaplan-Meier implant survival estimate for exchange was 71.4% (95% confidence interval [CI] = 66.9% to 76.3%) compared with 55.5% (95% CI = 49.1% to 62.7%) for non-exchange. With the analysis adjusted for confounders, DAIR with exchange was associated with a significantly decreased risk of another reoperation due to PJI compared with non-exchange (hazard ratio [HR] = 0.51 [95% CI = 0.38 to 0.68]).

CONCLUSIONS

In patients with a first-time PJI at the site of a primary THA, DAIR with exchange of modular components was superior to non-exchange DAIR. Surgeons should strive to exchange components when they perform DAIR, but there is a need to further identify how DAIR best should be practiced and which patients benefit from it.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Contemporary 2-Stage Treatment of Periprosthetic Hip Infection with Evidence-Based Standardized Protocols Yields Excellent Results: Caveats and Recommendations

BACKGROUND

This study quantified the effectiveness of contemporary and evidence-based standardized 2-stage treatment for periprosthetic hip infection. Findings illustrate potential limitations of criticisms of 2-stage protocols and potential consequences of adopting single-stage protocols before definitive data are available.

METHODS

Fifty-four consecutive hips treated with 2-stage resection and reimplantation were retrospectively reviewed. Standardized protocols were adhered to including implant resection, meticulous surgical debridement, antibiotic spacer, 6-week intravenous antibiotics, a 2-week drug holiday, and laboratory assessment of infection eradication before reimplantation. After reimplantation, patients were placed on prophylactic intravenous antibiotics until discharge and discharged on oral antibiotics for a minimum of 7 days until intraoperative cultures were final. Successful treatment was defined per Delphi-based International Multidisciplinary Consensus.

RESULTS

The overall treatment success rate was 95.7% (44 of 46 cases) with mean infection-free survivorship of 67.2 (range, 23.8-106.4) months. Success rates were 100% for early and acute hematogenous infections regardless of host type and 100% for chronic infections in uncompromised hosts. 95% (19/20) of chronic infections in compromised hosts and 83.3% (5/6) of chronic infections in significantly compromised hosts were successfully treated. About 4% of primary hips and 20% of revision hips required repeat debridement and spacer exchange after initial resection. No patients died because of treatment.

CONCLUSION

Details from this consecutive series of patients undergoing 2-stage treatment for hip infection suggest that some criticisms of 2-stage treatment as well as some arguments in support of single-stage treatment may be overstated. Promotion and uncritical adoption of single-stage treatment protocols are discouraged until further and more definitive data exist.

Post-surgery and recovery experiences following one- and two-stage revision for prosthetic joint infection-A qualitative study of patients' experiences

Deep prosthetic hip infection is a devastating complication of hip replacement surgery, and treatment often involves multiple revision surgeries with antibiotic chemotherapy to control the infection. The aim of this study was to explore patients’ experiences of early and longer-term recovery after one-stage or two-stage revision with an excised hip, a temporary cement spacer or a custom-made articulating spacer. We interviewed 32 participants taking part in a surgical trial at two time points (2–4 months and 18 months) following one- or two-stage revision surgery. The analytic approach was inductive using the constant comparative method to generate themes from the data. Participants’ early recovery after revision was characterised by a long hospital stay with burdensome antibiotics and limited physiotherapy provision. Participants undergoing two-stage revision with an excised hip or a cement spacer described severe mobility restrictions which affected all aspects of their lives, while those undergoing one-stage revision, or two-stage revision with an articulating spacer were more mobile and independent, with some limitations. Participants with a cement spacer also reported more pain than other treatment groups, while those with an articulating spacer appeared to perceive that their recovery was slow. At 18 months, participants in all groups described both improvements and losses in mobility and functional ability. Participants in all treatment groups expressed considerable emotional resilience during recovery from revision, which may be linked to opportunities to talk with the trial personnel. Participants identified the need for better information and psychological and physical support. Experience of recovery differs after one- and two-stage revision, and further in relation to the use of spacers. Mobility, function, independence and pain are important aspects of recovery which affect all aspects of day-to-day life. Increased information and more opportunities to talk and share experiences may provide psychological support during recovery.

Reflecting on and managing the emotional impact of prosthetic joint infections on orthopaedic surgeons-a qualitative study

AIMS

To investigate the experience and emotional impact of prosthetic joint infection (PJI) on orthopaedic surgeons and identify holistic strategies to improve the management of PJI and protect surgeons' wellbeing.

METHODS

In total, 18 prosthetic joint surgeons in Sweden were recruited using a purposive sampling strategy. Content analysis was performed on transcripts of individual in-person interviews conducted between December 2017 and February 2018.

RESULTS

PJI had a negative emotional impact on Swedish surgeons. Many felt guilt, stress, and a sense of failure, and several aspects of PJI management were associated with psychosocial challenges. Peer support was reported as the most important coping strategy as was collaborating with infectious disease specialists.

CONCLUSION

Our study affirms that there is a negative emotional impact of PJI on surgeons which can be minimized by improved peer support and working in multidisciplinary teams. Based on the surgeons' experiences we have identified desired improvements that may facilitate the management of PJI. These may also be applicable within other surgical specialties dealing with postoperative infections, but need to be evaluated for their efficacy. Cite this article: Bone Joint J 2020;102-B(6):736-743.

What are patients' preferences for revision surgery after periprosthetic joint infection? A discrete choice experiment

OBJECTIVES

Understanding patients' preferences for treatment is crucial to provision of good care and shared decisions, especially when more than one treatment option exists for a given condition. One such condition is infection of the area around the prosthesis after hip replacement, which affects between 0.4% and 3% of patients. There is more than one treatment option for this major complication, and our study aimed to assess the value that patients place on aspects of revision surgery for periprosthetic hip infection.

DESIGN

We identified four attributes of revision surgery for periprosthetic hip infection. Using a discrete choice experiment (DCE), we measured the value placed on each attribute by 57 people who had undergone either one-stage or two-stage revision surgery for infection.

SETTING

The DCE was conducted with participants from nine National Health Service hospitals in the UK.

PARTICIPANTS

Adults who had undergone revision surgery for periprosthetic hip infection (N=57).

RESULTS

Overall, the strongest preference was for a surgical option that resulted in no restrictions on engaging in valued activities after a new hip is fitted (β=0.7). Less valued but still important attributes included a shorter time taken from the start of treatment to return to normal activities (6 months; β=0.3), few or no side effects from antibiotics (β=0.2), and having only one operation (β=0.2).

CONCLUSIONS

The results highlight that people who have had revision surgery for periprosthetic hip infection most value aspects of care that affect their ability to engage in normal everyday activities. These were the most important characteristics in decisions about revision surgery.

One-Stage Arthroplasty or Revision for Seronegative Infections in Hip and Knee

Objective

To assess the safety and effectiveness of one‐stage total joint arthroplasty (TJA) or revision for seronegative infections after total hip arthroplasty (THA) and total knee arthroplasty (TKA).

Methods

This retrospective study included a total of 495 patients who had undergone one‐stage total joint (hip or knee) arthroplasty or revision with a diagnosis of osteoarthritis secondary to sepsis, osteoarthritis or osteonecrosis of the femoral head (ONFH) secondary to internal fixation surgery of the hip joint, and one‐stage revision for prosthesis loosening after THA or TKA from January 2012 to December 2016. Bacterial cultures were taken from all patients (from joint fluid or articular cavity fluid and four to six different parts of soft tissues) during the operation. If the cultures were positive, patients received antibiotic treatment. Microbiology results from surgical samples, clinical evaluations, SF‐12 score (physical component summary [PCS] and mental component summary [MCS]), Harris hip score (HHS) or Hospital for Special Surgery (HSS) score, and patients' satisfaction was recorded at every follow‐up session.

Results

A total of 24 patients had a positive result for bacterial culture (4.85%). The bacterial culture results showed that there were 19 cases (79.16%) of gram‐positive cocci (Staphylococcus aureus), 4 cases (16.67%) of gram‐negative bacilli, and 1 case (4.17%) of fungi. For at least 24 months (mean 35 months) follow‐up, no reinfection was discovered. The mean HHS or HSS score improved significantly from 36.29 points preoperatively to 84.21 points postoperatively (P < 0.001). The mean PCS score improved from 10.15 preoperatively to 20.34 postoperatively, and the mean MCS from 13.22 preoperatively to 21.76 postoperatively, with significant differences. Most of the patients were satisfied.

Conclusion

One‐stage arthroplasty or revision with exhaustive debridement, adequate dosage, and duration of sensitive antibiotics is safe and effective for patients who have seronegative infection of hip or knee joints.

Improved Patient-Reported Quality of Life and Hip Function After Cementless 1-Stage Revision of Chronic Periprosthetic Hip Joint Infection

BACKGROUND

Limited information is available on health-related quality of life (HRQoL) and patient-reported hip function following treatment for a chronic periprosthetic hip joint infection. The purpose of this study is to evaluate changes in HRQoL and patient-reported hip function 2 years following a cementless 1-stage revision for chronic periprosthetic hip joint infection.

METHODS

Patients (n = 52) enrolled in a previously published clinical study on cementless 1-stage revision in chronic periprosthetic hip joint infection prospectively answered the EuroQol-5D, Short-Form Health Survey 36 (SF-36), and Oxford Hip Score preoperatively and at 3, 6, 12, and 24 months follow-up. Results were compared to age-matched and gender-matched population norm.

RESULTS

A significant improvement in HRQoL and patient-reported hip function appeared in the first 3 months after surgery and reached a plateau after 6 months. The patients statistically reached age-matched and gender-matched population norm after 3 to 12 months follow-up on most items, except for Physical Functioning and Social Functioning on the SF-36. The largest effect sizes were found for Oxford Hip Score at 1.8 and for Role Limitation, Physical and Bodily Pain on the SF-36 at 1.5 and 1.6, respectively.

CONCLUSION

Patients treated with a cementless 1-stage revision for chronic periprosthetic hip joint infection experienced a marked increase in HRQoL and patient-reported hip function, and matched population norms on many parameters.

Treatment of Prosthetic Joint Infection: Established Patient Relationships May Impact Medical Decision-Making

BACKGROUND

Choosing the intervention for prosthetic joint infections, whether debridement, antibiotics, and implant retention (DAIR), or explant and antibiotic spacer placement, is multifactorial. One characteristic that may influence this decision is a previously established relationship with the patient. We hypothesized that patients receiving their arthroplasty at an outside institution and presenting with infection would be more likely to undergo removal of their implant without an attempt at DAIR compared to patients who underwent primary arthroplasty at the investigating institution.

METHODS

The institutional database was queried for primary total hip and knee arthroplasty infections. Manual review of medical records was performed, excluding patients who did not meet the Musculoskeletal Infection Society definition of infection. Patient demographics, medical comorbidities, presenting infection characteristics, and surgical intervention were collected. Multivariable analysis was performed to determine the independent predictors of treatment.

RESULTS

A total of 270 patients were included for analysis. McPherson score (P < .001) and duration of symptoms (P < .001) were associated with subsequent treatment. Additionally, when controlling for age, gender, symptom duration category, procedure, McPherson score, and American Society of Anesthesiologists category, patients with index procedures at outside hospitals were more likely to undergo implant removal (odds ratio, 36.30; 95% confidence interval, 8.16-161.51; P < .001).

CONCLUSION

Patients receiving their primary arthroplasty at an outside hospital and presenting with infection are more likely to undergo removal of hardware as their initial treatment. To avoid treatment bias, institutional protocols should be implemented to guide the shared decision-making process.

The Role of One-Stage Exchange for Prosthetic Joint Infection

PURPOSE OF REVIEW

In an era of increasing numbers of hip and knee replacements, strategies to manage prosthetic joint infection (PJI) that are effective at infection control with good patient-reported outcomes and cost containment for health systems are needed. Interest in single-stage exchange for PJI is rising and we assess evidence from the last 5 years related to this treatment strategy.

RECENT FINDINGS

Only five series for total knee replacement and ten series for total hip replacement have been reported in the last five years. More review articles and opinion pieces have been written. Reinfection rates in these recent studies range from 0 to 65%, but a meta-analysis and systematic review of all studies showed a reinfection rate of 7.6% (95% CI 3.4-13.1) and 8.8% (95% CI 7.2-10.6) for single-stage and two-stage revisions respectively. There is emerging evidence to support single-stage revision in the setting of significant bony deficiency and atypical PJIs such as fungal infections. Prospective randomised studies are recruiting and are necessary to guide the direction of single-stage revision selection criteria. The onus of surgical excellence in mechanical removal of implants, necrotic tissue, and biofilms lies with the arthroplasty surgeon and must remain the cornerstone of treatment. Single-stage revision may be considered the first-line treatment for all PJIs unless the organism is unknown, the patient is systemically septic, or there is a poor tissue envelope.

Intraoperative evaluation of polymorphonuclear leukocyte during second-stage revision surgery promote overdiagnosis of persistent periprosthetic joint infection

Objective

The aim of this study was to evaluate whether intraoperative histopathological examination could predict the risk of relapse of infection in periprosthetic joint infections (PJI).

Methods

The study included 25 patients (14 women and 11 men, with a mean age of 67.0 years (range, 37–83 years)), who had two-staged revision surgery for a PJI. Following prosthetic removal in the first stage, all patient underwent an intraoperative histopathological examination during the second stage. The patients were divided into PMNs-positive group (≥five PMNs per high-powered field) or -negative group (<five PMNs). A relapse was defined as the occurrence of PJI. Median follow-up was 51 months (range, 32–80 months) following second-stage revision surgery.

Results

Intraoperative histopathological revealed that 8.0% of cases were PMNs-positive. Postoperative histopathological examination revealed that 28.0% of cases were PMNs-positive. 28.0% of cases showed discrepancy between the PMNs-positivity. Intraclass correlation coefficient indicates poor reproducibility. Infection relapse after revision surgery occurred in two cases (8.0%); both relapse cases were from the PMNs-negative group. There was no statistical relationship between the presence of PMNs in periprosthetic tissue by intraoperative or postoperative histopathological examination and relapse of infection.

Conclusions

Our findings showed that intraoperative histopathological examination could not predict the relapse of infection. Intraoperative histopathological examination promotes overdiagnosis of the requirement for re-implantation of antibiotic-impregnated cement and prolonged treatment periods.

Level of evidence

Level III, diagnostic study