One- and two-stage surgical revision of peri-prosthetic joint infection of the hip: a pooled individual participant data analysis of 44 cohort studies

Setor K Kunutsor ,Valérie Zeller,Tim Board,Ernesto Muñoz-Mahamud,Matthew Wilson,Jason Webb,Alasdair Macgowan,Erik Lenguerrand,Camilo Restrepo,Ran Schwarzkopf,Paul Dieppe,Pang‐Hsin Hsieh ,Pr Kay ,Michael Whitehouse ,Shouyuan Chen ,B M Wroblewski ,Maria Luisa Sorlí Redó ,J Cabo ,Javad Parvızı ,Ashley Blom ,David Éverson Uip ,Emerson Kiyoshi Honda ,José Cordero‐Ampuero ,Elías Cañas ,Jean‐Yves Jenny ,Rachael Gooberman-Hill,Ronald Huang,Amir Herman,Simon Strange,Sergio Rudelli,Alba Ribera,Guillem Bori,Elizabeth Darley,Bassam A Masri,Ben Burston,John-Paul Whittaker,Andrew D Beswick

doi:10.1007/s10654-018-0377-9

Abstract

One-stage and two-stage revision strategies are the two main options for treating established chronic peri-prosthetic joint infection (PJI) of the hip; however, there is uncertainty regarding which is the best treatment option. We aimed to compare the risk of re-infection between the two revision strategies using pooled individual participant data (IPD). Observational cohort studies with PJI of the hip treated exclusively by one- or two-stage revision and reporting re-infection outcomes were retrieved by searching MEDLINE, EMBASE, Web of Science, The Cochrane Library, and the WHO International Clinical Trials Registry Platform; as well as email contact with investigators. We analysed IPD of 1856 participants with PJI of the hip from 44 cohorts across four continents. The primary outcome was re-infection (recurrence of infection by the same organism(s) and/or re-infection with a new organism(s)). Hazard ratios (HRs) for re-infection were calculated using Cox proportional frailty hazards models. After a median follow-up of 3.7 years, 222 re-infections were recorded. Re-infection rates per 1000 person-years of follow-up were 16.8 (95% CI 13.6–20.7) and 32.3 (95% CI 27.3–38.3) for one-stage and two-stage strategies respectively. The age- and sex-adjusted HR of re-infection for two-stage revision was 1.70 (0.58–5.00) when compared with one-stage revision. The association remained consistently absent after further adjustment for potential confounders. The HRs did not vary importantly in clinically relevant subgroups. Analysis of pooled individual patient data suggest that a one-stage revision strategy may be as effective as a two-stage revision strategy in treating PJI of the hip.

Highlights

Electronic supplementary material The online version of this article contains supplementary material, which is available to authorized users.Extended author information available on the last page of the articleHip replacement is one of the most common surgical procedures
An alternative one-stage revision procedure was in use from 1976 at the Endo-Klinik in Hamburg with the implant removed and replaced in one operation [9]; the two-stage strategy has traditionally been considered the gold standard for prosthetic joint infection (PJI) treatment [10]
We conducted this systematic review and individual participant data (IPD) pooled analysis using a predefined protocol registered in the PROSPERO International prospective register of systematic reviews (CRD42015016664) [15], and in accordance with methods recommended by the IPD Meta-analysis Methods Group of the Cochrane Collaboration [16], guidance of Riley and colleagues [17], and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Individual Participants Data (PRISMA-IPD) guidelines [18]

Summary

Introduction

In 1985, Fitzgerald and Jones described a series of twostage revisions for the treatment of infected hip implants [8]. With this two-stage strategy, the artificial hip joint is removed and replacement delayed for several months until clear evidence of infection eradication is obtained. An alternative one-stage revision procedure was in use from 1976 at the Endo-Klinik in Hamburg with the implant removed and replaced in one operation [9]; the two-stage strategy has traditionally been considered the gold standard for PJI treatment [10]

Objectives

Methods

Results