High success rate seen with debridement, two-stage revisions for infected THR

Kim YH. J Bone Joint Surg-Br. 2011. doi: 10.1302/0301-620X.93B1.25120.

Repeated debridement and two-stage cementless revision procedures may lead to a high success rate of controlling infection and allow most patients to maintain a functional total hip replacement, according to Korean investigators.

Investigators at The Joint Replacement Center of Korea in Seoul studied 294 patients who had an infected total hip replacement (THR). The investigators followed the patients for a mean of 10.4 years and noted the rates of infection control following patients’ first treatment, and after repeated debridement and two-stage revision procedures.

The study revealed that all of the early superficial infections were eventually controlled using the technique. In addition, more than 90% of the early deep, late chronic and acute hematogenous infections were controlled. At the latest follow-up, 98% of the patients had a functional THR, according to the study abstract.

“Repeated debridement and two-stage or repeated two-stage revisions further improved the rate of control of infection after the initial treatment and increased the likelihood of maintaining a functional THR,” the authors wrote.

This article is very broad-based and covers a large infection experience which includes superficial and deep infections, acute hematogenous and nonhematogenous infections, and established chronic infections. Many more recent papers have covered subsets in terms of establishing idealized protocols for each of these. I clearly have conflicts here in that I have published previously on cementless revision, but also in that we have a similar size experience which we have published part of recently in the JBJS and in that our focus is slightly different in that we have started to move towards single-stage revision in a selected subset.

This paper is a valuable one. It demonstrates a large experience, confirms the place of acute debridement in hematogenous and acute infection, and also establishes - possibly above that of any previous paper - the role of repeated debridement and repeated surgery in terms of eventually eradicating infection. The authors ought to be commended on establishing that. It is, therefore, a useful study in terms of reinforcing what is already established practice in many settings. The greatest value of the paper will be that each unit should look at this paper and then look at its protocols in terms of what they do for acute superficial infections, acute deep or hematogenous infections and their protocol for established deep infections.

There is a place for bringing together this paper and their algorithm of repeated debridement with ours of selective treatment based on the organism, the patient and the bone loss.

— Fares S Haddad, BSc MCh (Orth) FRCS (Orth) FFSEM
Divisional Clinical Director – Surgical Specialties
University College Hospital
Director, Institute of Sport, Exercise & Health
Division of Surgery & Interventional Science, University College London
London

Fares S Haddad, BSc MCh (Orth) FRCS (Orth) FFSEM, receives research support from Smith & Nephew, Stryker and Finsbury Orthopaedics.

This article by Kim et al, is of genuine interest and reflects realistic expectations for results of revision total hip replacement using repeated revision to achieve a completely infection-free surgical field and, finally, revising with cementless components.Although they could achieve a clean environment more quickly and reliably by using direct antibiotic infusion, their meticuous debridement and persistent approach to the infected hip allowed them to prevail even with intravenous antibiotics, which deliver low concentrations of antibiotics to the hip. Their use of cementless revision implants is certainly an excellent decision, since recurrent infection in cementless total joint arthroplasty can be treated by repeat debridement and cementless arthroplasty without causing progressive bone loss.

My first publication using cementless implants for revision of infected total knee arthroplasty appeared in Clinical Orthopaedics and Related research in 1994. In this study population, we also employed the two-stage method and results were similar to those reported here by Dr. Kim et al.

My co-authors, Tariq Nayfeh, Michael Peppers, and Marcel Roy published a second report in Clinical Orthopaedics and Related Research this year, describing the results of single-stage revision, cementless implants and direct infusion of antibiotics into the joint for 6 weeks to treat established Methicillin-resistant Staphylococcus aureus infection of total knee arthroplasties. Our results again were very similar to those reported by Kim et al.

Congratulations to these authors for their outstanding work and for furthering our understanding of the treatment of infected total joint arthroplasty.

– Leo A. Whiteside, MD
Missouri Bone & Joint Center
Saint Louis, MO

Disclosure:Whiteside has received royalties/consulting fee for consulting/speaking/teaching from Smith & Nephew Orthopaedics. He also has ownership interest in Signal Medical Corporation.