Abstract
BackgroundApproximately 88,000 primary hip replacements are performed in England and Wales each year. Around 1% go on to develop deep prosthetic joint infection. Between one-stage and two-stage revision arthroplasty best treatment options remain unclear. Our aims were to characterise consultant orthopaedic surgeons’ decisions about performing either one-stage or two-stage revision surgery for patients with deep prosthetic infection (PJI) after hip arthroplasty, and to identify whether a randomised trial comparing one-stage with two-stage revision would be feasible.MethodsSemi-structured interviews were conducted with 12 consultant surgeons who perform revision surgery for PJI after hip arthroplasty at 5 high-volume National Health Service (NHS) orthopaedic departments in England and Wales. Surgeons were interviewed before the development of a multicentre randomised controlled trial. Data were analysed using a thematic approach.ResultsThere is no single standardised surgical intervention for the treatment of PJI. Surgeons balance multiple factors when choosing a surgical strategy which include multiple patient-related factors, their own knowledge and expertise, available infrastructure and the infecting organism. Surgeons questioned whether it was appropriate that the two-stage revision remained the best treatment, and some surgeons' willingness to consider more one-stage revisions had increased over recent years and were influenced by growing evidence showing equivalence between surgical techniques, and local observations of successful one-stage revisions. Custom-made articulating spacers was a practice that enabled uncertainty to be managed in the absence of definitive evidence about the superiority of one surgical technique over the other. Surgeons highlighted the need for research evidence to inform practice and thought that a randomised trial to compare treatments was needed. Most surgeons thought that patients who they treated would be eligible for trial participation in instances where there was uncertainty about the best treatment option.ConclusionsSurgeons highlighted the need for evidence to support their choice of revision. Some surgeons' willingness to consider one-stage revision for infection had increased over time, largely influenced by evidence of successful one-stage revisions. Custom-made articulating spacers also enabled surgeons to manage uncertainty about the superiority of surgical techniques. Surgeons thought that a prospective randomised controlled trial comparing one-stage with two-stage joint replacement is needed and that randomisation would be feasible.
Highlights
88,000 primary hip replacements are performed in England and Wales each year
Approximately 88,000 primary hip replacements were performed in England and Wales during 2014 [1]
Cases of custom-made articulating spacer (CUMARS) hip replacements remaining in situ at 12 years follow-up have been reported [9]
Summary
88,000 primary hip replacements are performed in England and Wales each year. A variation on these one-stage or two-stage strategies is the use of a custom-made articulating spacer (CUMARS) This approach aims to provide the patient with a hip joint between stages that can bear weight and provides reasonable function. This technique involves the removal of the implant and insertion of a new implant that is “loosely” cemented into place. This first operation is intended to be the first of a two-stage process, if the implant provides the patient with sufficient function a further operation is not conducted. Cases of CUMARS hip replacements remaining in situ at 12 years follow-up have been reported [9]
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