What is the best way to treat infected hip replacements?

New research has
found treating an infected hip replacement in a single stage procedure may be
as effective or better than the widely used two-stage procedure. To date no
well-designed study has compared these procedures head-to-head to decide if one
is better or if they achieve the same results. Hip replacement is a very
common operation that is effective at providing pain relief and improving
mobility, however, infection can sometimes occur following joint
replacement. The findings have wide implications for orthopaedic surgery,
the NHS, and health systems worldwide.

The research team,
led by the University of Bristol, conducted a study that reviewed patient data
from 44 studies to compare the effectiveness of the two types of surgery
currently used to treat infections – one-stage and two-stage revisions.

In the two-stage
procedure, the existing artificial joint is removed in one operation and the
patient is treated for several months with antibiotics. A new joint is
then inserted in a second operation. In the one-stage procedure, the
artificial joint is removed along with all infected tissue and a new one
inserted in the same operation.

The study found
that the one-stage revision strategy is as good, if not better, as the
two-stage strategy. The one-stage strategy may also be better suited for
patients with certain types of infection or problems that were previously
thought not to be appropriate for this type of surgery.

Dr Setor Kunutsor, Research Fellow from the
Musculoskeletal Research Unit at the Bristol
Medical School: (THS) and lead researcher, said:

“For several decades, the two-stage
procedure has been presumed to be more effective than the one-stage. However,
it has disadvantages for patients such as having two major surgical procedures,
significant pain and limited function between stages, long hospital stays, as
well as high healthcare costs. The one-stage strategy has potential advantages
for patients which include having only one major surgery, shorter time in
hospital, reduced functional impairment, and is less expensive.

“When the research
team analysed the collected data, the findings confirmed what we had suspected
all along – the one-stage strategy may be as effective as, or better than the
two-stage strategy.”

Speaking about the
study, Co-investigator and Senior Author Mr. Andrew Beswick, also a Research
Fellow of the Musculoskeletal
Research Unit at the Bristol
Medical School: (THS), said:

“Our research and the subsequent adoption of
the one-stage strategy by surgeons and hospitals, could improve lives, prevent
unnecessary deaths, and save money.”

The researchers
suggest a clinical trial should be carried out to compare which of the two
strategies is better in treating infection, but it will require several
thousands of patients with hip infections.

The research team
at Bristol led by Professor Ashley Blom, Head of Translational Health Sciences,
Bristol Medical School, University of Bristol, is currently undertaking a trial
which is comparing the two surgical strategies using patient reported outcomes
such as pain and function. It is hoped that this trial will determine which is
the better way to treat infected hip replacements when pain and function are
thought to be the most important outcomes.

While the research
team await results of this trial and in the absence of any further evidence,
surgeons and policy makers are encouraged to consider the current evidence in
their practice and guidelines. The Bristol researchers will work with patients,
surgeons, nurses and other health professionals, and the NHS to ensure that the
results of the study have an appropriate impact on future practice.

Paper

“One- and two-stage
surgical revision of peri-prosthetic joint infection of the hip: A pooled
individual participant data analysis of 44 cohort studies” by The Global Infection Orthopaedic
Management Collaboration European Journal of Epidemiology