Similar success rates for single and multiple debridement surgery for acute hip arthroplasty infection

Background

Treatment of an acute total hip arthroplasty (THA) infection aims at control of the infection with retention of the implant by surgical debridement and antibiotic treatment. There is no clear evidence whether a single surgical debridement is sufficient or whether multiple procedures are necessary for optimal treatment.

Methods

From a prospective database of patients with acute THA infection, we retrospectively reviewed 68 patients treated in 2 large teaching hospitals. Hospital S used a protocol in which each patient received a single surgical debridement and only additional surgery if infectious symptoms persisted (group S; n = 33). In hospital M, patients always received multiple surgical debridements (group M; n = 35). Both groups received systemic antibiotic treatment. Removal of the implant or persistent infection at follow-up was considered failure of treatment. Mean follow-up of the patients was 5 (2–11) years.

Results

Mean time between implantation and debridement was 19 days. 4 patients in group S were considered failure, as opposed to 10 patients in group M (p = 0.09). 9 patients in group S had additional surgery, which resulted in 3 of the 4 failures. At final follow-up, 30 patients in group S and 33 patients in group M had a good clinical result (p = 0.6).

Interpretation

In patients with acute THA infection, a single debridement with only additional surgery on indication appears to be at least as successful for retention of the primary implant and control of infection as a strategy with multiple surgical debridements.The strategy for treating prosthetic joint infection depends on the type infection encountered. In early postoperative and acute hematogenic infections, the aim of treatment is control of infection and retention of the implant. In contrast, in delayed or late postoperative infections the matured bacterial biofilm cannot be fully removed from the implant and surgical treatment consists of a 1- or 2-stage revision of the implant. Both surgical strategies should be accompanied by a course of systemic antibiotics (Zimmerli et al. 2004, Bernard et al. 2010). To facilitate treatment decisions, algorithms have been developed. Especially the algorithm proposed by Zimmerli et al. (2004) has gained popularity in recent years. Several reports have shown that these guidelines improve success rates (Giulieri et al. 2004, Betsch et al. 2008, De Man et al. 2011).The surgical strategy for retention of the implant consists of extensive irrigation and debridement of the infected joint, often accompanied by the exchange of modular implant components and application of local antibiotic carriers, such as beads or collagen fleeces. However, there is no scientific evidence or consensus as to whether a single surgical debridement is sufficient or whether multiple repeat procedures are necessary for optimal treatment. Studies involving both strategies have been published, with success rates ranging from poor to excellent (Azzam et al. 2010, Estes et al. 2010, Van Kleunen et al. 2010, Aboltins et al. 2013, Geurts et al. 2013, Kuiper et al. 2013, Romano et al. 2013). As a consequence of this, different surgeons use different treatment regimes.We investigated results of 2 different surgical protocols for control of the infection in combination with retention of the primary implant in patients with early postoperative infection after primary THA. We hypothesized that a single-shot debridement regime would be as effective in controlling the infection and retaining the implant as a regime that routinely used multiple surgical debridements.