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    Managing the Infected Total Hip Arthroplasty

    Dr. Arlen Hanssen discusses key issues surrounding the infected hip: diagnosis, staging, and treatment options.

    Although there has been a recent proliferation of studies promoting 1-stage revision for infected total hip arthroplasty, [1-4] none has convinced Arlen D. Hanssen, MD, that 1-stage exchange should replace 2-stage exchange as the gold standard.

    Dr. Hanssen, from Mayo Clinic in Rochester, Minnesota, shared his thoughts on management of the infected hip following total hip arthroplasty in a presentation at ICJR’S Pan Pacific Orthopaedic Congress. Besides affirming the superiority of 2-stage exchange for most infections, Dr. Hanssen made 2 other important points worth noting:

    • Obtaining a correct diagnosis of infection is essential.
    • Ordering a C-reactive protein level and an erythrocyte sedimentation rate is a good starting point, but Dr. Hanssen said these are somewhat crude screening tests, with about 5% of infected patients having normal results.

    Dr. Hanssen recommends that surgeons do more joint aspirations when an infection is suspected. This will help identify the infecting organism and allow for analysis of synovial white blood cells and synovial biomarkers.

    Not all infected hips are equal, so staging the patient’s infection will help guide treatment. Dr. Hanssen recommends a staging system published by McPherson et al [5] in 1999 that categorizes the infection by:

    • Type of infection
      • Early, less than 4 weeks postop (I)
      • Hematagenous, less than weeks’ duration (II)
      • Late, more than 4weeks postop (III)
    • Systemic host comorbidities, such as diabetes, cardiac or pulmonary insufficiency, HIV infection or other systemic immune disorder, smoking or nicotine use, alcoholism
      • No factors: Uncompromised (A)
      • 1 or 2 factors: Compromised (B)
      • More than 2 factors: Significantly compromised (C)
    • Local extremity factors, such as soft tissue loss from prior trauma, vascular insufficiency, severe bone loss, prior irradiation, prior periarticular fracture (especially crush)
      • No factors: Uncompromised (1)
      • 1 or 2 factors: Compromised (2)
      • More than 2 factors: Significantly compromised (3)

    The combination of the type of infection, the host factors, and the local factors will help the surgeon understand the best treatment options.

    In the abstract for this presentation, Dr. Hanssen lays out these options.

    • Antibiotic suppression is rarely indicated due to its low success rate (about 67% failure rate). This treatment option may be indicated in the following scenarios:
      • Prosthesis removal not feasible
      • Low-virulence microorganism
      • Microorganism susceptible to oral antibiotic
      • Antibiotic tolerated without serious toxicity
      • Well-fixed prosthesis
    • Debridement with prosthesis retention can be successful in Type II and Type IV infections, with success related to the duration of the symptoms (for example, Staphylococcus aureus for less than 48 hours).
      • Treatment should be prompt and considered emergent once the diagnosis has been confirmed.
      • Note that debridement with prosthesis retention should not be attempted in Type III (chronic) infections; failure is universal failure in this situation.
    • Resection arthroplasty is usually a temporizing procedure.
      • Occasionally, it can be a definitive cure for the infection.
    • Arthrodesis and disarticulation are rarely indicated.
      • Disarticulation should be reserved for life-threatening infection.
    • Insertion of a new prosthesis (direct exchange) requires a careful selection process and can have a 75% to 80% success rate. Most series in the literature report on highly selected cases with the following characteristics:
      • Absence of wound complications after initial the primary total hip arthroplasty
      • Good general health
      • Infecting organism: Methicillin-sensitive Staphylococcus. epidermidis, S. aueus, or Streptococcus species
      • Infecting organism sensitive to the antibiotic mixed into the bone cement
      • The opportunity to use this option is currently limited by the increasing prevalence of multidrug-resistant organisms and the use of cementless implants in many revision procedures.
    • Delayed reconstruction (2-stage exchange) is the preferred approach, with greater than 90% success for all patients, including those excluded from direct exchange.

    Dr. Hanssen also identified future directions for research on the infected total hip arthroplasty, including:

    • Accurate prediction of specific risk factors
    • Improved imaging studies and bacterial genetic detection technology for diagnosis
    • Improved antibiotics, with more use of oral drugs and less reliance on intravenous therapy
    • Use of new staging systems for patient outcome with various treatment options
    • Technological advance in local antibiotic delivery systems

    Dr. Hanssen’s presentation can be found here.

    References

    • Wolf CF, Gu NY, Doctor JN, Manner PA, Leopold SS. Comparison of one and two-stage revision of total hip arthroplasty complicated by infection: a Markov expected-utility decision analysis. J Bone Joint Surg Am. 2011 Apr 6;93(7):631-9. doi: 10.2106/JBJS.I.01256.
    • Hansen E, Tetreault M, Zmistowski B, et al. Outcome of one-stage cementless exchange for acute postoperative periprosthetic hip infection. Clin Orthop Relat Res. 2013 Oct;471(10):3214-22. doi: 10.1007/s11999-013-3079-3.
    • Wolf M, Clar H, Friesenbichler J, et al. Prosthetic joint infection following total hip replacement: results of one-stage versus two-stage exchange. Int Orthop. 2014 Jul;38(7):1363-8. doi: 10.1007/s00264-014-2309-y. Epub 2014 Mar 18.
    • Zeller V, Lhotellier, Marmor S, et al. One-stage exchange arthroplasty for chronic periprosthetic hip infection: results of a large prospective cohort study. J Bone Joint Surg Am. 2014 Jan 1;96(1):e1. doi: 10.2106/JBJS.L.01451.
    • McPherson EJ, Tontz W Jr, Patzakis M, et al. Outcome of infected total knee utilizing a staging system for prosthetic joint infection. Am J Orthop 1999 Mar;28(3):161-5.