Single- or Two-stage Revision for Infected Total Hip Arthroplasty? A Systematic Review of the Literature
ABSTRACT The best approach for surgical treatment of an infected THA remains controversial. Two-stage revision is believed to result in lower reinfection rates but may result in significant functional impairment. Some authors now suggest that single-stage revision may provide comparable results in terms of infection eradication while providing superior functional outcomes.
We performed a systematic review to determine whether single- or two-stage revision for an infected THA provides lower reinfection rates and higher functional outcome scores.
We conducted a comprehensive search of PubMed and Embase, using the search string [Infection AND ("total hip replacement" OR "total hip arthroplasty") AND revision]. All studies comparing reinfection rates or functional scores for single- and two-stage revision were retrieved and reviewed. A systematic review was performed according to the PRISMA checklist.
The initial search retrieved 1128 studies. Following strict exclusion criteria, we identified nine comparative studies comparing reinfection rates (all nine studies) or functional scores (four studies) between single- and two-stage revisions. The overall quality of studies was poor with no randomized studies being identified. Groups often varied in their baseline characteristics. There was no consensus among the studies regarding the relative incidence of reinfection between the two procedures. There was a trend toward better functional outcomes in single-stage surgery, but this reached significance in only one study.
In appropriate patients, single-stage revision appears to be associated with similar reinfection rates when compared with two-stage revision with superior functional outcomes. This concurs with earlier studies, but given the methodologic quality of the included studies, these findings should be treated with caution. High-quality randomized studies are needed to compare the two approaches to confirm these findings, and, if appropriate, to determine which patients are appropriate for single-stage revision.
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ABSTRACT: Prosthetic joint infection (PJI) is a serious complication of arthroplasty that is associated with significant mortality, morbidity and costs. PJI is difficult to cure because causative bacteria form and persist in biofilm adherent to the prosthesis surface. PJI can be classified in to early, delayed or late according to the time of onset after insertion of the prosthesis and this classification can help determine pathogenesis and appropriate management. Traditional treatment has been with prolonged intravenous antibiotics and prosthesis exchange, which has been successful in treating infection but is technically difficult and has high rates of associated morbidity. On the basis of in vitro and animal studies, interest has turned to the use of antimicrobials that are particularly active against biofilm-associated bacteria. Recent clinical evidence shows success in more than 77% of early PJI with surgical debridement, retention of prosthesis and the use of rifampicin-based combinations for staphylococcal PJI. Fluoroquinolones are preferred for Gram-negative PJI. Optimal antimicrobial treatment duration and the management of polymicrobial, enterococcal, fungal and culture-negative infections is still yet to be defined but will become more clear as the results of current research comes to hand.Internal Medicine Journal 06/2014; 44(9). DOI:10.1111/imj.12510 · 1.70 Impact Factor
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ABSTRACT: Hintergrund Megaprothesen finden zunehmende Anwendung nach knöcherner Segmentresektion bei Knochensarkomen, Skelettmetastasen und bei ausgedehnten knöchernen Defekten in der Revisionsendoprothetik. Fragestellung Beschreibung der Inzidenz der häufigsten Komplikationen in der Megaprothetik. Darstellung des Komplikationsmanagements mitsamt Therapieempfehlungen. Material und Methoden Es erfolgte eine selektive Literaturrecherche sowie das Einbringen eigener Erfahrungen zur Darstellung aktueller Erkenntnisse auf dem Gebiet des Komplikationsmanagements in der Megaprothetik. Ergebnisse Prospektiv-randomisierte Studien oder Metaanalysen fehlen zu diesem Thema. Die Literaturrecherche zeigt dennoch, dass neben dem Lokalrezidiv die periprothetische Infektion die gravierendste Komplikation darstellt. Der zweizeitige Prothesenwechsel ist weiterhin als Goldstandard zu betrachten, auch wenn in ausgesuchten Fällen ein einzeitiger Wechsel unter Belassung der Prothesenschäfte gerechtfertigt erscheint. Die periprothetische Infektion ist jedoch weiterhin mit einem nicht unerheblichen Risiko der sekundären Amputation vergesellschaftet. Mechanische Komplikationen wie der Verschleiß des Gelenkmechanismus bei megaprothetischem Ersatz des Kniegelenks und die aseptische Schaftlockerung sind in der Regel extremitätenerhaltend therapierbar. Eine Luxation eines proximalen Femurersatzes stellt bei Verwendung eines bi- oder tripolaren Pfannensystems die Ausnahme dar. Schlussfolgerungen Komplikationen in der Megaprothetik sind in den meisten Fällen durch Revisionsoperationen zu beherrschen.Der Unfallchirurg 07/2014; 117(7):607-13. DOI:10.1007/s00113-013-2477-z · 0.61 Impact Factor
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ABSTRACT: We describe two cases of prosthetic joint infection (PJI) of the hip due to Salmonella. The first patient presented with an early infection 5 d after being discharged following a total hip replacement and the second patient presented at the emergency ward with a late infection, thirteen years following a total hip replacement. Both cases occurred within one month of each other at our institution and both were successfully treated with a one-stage revision. PJI caused by Salmonella species is very rare: so far only 20 Salmonella PJIs of the hip have been described. Therefore, full consensus on the best treatment approach has not yet been reached. An aggressive two-stage approach is advised because of the virulence of Salmonella, although a limited number of successful one-stage approaches have been described as well. According to the latest guidelines, one-stage revision has comparable success rates and less morbidity compared to two-stage treatment, when selecting the right patients. In our opinion, PJI caused by Salmonella should be treated just as PJI caused by other bacteria, with consideration of the selection criteria as mentioned in several treatment guidelines. As illustrated by these two cases, one-stage revision can be successful in both early and late Salmonella PJI of the hip.