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

Abstract

Background: Two-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. Methods: Consecutive 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. Results: Twenty-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. Conclusions: Our 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.

Single vs 2-Stage Revision for the Treatment of Periprosthetic Joint Infection

“…Despite the obvious advantages of 2-stage revision including 2 chances at thorough debridement, interval period of antibiotics in between stages, and historically high eradication rates and functional outcome scores, there are some important risks [49,95]. This process subjects a patient to 2 major operations.…”

Who Should Manage Periprosthetic Joint Infection? The Case for a Multidisciplinary Approach

“…Access to a multidisciplinary group of healthcare providers is often difficult, and high-volume, specialized treatment centers are often best equipped to provide such care [6,16,17]. For this reason, treatment with a multidisciplinary approach and treatment at a high-volume tertiary care center are closely intertwined [5].…”

“…(Bannister) In addition, fellowship-trained orthopedic surgeons who treat a high-volume of patients are better equipped to handle complex cases, and have likely developed a more refined surgical technique, established muscle memory, high attention, and faster recall [17]. Both hospital volume and surgeon volume are associated with improved clinical outcomes including decreased morbidity, mortality, and length of stay [16]. Complication rates after primary TJA were found to drop off significantly after a surgeon reaches a case volume of 35 per year [18].…”

“…One strategy to address this and increase case volume for surgeons practicing in less densely populated settings may be to assign one or two surgeons with subspecialty interest and experience to handle PJI. While the literature on this strategy is fairly scarce, a study done by Matar et al found that such specialists at a general hospital were able to produce comparable results when compared to a high-volume tertiary center if given an adequate caseload [16]. If this is not possible, PJI cases that present to general hospitals should strongly be considered for referral [12].…”

“…If this is not feasible, patients should be risk stratified, and transfer of the most complex cases to centers with experience in treating such cases is recommended. Standard protocols consistent with published guidelines to treat PJI should be established and adhered to at hospitals and, if possible, networks between general and tertiary centers should be established to provide support [5,10,16].…”