What is the evidence base to guide surgical treatment of infected hip prostheses? systematic review of longitudinal studies in unselected patients

Abstract

BackgroundProsthetic joint infection is an uncommon but serious complication of hip replacement. There are two main surgical treatment options, with the choice largely based on the preference of the surgeon. Evidence is required regarding the comparative effectiveness of one-stage and two-stage revision to prevent reinfection after prosthetic joint infection.MethodsWe conducted a systematic review to identify randomised controlled trials, systematic reviews and longitudinal studies in unselected patients with infection treated exclusively by one- or two-stage methods or by any method. The Embase, MEDLINE and Cochrane databases were searched up to March 2011. Reference lists were checked, and citations of key articles were identified by using the ISI Web of Science portal. Classification of studies and data extraction were performed independently by two reviewers. The outcome measure studied was reinfection within 2 years. Data were combined to produce pooled random-effects estimates using the Freeman-Tukey arc-sine transformation.ResultsWe identified 62 relevant studies comprising 4,197 patients. Regardless of treatment, the overall rate of reinfection after any treatment was 10.1% (95% CI = 8.2 to 12.0). In 11 studies comprising 1,225 patients with infected hip prostheses who underwent exclusively one-stage revision, the rate of reinfection was 8.6% (95% CI = 4.5 to 13.9). After two-stage revision exclusively in 28 studies comprising 1,188 patients, the rate of reinfection was 10.2% (95% CI = 7.7 to 12.9).ConclusionEvidence of the relative effectiveness of one- and two-stage revision in preventing reinfection of hip prostheses is largely based on interpretation of longitudinal studies. There is no suggestion in the published studies that one- or two stage methods have different reinfection outcomes. Randomised trials are needed to establish optimum management strategies.

Two-Stage Cementless Revision Total Hip Arthroplasty for Infected Primary Hip Arthroplasties

“…According to Stockley et al, similar rates of eradication of the infection could be achieved without prolonged antibiotic therapy during two-stage revision [23]. In recent systematic reviews of the literature about infected THAs, similar reinfection rates were detected in both one-stage and two-stage revisions [24,25]. On the other hand, in the last decade the prevalence of infections caused by resistant microorganisms such as Methicillin-resistant Staphylococcus epidermidis (MRSE) and Methicillin-resistant Staphylococcus aureus (MRSA) has become increasingly common [14,26].…”

Preventing Implant-Associated Infections by Silver Coating

“…However, in the last decade the infection rate after implantation of prosthesis has remained unchanged, ranging between 1 and 2% for hip and knee prostheses in primary arthroplasty and increasing up to 10% in secondary revisions after IAIs (48). Previous in vitro data demonstrate that antibiotics fail to eradicate surfaceadherent bacteria independent of biofilm formation (30,49,50), suggesting that perioperative antibiotics may only reduce the bacterial load around the implant but not eradicate bacteria already attached to the implant.…”

Staphylococcus aureus Infections: Epidemiology, Pathophysiology, Clinical Manifestations, and Management

“…Staphylococcal early postoperative PJI has been traditionally treated with 2-stage joint replacement, with resultant cure rates of Ͼ90% (405,548). Over the past 2 decades, the debridement and implant retention (DAIR) procedure has been increasingly practiced, and there are accumulating data that this strategy leads to acceptable cure rates of 70 to 80% in appropriately selected patients (549,550).…”

“…While 2-stage replacement is the most common mode of exchange arthroplasty, one-stage joint replacement (where the infected prosthesis is removed and replaced with a new one at a single operation) appears to have similar success rates in experienced centers. In a meta-analysis including 62 observational studies and 2,500 patients comparing one-and two-stage joint replacements for PJI, successful outcomes at 24 months were reported for 91% of patients following one-stage replacement and for 90% of patients following two-stage replacement (548). For a more detailed discussion on the management of S. aureus PJI, the reader is referred to recent IDSA guidelines (543) and recent reviews (545,564,565).…”