Single-stage total hip arthroplasty after failed fixation of proximal femoral fractures: an increased risk for periprosthetic joint infections?

Abstract

Background Higher complication rates have been reported for total hip arthroplasty (THA) after osteosynthesis of proximal femur fractures (PFF). This study evaluated the infection risk for conversion of internal fixation of PFF to THA by a single-staged procedure in the absence of clear infection signs. Methods Patients undergoing a one-staged conversion to THA (2013–2018) after prior internal fixation of the proximal femur were included. Preoperative diagnostics with laboratory results, hip aspirations as well as intraoperative microbiology and sonication were assessed. Postoperative complications were recorded as well as patient demographics, duration between initial and conversion to THA, explanted osteosynthesis and implanted THA. Results Fifty-eight patients (24 male/34 female, 62.8 ± 14.5 years) were included with a mean time of 3.8 ± 7.5 years between internal fixation and conversion to THA (45 cementless, 3 cemented, 3 hybrid and 7 hybrid inverse THAs). Preoperative mean blood level CRP was 8.36 ± 14 mg/l (reference value < 5 mg/l) and leukocyte count was 7.11 ± 1.84^3/µl (4.5–10.000^3/µl). Fifty patients had intraoperative microbiological diagnostics, with either swabs in 86.2% and/or sonication in 29.3%. Positive microbiological results were recorded in 10% (5 of 50 patients), with pathogens identified being mainly Staphylococcus. Complications after conversion occurred in 9.6% including a postoperative low-grade infection rate of 5.8% after a mean of 2.5 years. Conclusion This study found a positive microbiological test result in 10% of a one-stage conversion of PFF fixation to THA. Moreover, we found a high infection rate (5.8%) for early postoperative periprosthetic joint infection. Interestingly, CRP has not been proven to be an adequate parameter for low-grade infections or occult colonized implants. Therefore, we recommend a comprehensive pre- and intraoperative diagnostic including hip aspiration, swabs and sonication when considering one-staged revision.

Best of Both Worlds? Fixation of Distal Femur Fractures with the Nail‐Plate Construct

“…Interestingly, both these patients had previously undergone revision operation from short IM nail to total hip arthroplasty, which was then complicated by distal femur periprosthetic fracture. Revision surgery comes with a significant risk of infection, with one study reporting an infection rate of 5.8% 25 . Our patients had additional risk factors including diabetes, emphysema and renal cancer.…”

High rate of undetected infections in failed osteosynthesis of pertrochanteric fractures

“…Different studies reported microbiological results when converting internal fixation to total hip arthroplasty (THA) and when exchanging loosened THA. [16][17][18] Gittings et al reported an 18% infection rate in patients who had undergone THA following a previous hip surgery for a femoral fracture, acetabular fixation, or slipped capital femoral epiphysis. Renard et al 19 detected a 7% incidence of hidden infection among THA aseptic revisions, being this rate higher in patients presenting with dislocation.…”

“…Then again, Akgun et al reported a 50% rate of positive cultures in a presumed aseptic revision of proximal humerus osteosynthesis. 22,23 Regarding hip surgery, Hemmann et al 16 conducted a study to analyze the safety of a single-stage revision of Total Hip Arthroplasty (THA) in failed fixations of PFFs. They found that 10% of the cases presented with positive microbiological tests despite a lack of clinical signs of infection preoperatively.…”

Best of Both Worlds? Fixation of Distal Femur Fractures with the Nail-Plate Construct. Patient-Reported Outcomes and One-Year Results in a Heterogenous Population

“…There is a signi cant risk of infection in revision surgery, with one study reporting a 5.8% rate of infection in revision from IM nail xation to total hip arthroplasty. 21 Additional risk factors in these patients included diabetes, emphysema and renal cancer. Our reduced length of stay and lower rates in morbidity and mortality may be attributable to improved mobility in the immediate post-operative period with NPC xation.…”