Infected Hip Replacement Research Articles

Long Cephalomedullary Nails Can Be a Cheap and Effective Interval Revision Prosthesis in Infected Hip Replacements That Require Proximal Femoral Replacement: A Small Case Series.

Hip prosthetic joint infection management is complex and expensive, especially in severe bone loss.Reducing the price of interval prosthesis when performing staged revision could minimize costs without compromising outcomes. We present 2 similar techniques developed independently that use an antibiotic-coated cephalomedullary nail with a total hip arthroplasty bearing (head and cemented acetabular component) attached to it as an interval proximal femoral replacement prosthesis. Using this technique, the femoral implant cost was reduced up to 10-fold. All patients have recovered well with resolution of infection and functional recovery similar to patients undergoing proximal femoral replacement. In one case, the lag screw (femoral neck) fractured at 5 months prompting the second-stage revision. This complication should be considered when deciding the timing of second-stage revisions in these cases.

Possible routes of infection in hip replacement

To evaluate the probability of direct inoculation of pathogens into the bone bed by surgical instruments and implants. The study included 22 patients who underwent surgery at the Vreden National Medical Research Center of Traumatology and Orthopedics. Mean age was 73.3±3.7 years. These patients underwent total hip replacement. Intraoperative skin scrapings within the wound edge were made. Pressure on the scalpel was applied in two fashions. In 10 cases, scraping was performed by minimally pressure on the skin (superficial contact). In 12 cases, scalpel was pressed with force (skin deformation to a depth of 3-4 mm). Next, microbiological analysis of scrapings was performed. There was no growth of microorganisms in samples obtained by minimal pressure on the scalpel. Analysis of 12 scrapings in the second group (tight contact simulating damage to the skin with surgical instruments) revealed growth of microflora in all cases. Contact of cutters, rasps and implants with skin can be a mechanism for direct inoculation of pathogens into the bone tissue and potentially cause periprosthetic infection.

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

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

Infección protésica de cadera. Recambio en dos tiempos en una serie de 50 casos.

Chronic infection in hip replacement is an important complication with a complex treatment, that is solved by adequate antibiotic therapy together with single-stage exchange or two-stage exchange. We present a descriptive and retrospective study of a series of 50 consecutive patients operated on in our center with a diagnosis of chronic infection of the hip prosthesis between 2007 and 2018 with a two-stage exchange. At a mean follow-up of 52 months, the overall implant survival was 89%, with a 91% infection cure rate. The most frequent microorganism isolated was Staphylococcus epidermidis. The mean score achieved on the HHS was 82,4 points and 1.67 points on the visual analogue scale. We obtained better functional results (p=0,021) in those patients who had a preformed antibiotic-loaded spacer in the first surgical stage. As complications, we recorded four cases of prosthetic reinfection (8,7%), three cases of dislocation (6,5%), and one case of postsurgical hematoma (4,6%). No case of neurovascular injury or component loosening was recorded. According to the showed results, we consider that two-stage revision procedure, although it is a demanding surgery, is an effective method for the treatment of periprosthetic hip infection, with high implant survival and erradication of the infection.

The psychological burden of a two-stage exchange of infected total hip and knee arthroplasties.

Infection is one of the most challenging complications after total joint arthroplasties affecting up to 30,000 patients in the US per year. This study investigates the psycho-social burden induced by the two-stage intervention in infected hip or knee replacements. All patients were treated with a two-stage exchange and were assessed at three different timepoints regarding their psychological conditions. Our findings suggest that psychological sequelae after treatment of periprosthetic joint infection are clearly underestimated in the literature and psychological correlates and side effects should be further highlighted during the training process of young surgeons.

Two-stage revisions of infected hip replacements: Subspecialisation and patient-reported outcome measures

BackgroundTwo-stage revision arthroplasty remains the gold standard for managing infected hip replacements. Subspecialisation, high-volume hospitals and surgeons have been linked to improved clinical outcomes. The aim of this study was to assess clinical outcomes of 2-stage revision infected hip replacements of a subspecialist surgeon. MethodsConsecutive single surgeon series of 2-stage revisions of infected total hip replacements in a district genearl hospital settings with minimum 2 years follow up using clinical and patient-reported outcome measures. ResultsTwenty-nine consecutive patients were included with average follow up of 5 years (range 2–9 yrs). Average age was 63 yrs (range 30–75), osteoarthritis was the underlying diagnosis in 65%, 31% had previous hip surgeries prior to index hip replacements. Two-thirds presented with chronic infections, staph aureus was isolated in 55%. Infection eradication rate at final follow up was 96.5% (1 reinfection). Overall complication rate was 13.8% (1 dislocation, 1 reinfection, 2 post-op wound haematoma requiring wash-outs). Mean patients reported outcome measures at final follow up were WOMAC hip score 76.3 (SD 13.6) (range 39.1–94.5); Oxford hip score 35.4 (SD 7.7) (range 17–45); and Hip disability & osteoarthritis outcome score (HOOS) 76 (SD 12.5) (range 41.9–92.5) suggesting satisfactory patient-reported outcomes. ConclusionsOur study demonstrates successful clinical outcomes and high infection-eradication rate achieved within district general hospital settings. Our experience suggests that comparable outcomes to tertiary centres in managing periprosthetic joint infections can be achieved in district general hospital settings through a local pathway of subspecialty trained arthroplasty surgeons within a local multidisciplinary MDT approach and adequate microbiology support.

APPLICATION OF THE VACUUM-ASSISTED CLOSURE THERAPY IN COMPLEX TREATMENT OF EARLY PERIPROSTHETIC INFECTION AFTER HIP ARTHROPLASTY

OBJECTIVE. The aim of this study was to improve the results of the complex treatment of early periprosthetic infection in hip replacement by using a vacuum therapy. MATERIAL AND METHODS. The study included 82 patients with periprosthetic infection who had been hospitalized to the department of traumatology and orthopedics federal state budgetary educational Institution of higher education «north-Western state Medical University named after I. I. Mechnikov» from 2008 to 2016. We compared the results of the treatment in the retrospective group (without vacuum therapy) and in the prospective panel (using the local negative pressure method). RESULTS. The studies demonstrated the efficacy of the method of vacuum therapy in combination with standard methods of periprosthetic infection treatment. The clinical effects were: decrease of tissue edema, good reduction of wound exudate, decreasing the concentration of the microflora in the surgical wound area, granulation growth, stimulation of epithelialization, reducing of the time spent in the hospital. CONCLUSION. All these effects lead to the fact that the number of cases where we were able to maintain the implant increased from 52,9 % in retrospective groups to 78,8 % in prospective groups.

Preliminary Results After Changing From Two-Stage to One-Stage Revision Arthroplasty Protocol Using Cementless Arthroplasty for Chronic Infected Hip Replacements

BackgroundThe objective of our study is to evaluate our preliminary results after changing from a 2-stage revision arthroplasty protocol to a 1-stage revision arthroplasty protocol using cementless arthroplasty for all patients with chronic infected hip replacements. MethodsProspective study of all hip arthroplasties that were diagnosed with chronic infection and were treated using the 1-stage revision without taking into account the traditional criteria used to determine the use of a 1-stage revision was conducted. There were 2 main variables evaluated: infection control and costs. The definitive diagnosis of infection of the revision was determined using the criteria proposed by the Musculoskeletal Infection Society. The costs were calculated using average cost in USD, excluding social expenses, as described by Klouche (2010) for 1-stage or 2-stage revisions. ResultsNineteen patients were included in the study and the infection was controlled in 18 patients. The total economic savings for our hospital for these 19 patients was 391.609 USD. ConclusionThis clinical success has led to an important change in our hospital in treating chronic infected hip replacements and an important cost reduction from an economic point of view.

Mechanical complications with self-made, antibiotic-loaded cement articulating spacers in the treatment of the infected hip replacement

To study the complications and efficacy of self-made, antibiotic-loaded cement articulating spacers in the treatment of the infected hip replacement. Between January 2006 and July 2016, 265 patients (266 hips) received a self-made, antibiotic-loaded cement articulating spacer as part of a two-stage protocol. Among those patients, there were 143 males(144 hips) and 122 females(122 hips). The cement articulating spacers with vancomycin and two Steinman pins were made by a self-made mold system. Meanwhile, another antibiotic was added to the spacers according to the drug sensitivity test. Record if the infected prosthesis was removed, related complication with spacer(breakage and dislocation), Harris score, and control rate of infection. The mean age of two-stage revision operation was(57.4±14.2) years. Thirty-nine patients(14.7%) used extended trochanteric osteotomy(ETO) to remove the infected prosthesis. And 38 patients occurred mentioned complications(14.3%). Spacer breakage occurred in 28 cases(10.5%) and dislocation occurred in 10 cases(3.8%). The mean follow-up time was(83.4±14.6) months. The Harris hip score was from 47.56±14.23 preoperatively to 86.43±12.84 at final follow-up(P<0.05). The infection of 256 cases(96.6%) got control after revision operation. However, during postoperative follow-up, 4 cases occurred re-infection, and they were reoperated, and the infections obtained effective control after the operation. Thus total infection control rate was 95.1%(252/265). Antibiotic-loaded cement articulating spacer made by a self-made mold system is effective in controling infection caused by hip replacement. Related complication is less with spacer by a mould enclosing two Steinman pins. Using metallic internal fixation or allograft bone combined with spacer does not affect infection control.

Erratum to: Does laminar airflow make a difference to the infection rates for lower limb arthroplasty: a study using the National Joint Registry and local surgical site infection data for two hospitals with and without laminar airflow.

This study compared the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man (NJR) data for total hip replacements (THRs) and total knee replacements (TKRs) from Hospital A [with laminar airflow (LAF)] and Hospital B (without LAF). These hospitals were originally managed by two different trusts that subsequently merged. Consequently, the theatres in Hospital A have always had LAF and those in Hospital B had only conventional ventilation systems. As this merger happened before the establishment of the NJR, it puts us in a unique position, enabling direct comparison of the revision rates for infected hip and knee replacements between the two hospitals that follow similar infection protocols. Analysis of the NJR data showed there were no statistical differences. Of the 2234 TKRs performed at Hospital A, 16 were revised for infection, whereas 19 of the 3694 TKRs at Hospital B were revised (p < 0.33). Of the 1752 THRs at Hospital A, 5 were revised for infection, whereas this was the case for 12 of the 3163 THRs at Hospital B (p < 0.59). There was also no statistical difference when combining the figures for TKRs and THRs (p < 0.59). Our local surgical site infection (SSI) data from these two hospitals were also analysed. Again, there was no statistical difference between the two sites (p < 0.34). Using LAF has not reduced the rate of revision for infection nor it has reduced the incidence of SSI in our theatres. This is the first study comparing infection rates in two different hospitals serving similar patient populations using the NJR and SSI data. Our study questions the rationale of increasing use of LAF in routine lower limb arthroplasty. We call for greater debate and more robust studies on the subject.

Does laminar airflow make a difference to the infection rates for lower limb arthroplasty: a study using the National Joint Registry and local surgical site infection data for two hospitals with and without laminar airflow.

This study compared the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man (NJR) data for total hip replacements (THRs) and total knee replacements (TKRs) from Hospital A [with laminar airflow (LAF)] and Hospital B (without LAF). These hospitals were originally managed by two different trusts that subsequently merged. Consequently, the theatres in Hospital A have always had LAF and those in Hospital B had only conventional ventilation systems. As this merger happened before the establishment of the NJR, it puts us in a unique position, enabling direct comparison of the revision rates for infected hip and knee replacements between the two hospitals that follow similar infection protocols. Analysis of the NJR data showed there were no statistical differences. Of the 2234 TKRs performed at Hospital A, 16 were revised for infection, whereas 19 of the 3694 TKRs at Hospital B were revised (p<0.33). Of the 1752 THRs at Hospital A, 5 were revised for infection, whereas this was the case for 12 of the 3163 THRs at Hospital B (p<0.59). There was also no statistical difference when combining the figures for TKRs and THRs (p<0.59). Our local surgical site infection (SSI) data from these two hospitals were also analysed. Again, there was no statistical difference between the two sites (p<0.34). Using LAF has not reduced the rate of revision for infection nor it has reduced the incidence of SSI in our theatres. This is the first study comparing infection rates in two different hospitals serving similar patient populations using the NJR and SSI data. Our study questions the rationale of increasing use of LAF in routine lower limb arthroplasty. We call for greater debate and more robust studies on the subject.

The cost of infection in hip arthroplasty: A matched case–control study

ObjectiveSurgical site infection (SSI) represents 30% of all causes of health care-associated infection (HAI) and is one of the most dreaded complications in surgical patients. We estimated the excess direct costs of SSI using a matched nested case–control study in acute-term care at Ramon y Cajal University Hospital in Spain. Material and methodCases were patients who developed a first episode of SSI according to the criteria established by the CDC's National Healthcare Safety Network. Controls were matched to cases in 1:1 ratio taking into account the American Society of Anaesthesiologists score, age, sex, surgery date, and principal diagnosis. ResultsThis study found that infection in hip replacement increased direct costs by 134%. Likewise, the excess cost due to the infections caused by methicillin resistant Staphylococcus aureus was 69% higher than the excess cost attributable to infections caused by other microorganisms. ConclusionsSSI after hip replacement continues to be a costly complication from the hospital perspective. Costs due to SSI can be used to prioritise preventive interventions to monitor and control HAI.

El coste de la infección en artroplastia de cadera: estudio de casos y controles emparejado

ObjectiveSurgical site infection (SSI) represents 30% of all causes of health care–associated infection (HAI) and is one of the most dreaded complications in surgical patients. We estimated the excess direct costs of SSI using a matched nested case-control study in acute-term care at Ramon y Cajal University Hospital in Spain. Material and methodCases were patients who developed a first episode of SSI according to the criteria established by the CDC's National Healthcare Safety Network. Controls were matched to cases in 1:1 ratio taking into account the American Society of Anesthesiologists score, age, sex, surgery date, and principal diagnosis. ResultsThis study found that infection in hip replacement increased direct costs by 134%. Likewise, the excess cost due to the infections caused by methicillin resistant Staphylococcus aureus was 69% higher than the excess cost attributable to infections caused by other microorganisms. ConclusionsSSI after hip replacement continues to be a costly complication from the hospital perspective. Costs due to SSI can be used to prioritise preventive interventions to monitor and control HAI.

Patient-Adapted Treatment for Prosthetic Hip Joint Infection

Hip joint replacement is 1 of the most successful surgical procedures of the last century and the number of replacements implanted is steadily growing. An infected hip arthroplasty is a disaster, it leads to patient suffering, surgeon's frustration and significant costs to the health system. The treatment of an infected hip replacement is challenging, healing rates can be low, functional results poor with decreased patient satisfaction. However, if a patient-adapted treatment of infected hip joints is used a success rate of above 90% can be obtained.Patient-adapted treatment is based on 5 important concepts: teamwork; understanding the biofilm; diagnostic accuracy; correct definition and classification of PJI; and patient-tailored treatment.This review presents a patient-adapted treatment strategy to prosthetic hip infection. It incorporates the best aspects of the single and staged surgical strategies and promotes the short interval philosophy for the 2-stage approach.

Treatment for infected hip replacement: antibiotic therapy and two-stage revision

Treatment for infected hip replacement: antibiotic therapy and two-stage revision

Partial two-stage exchange of the infected total hip replacement using disposable spacer moulds.

The common recommended treatment for infected total hip replacement is two-staged exchange including removal of all components. However, removal of well-fixed femoral stems can result in structural bone damage. We recently reported on an alternative treatment of partial two-stage exchange used in selected cases, in which a well-fixed femoral stem was left and only the acetabular component removed, the joint space was debrided thoroughly, an antibiotic-laden polymethylmethacrylate spacer was moulded using a bulb-type syringe and placed in the acetabulum, intravenous antibiotics were administered during the interval, and delayed re-implantation was performed. In 19 patients treated with this technique from January 2000 to January 2011, 89% were free of infection at a mean follow-up of four years (2 to 11). Since then, disposable silicone moulds have become available to fabricate spacers in separate femoral and head units. The head spacer mould, which incorporates various neck taper adapter options, greatly facilitates the technique of partial two-stage exchange. We report our early experience using disposable silicone head spacer moulds for partial two-stage exchange in seven patients with infected primary hip replacements.

A multidisciplinary team approach to two-stage revision for the infected hip replacement: a minimum five-year follow-up study.

We report the five year outcomes of a two-stage approach for infected total hip replacement. This is a single-surgeon experience at a tertiary centre where the more straightforward cases are treated using single-stage exchange. This study highlights the vital role of the multidisciplinary team in managing these cases. A total of 125 patients (51 male, 74 female) with a mean age of 68 years (42 to 78) were reviewed prospectively. Functional status was assessed using the Harris hip score (HHS). The mean HHS improved from 38 (6 to 78.5) pre-operatively to 81.2 (33 to 98) post-operatively. Staphylococcus species were isolated in 85 patients (68%). The rate of control of infection was 96% at five years. In all, 19 patients died during the period of the study. This represented a one year mortality of 0.8% and an overall mortality of 15.2% at five years. No patients were lost to follow-up. We report excellent control of infection in a series of complex patients and infections using a two-stage revision protocol supported by a multidisciplinary approach. The reason for the high rate of mortality in these patients is not known.

Hip &amp; Pelvis

The April 2014 Hip &amp; Pelvis Roundup360 looks at: Recent arthroplasty and flight; whether that squeak could be a fracture; diagnosing early infected hip replacement; impaction grafting at a decade; whether squeaking is more common than previously thought; femoral offset associated with post THR outcomes; and periprosthetic fracture stabilisation.

Antibiotic Treatment and Timing of Reimplantation

PJI is traditionally treated with intravenous (IV) antibiotics in order to obtain the minimum inhibitory concentration in the shortest time possible. Once this goal is met and there is clinical evidence of improvement, some IV antibiotic regimens can be switched to oral regimens. There is scarce literature reporting on the use of oral (combined or single) antibiotic therapy for the treatment of PJIs without an initial IV regimen [1–5]. Most of these studies were conducted in cases where the prosthesis was retained. There is one study in which no oral or prolonged IV regimen was used after debridement and the use of an antibiotic-impregnated cement spacers led to a 87% eradication rate [6]. No literature conclusively supports the use of only oral (combined or single) antibiotic therapy prior to reimplantation. The recently-published guidelines of the Infectious Diseases Society of America (IDSA) [7] suggest that pathogen-specific, highly bioavailable oral therapy (e.g. linezolid or fluoroquinolones) may be an alternative as initial therapy for some cases of PJI. Concerns against the routine use of appropriate oral agents in the treatment of PJI largely comprise questions of patient medication compliance and the long-term use of medication therapy with less intensive efficacy and toxicity monitoring.

One‐stage Versus Two‐stage Exchange

Liaison: Paul Lichstein MD, MSLeaders: Thorsten Gehrke MD (International), Adolph Lombardi MD, FACS (US), Carlo RomanoMD (International), Ian Stockley MB, ChB, MD, FRCS (International)Delegates: George Babis MD, Jerzy Bialecki MD, La´szlo´ Bucsi MD, Xu Cai MD, Li Cao MD, Briande Beaubien MD, Johannes Erhardt MD, Stuart Goodman MD, PhD, FRCSC, FACS, FBSE,William Jiranek MD, Peter Keogh, David Lewallen MD, MS, Paul Manner MD, WojciechMarczynski MD, J. Bohannon Mason MD, Kevin Mulhall MB, MCh, FRCSI, Wayne PaproskyMD, Preetesh Patel MD, Francisco Piccaluga MD, Gregory Polkowski MD, Luis Pulido MD, IanStockley MBBS, ChB, FRCS, Juan Suarez MD, Fritz Thorey MD, Rashid Tikhilov MD, JobDiego Velazquez MD, Heinz Winkler MD