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The Journal of Bone and Joint Surgery 80:1306-1313 (1998)
© 1998 The Journal of Bone and Joint Surgery, Inc.

Treatment of Infection with Débridement and Retention of the Components following Hip Arthroplasty*

JOHN R. CROCKARELL, JR., M.D.{dagger}, ARLEN D. HANSSEN, M.D.{dagger}, DOUGLAS R. OSMON, M.D.{dagger} and BERNARD F. MORREY, M.D.{dagger}, ROCHESTER, MINNESOTA

Investigation performed at the Mayo Clinic and Mayo Foundation, Rochester


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Forty-two patients (forty-two hips) who had an infection following a hip arthroplasty were managed with open débridement, retention of the prosthetic components, and antibiotic therapy. After a mean duration of follow-up of 6.3 years (range, 0.14 to twenty-two years), only six patients (14 per cent)—four of nineteen who had had an early postoperative infection and two of four who had had an acute hematogenous infection—had been managed successfully. Of the remaining thirty-six patients, three (7 per cent of the entire group) were being managed with chronic suppression with oral administration of antibiotics and thirty-three (79 per cent of the entire group) had had a failure of treatment. All nineteen patients who had a late chronic infection were deemed to have had a failure of treatment. Débridement had been performed at a mean of six days (range, two to fourteen days) after the onset of symptoms in the patients who had been managed successfully and at a mean of twenty-three days (range, three to ninety-three days) in those for whom treatment had failed. Débridement with retention of the prosthesis is a potentially successful treatment for early postoperative infection or acute hematogenous infection, provided that it is performed in the first two weeks after the onset of symptoms and that the prosthesis previously had been functioning well. In our experience, this procedure has not been successful when it has been performed more than two weeks after the onset of symptoms. Retention of the prosthesis should not be attempted in patients who have a chronic infection at the site of a hip arthroplasty as this approach universally fails.


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Options for the treatment of infection following hip arthroplasty include long-term antibiotic therapy in an effort to suppress the infection, débridement with retention of the prosthesis, resection arthroplasty, arthrodesis, disarticulation at the hip, one-stage exchange of the implant, and a staged revision operation10. The success of débridement and retention of the prosthesis has been extremely variable1-3,5,7-9,11-13,15-19,21-23. The use of strict guidelines for the selection of patients has led to higher rates of success23. Although many prognostic factors have been extrapolated from reports on débridement for the treatment of infection following hip arthroplasty, the published experience with this procedure is quite limited.

If successful, débridement without removal of the prosthesis is a cost-effective approach as the need for a revision operation is eliminated. In contrast, if this treatment fails, the benefits of avoiding the morbidity associated with a major operative procedure and of avoiding the consumption of health-care resources are lost as additional intervention, including removal of the prosthesis, is then usually necessary to eradicate the infection.

The purpose of the current study was to analyze our experience with attempts at curative débridement for the treatment of infection following hip arthroplasty. The specific goals were to identify groups of patients for whom débridement may be successful, to define risk factors for predicting failure, and to offer guidelines for physicians who decide to use this treatment approach.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Of 17,295 primary and revision hip arthroplasties performed at our institution between 1975 and 1991, 234 (1.4 per cent) were followed by a deep infection. Fifty-two infected hips (22 per cent) initially were treated with débridement, retention of the prosthesis, and antimicrobial therapy. Of these hips, ten were not included in the study: eight were excluded because the infection had developed after a reimplantation that had been performed because of a previous infection at the site of a hip arthroplasty, and two were excluded because the patients had died from other causes (at three and nineteen months postoperatively). The remaining forty-two patients (forty-two hips) constituted the basis of this study (Table I). All patients were followed for at least two years or until treatment was considered to have failed because of reinfection. The mean duration of follow-up was 6.3 years (range, 0.14 to twenty-two years).


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  		TABLE I DATA ON THE FORTY-TWO PATIENTS (FORTY-TWO HIPS) WHO HAD DÉBRIDEMENT WITH RETENTION OF THE PROSTHESIS

 
The infections were classified with use of the criteria of Tsukayama et al. According to that system, early postoperative infections are diagnosed within the first month after the arthroplasty; late chronic infections have an insidious clinical course and are diagnosed later than one month postoperatively; and acute hematogenous infections are characterized by an acute onset of symptoms, more than one month after the operation, in a patient in whom the prosthesis previously had been functioning well23. Of the forty-two hips, nineteen had an early postoperative infection, nineteen had a late chronic infection, and four had an acute hematogenous infection (Table I).

The diagnosis of deep infection in thirty-five hips was confirmed by growth of the same organism in at least two cultures of specimens that had been obtained by aspiration or débridement of tissue at or beneath the fascia or by one positive culture as well as one of three criteria: (1) evidence of acute inflammation (more than five polymorphonuclear leukocytes per high-power field) in histological specimens of intra-articular tissue, (2) gross purulence at the time of the débridement, or (3) an actively draining sinus tract. There was no growth of organisms on cultures of specimens from seven patients, all of whom were using antibiotics at the time of presentation. However, these patients had signs and symptoms of infection and met at least two of the three criteria.

Our definition of reinfection included infection with the same organism, infection with a different strain of the same organism, or infection with another organism. It is often difficult to know if a subsequent infection with a different organism occurs because of the emergence of antimicrobial resistance during treatment, the development of a secondary acquired infection during treatment, or an inability to initially identify all organisms. Since the goal of treatment is salvage of the prosthesis, reinfection with any organism generally necessitates removal of the prosthesis to eradicate the infection and thereby represents a failure of treatment.

Radiographs made at the time of the diagnosis of the infection were available for forty-one of the forty-two hips and were reviewed for the presence of radiolucent lines. Nineteen hips (46 per cent) had no radiolucent lines, fifteen (37 per cent) had an incomplete radiolucent line adjacent to at least one component, and seven (17 per cent) had a complete radiolucent line surrounding at least one component (although none of the implants were deemed loose at the time of débridement).

During the time of the study, there were no formal parameters for the selection of patients or protocols for débridement as a definitive treatment at our institution. Therefore, an attempt to retain the prosthesis also was made in patients who had a chronic infection or a polymicrobial infection. Twelve hips (29 per cent) had an actively discharging sinus tract. The one requirement for retention of the prosthesis was that the implant be well fixed as determined at the time of débridement.

Débridement was performed at a mean of twenty days (range, two to ninety-three days) after the onset of symptoms. Intraoperative tissue specimens were obtained from all forty-two hips for culture, histological analysis, and gram-staining. Gross purulence was observed in nineteen hips (45 per cent), and histological evidence of acute inflammation was noted in twenty (48 per cent). Coagulase-negative Staphylococcus, which was found on culture of specimens from eleven hips (26 per cent), was the most commonly isolated organism. Thirteen hips (31 per cent) had an infection with multiple organisms (Table II). Strategies for wound management were chosen at the discretion of the treating physician. A mean of 2.2 débridements (range, one to seventeen débridements) were performed before closure of the wound. Thirty-seven patients had definitive closure of the wound at the time of the final débridement; in the remaining five, the wound was allowed to heal by secondary intention.


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  		TABLE II RESULTS OF CULTURE FOR THIRTY-FIVE HIPS

 
The type of antibiotic was selected with use of in vitro susceptibility testing of organisms that grew on culture of preoperative aspirates of joint fluid or intraoperative tissue specimens. Forty-one patients were managed with intravenous administration of antibiotics for a mean of twenty-nine days (range, two to seventy-two days). The remaining patient (Case 40) initially was managed with only oral administration of antibiotics and had removal of the prosthesis two weeks later because of persistent infection (Table I). Twenty-six patients received antibiotics orally after the course of intravenously administered antibiotics; the mean duration of the oral therapy was seventy days (range, five to 376 days). Three patients were managed with chronic suppression with oral administration of antibiotics.

Statistical Analysis
The possible risk factors for reinfection that were assessed included the age and gender of the patient, the diagnosis, the presence of diabetes mellitus or a malignant tumor, the use of steroids or tobacco, the number and type of infecting organisms, the interval until débridement, the method of fixation of the prosthesis, the presence of sinus tracts, the type of arthroplasty (primary or revision), and the presence of radiolucent lines at the time of presentation. The cumulative probability of failure of treatment was estimated according to the survivorship method of Kaplan and Meier, with use of the log-rank test20. Comparisons between subgroups and multivariate analyses were performed with use of the Cox proportional-hazards model.


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 

Reinfection
Thirty-three patients (79 per cent) had a reinfection following the attempt at débridement (Table I). The overall rate of infection-free survival of the prosthesis was 72 per cent (95 per cent confidence interval, 60 to 87 per cent) at one year, 56 per cent (95 per cent confidence interval, 42 to 73 per cent) at two years, and 26 per cent (95 per cent confidence interval, 15 to 45 per cent) at five years. Twenty-nine patients who were deemed to have had failure of treatment had removal of the prosthesis, and thirteen of them eventually were managed with reimplantation, at a mean of 2.2 years (range, three weeks to eight years) after the removal.

Prognostic Factors
The six patients who were managed successfully had débridement earlier after the onset of symptoms (mean, six days; range, two to fourteen days) than did those for whom the treatment failed (mean, twenty-three days; range, three to ninety-three days), although the difference was not found to be significant, with the numbers available (p = 0.06) (Fig. 1). The difference in the rate of infection-free survival of the prosthesis between the patients who had débridement within the first six days after the onset of symptoms and those who had it at least one week after the onset also seemed important, but, again, with the numbers available, it was not found to be significant (p = 0.08) (Fig. 2).



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  		FIG. 1: Fig. 1 Graph showing the time to débridement after the onset of infection in the patients who were managed successfully and in those who had failure of the treatment (mean, six compared with twenty-three days).

 


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  		FIG. 2: Fig. 2 Graph showing the rates of infection-free survival of the prostheses in the patients who had débridement within the first six days after the onset of symptoms and in those who did not have it until at least seven days after the onset of symptoms. The vertical bars indicate the 95 per cent confidence intervals.

 
Four of the nineteen patients who had an early postoperative infection and two of the four who had an acute hematogenous infection were managed successfully (Table III). When only these two types of infections are considered, treatment was successful for four of the twelve patients who had débridement within the first week, two of the seven who had it during the second week, and none of the four who had it after two weeks. All nineteen patients who had a late chronic infection eventually were deemed to have had a failure of treatment.


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  		TABLE III RESULTS OF THE TREATMENT OF THE FORTY-TWO PATIENTS (FORTY-TWO HIPS)

 
With the numbers available for analysis, no significant relationship was detected between the success of treatment and the number or type of infecting organisms; the presence of sinus tracts, a malignant tumor, diabetes mellitus, rheumatoid arthritis, or radiolucent lines; the use of tobacco or steroids; age or gender; the method of wound management or fixation of the prosthesis; or the type of arthroplasty (primary or revision).

Successful Treatment
Six patients (14 per cent) were managed successfully; that is, at the time of the most recent follow-up (mean, 7.6 years; range, 3.2 to twenty-two years), they had no evidence of infection and were no longer using antibiotics. Although the prognostic factors that were analyzed in this study were not found to be significant, these patients had several variables in common (Table I). All six had had an early postoperative or acute hematogenous infection, all had had an expeditious débridement, all had a prosthesis that had been inserted during a primary arthroplasty with use of acrylic bone cement, and all had had definitive closure of the wound rather than healing by secondary intention. Surprisingly, three of these patients had had an infection with more than one organism and two of the polymicrobial infections included Pseudomonas aeruginosa.

Chronic Antibiotic Suppression
It is important to point out that the decision to manage certain patients with chronic antibiotic suppression was made empirically by the treating physician and was not based on evidence of recurrent infection. This treatment method, initially selected for twelve patients, was advantageous for only three (Cases 13, 36, and 42); these three patients, all of whom were elderly, died at a mean of four years (3.8, 4.0, and 4.1 years) after the débridement with no signs or symptoms of infection. The infection in these three patients was classified as having been suppressed but not cured. The remaining nine patients (Cases 24, 25, 26, 31, 35, 37, 39, 40, and 41) who initially had been managed with chronic antibiotic suppression eventually had removal of the prosthesis in order to control the infection.

Complications
Perioperative medical complications included recurrent dislocation of the hip, deep venous thrombosis, periprosthetic femoral fracture, and death due to sepsis and adult respiratory-distress syndrome in one patient each. Complications that were directly attributable to the antibiotic therapy were recorded for seven patients (17 per cent). These included mild maculopapular rashes in four patients, mild renal insufficiency in three, and pseudomembranous colitis and ototoxicity in one patient each.


   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
The goals of treatment of an infection following hip arthroplasty include eradication of the infection while maintaining a functional and relatively pain-free joint10. Débridement with retention of the prosthesis is an attractive treatment option; however, the results have been quite variable, with rates of success ranging from 0 to 80 per cent in studies ranging in size from one to forty-one patients; when multiple series are combined, the rate of success is only seventy-two (31 per cent) of 229 hips1-3,5,7-9,11-13,15-19,21-23. The outcome of this treatment seems to depend on many factors, but because of the small number of cases that have been reported it is difficult to draw definitive conclusions about specific prognostic variables. Tsukayama et al., who reported on the largest series of which we are aware, described a treatment protocol with strict guidelines for the selection of patients. In that study, twenty-five (71 per cent) of thirty-five early postoperative infections and three of six acute hematogenous infections were treated successfully—an overall success rate of 68 per cent; the patients who had a chronic infection were not managed with débridement and retention of the prosthesis.

The issue of whether to perform débridement of a chronically infected hip that has a well fixed prosthesis is a relatively common one despite the fact that other authors, including those from our institution, have advised against it9,19,21. As demonstrated in the present study, these futile attempts continue to be made, despite the availability of evidence contraindicating such treatment, for a variety of reasons. These reasons include a request by the patient to retain the prosthesis at all costs, an excessively optimistic attitude about the effectiveness of current antimicrobial agents, and the impression that a failed attempt causes little harm. In reality, a failed attempt at débridement and retention of the prosthesis incurs the morbidity associated with a major operative procedure and consumes valuable health-care resources because an additional operation is then needed. It is quite clear, from the present study, that a chronically infected hip should not be treated with débridement and retention of the prosthesis as failure of such treatment is a certainty.

There are very few data with regard to the timing of débridement after the onset of symptoms. It has been suggested that débridement should be attempted only in the first three weeks after the arthroplasty17. The performance of débridement in the first week after the operation has more prognostic consequence with regard to the success of the treatment than does the type of microorganism that is causing the infection21. Fitzgerald et al. emphasized the importance of expedient débridement on the basis of the results for seven patients who had had an acute hematogenous infection. In another series, of patients who had an infection with Staphylococcus aureus following a hip or knee arthroplasty, débridement that was performed more than two days after the onset of symptoms was associated with a higher rate of failure of treatment than was débridement performed within the first two days4. In the present study, performance of the débridement within the first week after the onset of symptoms appeared to influence the outcome favorably in patients who had an early postoperative infection or an acute hematogenous infection, although, with the numbers available, this effect was not found to be significant (p = 0.08). It is important to note that none of the patients who were managed successfully had had more than a fourteen-day delay until the débridement.

Although it is commonly assumed that infections with gram-negative bacteria or multiple organisms are more difficult to treat with débridement and retention of the prosthesis, we are unaware of any data that support this position. Successful treatment of a gram-negative infection is possible if débridement is performed expeditiously21,23. In the present study, three of the six patients who were managed successfully had a polymicrobial infection and two of the three polymicrobial infections included a gram-negative bacillus. This suggests that the results of cultures should not be a primary parameter in the initial selection of patients for management with débridement and retention of the prosthesis; a delay in order to wait for the final culture report only prevents the physician from proceeding with expeditious treatment.

The status and type of fixation of the prosthesis may have important prognostic implications with regard to the success of a débridement performed in the early postoperative period. Of the thirty-five early postoperative infections that were treated with débridement in the study by Tsukayama et al., all twenty-three of those that occurred in patients in whom the prosthesis had been inserted with cement were associated with a successful result compared with only two of the twelve that occurred in patients in whom the prosthesis had been inserted without cement. This marked difference, which was highly significant (p < 0.001), may have been due to spread of infection along the bone-prosthesis interface of implants that had been fixed without cement and had not yet undergone complete osseointegration; in contrast, the interface between well fixed cemented implants and bone is effectively sealed to prevent the initial spread of infection. Although none of our four patients who had one or both components inserted without cement had a successful outcome, it should be noted that all had a late chronic infection. On the basis of these data, we are unable to comment on the relationship between the method of fixation and the eventual outcome.

A loose prosthesis has been assumed to be a contraindication to débridement with retention of the prosthesis, and this was one of the parameters that was used to exclude patients from the present study. It was relatively common to observe radiolucent lines about the prosthetic components before débridement (such lines were seen in twenty-two [54 per cent] of forty-one hips) only to find that these components were well fixed at the time of débridement. We were unable to associate the presence of these radiolucent lines with failure of treatment; however, we recommend that every effort be made to debride any areas of radiolucency carefully at the time of the operation, if the decision is made to retain the prosthesis. The quality of the débridement and the type of wound management are likely to affect the eventual outcome. Unfortunately, the ability to assess and compare the quality of débridement among patients is extremely difficult; therefore, we were unable to address this variable specifically in the present study. Although, with the numbers available, the difference between the results associated with open and closed wound management was not found to be significant (p = 0.17), it is notable that all six patients who were managed successfully had definitive closure of the wound. Currently, we recommend that multiple serial débridements and open wound-packing be avoided to prevent secondary invasion with nosocomial organisms.

In summary, débridement and retention of the prosthesis for the treatment of an infection following a hip arthroplasty should be used sparingly and only after specific criteria for the selection of patients have been met. Appropriate candidates for this treatment include patients who have an early postoperative infection and those who have an acute onset of symptoms in association with a previously well functioning prosthesis. Rapid diagnosis and expeditious treatment are consequential to the final outcome, and, whenever possible, débridement should be performed within the first few days after the onset of symptoms. Débridement that has been performed after two weeks has not been successful in our experience. An attempt at débridement with retention of the prosthesis for the treatment of chronic infection is not recommended as failure is universal.


   Footnotes
 
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

{dagger}Department of Orthopedics (J. R. C., Jr.; A. D. H.; and B. F. M.) and Division of Infectious Diseases (D. R. O.), Mayo Clinic, 200 First Street S.W., Rochester, Minnesota 55905. Please address requests for reprints to Dr. Hanssen.


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Ahlberg, Å.; Carlsson, Å. S.; and Lindberg, L.: Hematogenous infection in total joint replacement. Clin. Orthop., 137: 69-75, 1978.
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