A one-stage surgical approach could be as effective in treating prosthetic joint infection (PJI) as the more common two-stage method, a recent British study found.
More than 2.5 million Americans have artificial hips, and the surgery is generally successful in enhancing mobility. While the likelihood of prosthetic hip joint infection is low — affecting approximately 1 percent of patients, according to the American Academy of Orthopaedic Surgeons — when such infections do occur, they can lead to intense pain, restricted movement, disability or death.
Biofilm formation usually makes treatment with antibiotics alone ineffective, according to Andrew Beswick, BSc, Research Fellow in Systematic Reviews at the University of Bristol, where the study was conducted. More than 50 percent of patients who develop a PJI require surgery to address the infection and replace the prosthetic.
These surgeries are performed in either one or two stages. In the two-stage approach, physicians remove the infected joint during the initial operation, after which patients are prescribed a course of antibiotics for several months. During the second stage, a surgeon implants a new joint. In the single-stage approach, infected prosthetic joints are removed and replaced with new joints in one operation.
The antibiotic regimen and the opportunity to monitor for complete clearance of infection have led most hospitals in the U.S. and the U.K. to favor the two-stage approach. However, findings from the University of Bristol study suggest one-stage surgery may be just as effective, if not more so.
“For several decades, the commonly used two-stage procedure has been presumed to be more effective than the one-stage procedure,” says Setor Kunutsor, PhD (Cantab.), MBChB (Legon), MA (Cantab.), BA (Legon), Research Fellow in Evidence Synthesis at the University of Bristol. “The one-stage strategy is less commonly used because of limited evidence on its effectiveness. It, however, has potential advantages, which include having only one major surgery, a shorter overall stay in the hospital, reduced functional impairment and less expense. With these new findings and subsequent adoption of the one-stage strategy by surgeons and hospitals, quality of life could be improved, unnecessary deaths averted, and this could all be achieved at a lower cost.”
The study, in the European Journal of Epidemiology, analyzed re-infection rates among 1,856 participants across four continents who underwent surgery for prosthetic hip joint infections. At median follow-up of 3.7 years, 16.8 percent of one-stage surgery patients experienced re-infection, compared with 32.3 percent of two-stage surgery patients. Further research is underway to measure outcomes of both approaches. (See sidebar “INFORM Program and Clinical Trial.”)
While Kunutsor believes additional research will provide valuable perspective, he recommends surgeons consider the one-stage strategy to treat PJI, due to a range of potential advantages — the most obvious being that patients undergo only one major surgery.
Beswick urges caution in interpreting the data, as patient characteristics and other factors besides choice of revision strategy may have affected the findings. Nonetheless, he sees significant potential for the one-stage approach.
“In a two-stage revision, patients do not have a fully functioning hip joint for between two weeks and 12 months,” Beswick says. “A temporary spacer may be fitted, but patients experience considerable physical and psychological difficulties during this period, and spacers are associated with a high incidence of complications ... . While the operation in a one-stage revision may be of longer duration, rehabilitation and recovery can commence immediately.”