Deep infection after hip hemiarthroplasty: risk factors for infection and outcome of treatments

Abstract

Aims Deep surgical site infection (SSI) remains an unsolved problem after hip fracture. Debridement, antibiotic, and implant retention (DAIR) has become a mainstream treatment in elective periprosthetic joint infection; however, evidence for DAIR after infected hip hemiarthroplaty is limited. Methods Patients who underwent a hemiarthroplasty between March 2007 and August 2018 were reviewed. Multivariable binary logistic regression was performed to identify and adjust for risk factors for SSI, and to identify factors predicting a successful DAIR at one year. Results A total of 3,966 patients were identified. The overall rate of SSI was 1.7% (51 patients (1.3%) with deep SSI, and 18 (0.45%) with superficial SSI). In all, 50 patients underwent revision surgery for infection (43 with DAIR, and seven with excision arthroplasty). After adjustment for other variables, only concurrent urinary tract infection (odds ratio (OR) 2.78, 95% confidence interval (CI) 1.57 to 4.92; p < 0.001) and increasing delay to theatre for treatment of the fracture (OR 1.31 per day, 95% CI 1.12 to 1.52; p < 0.001) were predictors of developing a SSI, while a cemented arthroplasty was protective (OR 0.54, 95% CI 0.31 to 0.96; p = 0.031). In all, nine patients (20.9%) were alive at one year with a functioning hemiarthroplasty following DAIR, 20 (46.5%) required multiple surgical debridements after an initial DAIR, and 18 were converted to an excision arthroplasty due to persistent infection, with six were alive at one year. The culture of any gram-negative organism reduced success rates to 12.5% (no cases were successful with methicillin-resistant Staphylococcus aureus or Pseudomonas infection). Favourable organisms included Citrobacter and Proteus (100% cure rate). The all-cause mortality at one year after deep SSI was 55.87% versus 24.9% without deep infection. Conclusion Deep infection remains a devastating complication regardless of the treatment strategy employed. Success rates of DAIR are poor compared to total hip arthroplasty, and should be reserved for favourable organisms in patients able to tolerate multiple surgical procedures. Cite this article: Bone Jt Open 2021;2(11):958–965.

Periprosthetic joint infection following hip hemiarthroplasty

“…6 Based on these guidelines, DAIR is often the treatment of choice since it is associated with less morbidity and therefore is perhaps more appropriate for this frail patient population. However, the results of this study, and others alike, [7][8][9][10][11]21,22 challenge this perception given the inferior treatment success rates of DAIR for HA PJI, which range from 22% to 82% (Table VI). In our study, DAIR was the most common treatment modality used (59%).…”

“…7,8 Perhaps HA PJI should be managed by surgeons skilled in arthroplasty as they would be more likely to employ the optimal surgical strategy: single-stage revision arthroplasty with conversion to THA. Craxford et al 9 reported on patients who underwent surgical treatment (43 DAIR, seven excision arthroplasty) for surgical site infection following HA. They showed that stem exchange was not associated with improved treatment success.…”

“…Craxford et al 9 reported on patients who underwent surgical treatment (43 DAIR, seven excision arthroplasty) for surgical site infection following HA. They showed that stem exchange was not associated with improved treatment success.…”

“…Current standards of treatment share principles outlined by the International Consensus Meeting 6 that relate to PJI following elective total hip arthroplasty (THA). With evidence suggesting differences in epidemiology, clinical features, and outcome exist between patients who undergo elective THA and HA for hip fracture, 7,8 these may in part explain why debridement, antibiotic therapy, and implant retention (DAIR) has much lower chances of success with a HA (21% to 82%), [7][8][9][10][11] compared to elective THA (72.2%). 12 The aims of this study were to determine the incidence and risk factors for developing PJI among patients who had a HA for hip fracture at our centre, evaluate the treatment outcome of HA PJI, and identify factors associated with treatment outcome.…”

A radio- and fluorescently labelled tracer for imaging and quantification of bacterial infection on orthopaedic prostheses

“…Unfortunately, the reported success rates of debridement with prosthesis retention and long-term antibiotic use are found to be variable (21% to 89%). [4][5][6][7][8] The alternative is revision surgery, which has severe implications for the patient including prolonged hospitalization, high health and social costs, 9,10 and up to 10% risk of recurrence. 3 The latter is likely related to residual bacteria in the wound.…”