CORR Insights®: The Role of Highly Selective Implant Retention in the Infected Hip Arthroplasty
1 CORR Insights : The Role of Highly Selective Implant Retention in the Infected Hip Arthroplasty
Thoralf Randolph Liebs 0
Where Are We Now? 0
0 T. R. Liebs MD, PhD (&) Inselspital University Hospital, University of Bern , Freiburgstrasse 10, 3010 Bern , Switzerland
This CORR Insights1 is a commentary on the article ''The Role of Highly Selective Implant Retention in the Infected Hip Arthroplasty'' by El-Husseiny and Haddad available at: DOI: 10.1007/s11999-0164936-7. The author certifies that he, or a member of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/ licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research1 editors and board
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P
eriprosthetic joint infection
(PJI) is among the most
devastating complications after hip
replacement surgery [
2, 6
]. In chronic
PJI, a removal of all implant
components, de´bridement, and a subsequent
revision arthroplasty (either as a
onestage or a two-stage procedure) is
recommended [
2, 7, 9, 14, 16
] since
de´bridement and component retention
alone is associated with a high
likelihood that the infection will persist.
However, removal of well-ingrown
implants can result in substantial bone
defects, making subsequent
reimplantation difficult. For this reason, we
must consider whether indeed we need
to remove all implant components for
patients with PJI.
The answer appears clear if the
symptoms of PJI are acute and found
early after the index procedure. In the
latest consensus conference held in
2013, there was an 84% consensus
agreement that incision and drainage
with component retention can be
performed for early postoperative
infections occurring within 3 months
of index primary arthroplasty with less
than 3 weeks of symptoms [
14
].
Partial revision hip arthroplasty is
somewhat of a compromise between
incision and drainage with component
retention and total revision
arthroplasty. In contrast to the classic
incision and drainage indication,
partial revision hip is intended for
patients with a chronic PJI [
4, 11
].
Ekpo and colleagues [4] reported on
19 patients with PJI in which a
twostage partial revision hip arthroplasty,
including complete acetabular
component removal, retention of
wellfixed femoral stems, placement of an
antibiotic-laden cement femoral head,
and delayed reimplantation was
performed. Of the 19 patients, two with
prior failure of two-staged treatment
of infection failed secondary to
recurrence of infection at an average
of a little more than 3 years [
4
]. In
another study, Lee and colleagues
evaluated 19 patients with a PJI and
cementless stems [
11
] in which
acetabular components and femoral
heads were removed, but stems were
left in situ if they could not be
removed easily or were well-ingrown.
Of those 19 patients, 17 received a
second-stage reimplantation and 15
CORR Insights
patients showed no evidence of
infection after a minimum of 2 years
followup [
11
].
El-Husseiny and Haddad now take
this concept further, by progressing
from a two-stage partial to a one-stage
partial hip arthroplasty. The authors
note that the short-term results are
reassuring, but we still need long-term
data before this technique can become
more widely adopted.
At first glance, the results of the
study by El-Husseiny and Haddad
appear promising. While the authors
suggest that the technique should not
be widely adopted until or unless
larger groups of patients with longer-term
data have been studied, they also note
that their results reaffirm that partial
implant retention and joint
de´bridement can be an alternative for some
highly-selected patients with PJI.
Where Do We Need To Go?
Still, there are several concerns that
will require future research. For
example, in the current study, 18 out of
293 (6%) patients who underwent
surgery for PJI were treated with a
partial one-stage revision hip
arthroplasty. This small number of patients
treated with a partial one-stage
revision indicates that the study results
may not apply broadly in typical
practices and that further research is
necessary to develop criteria for
identifying patients who could benefit from
this procedure.
A clear definition of the underlying
type of PJI and its detailed description is
necessary. This includes, for example,
the reporting of preoperative joint
aspirates and if the cultures of
intraoperative specimens yielded the same
microorganism, as well as the reporting
of the histopathological examination
results [
3
].
The current study also brings to light
an interesting topic—partial revision of
PJI of the hip appears to control
infection in a majority of patients who met
the study’s indications. This is
somewhat astonishing, and contradicts
previously published studies on biofilms
[
6, 13, 16
]. Biofilms make it difficult to
diagnose and (...truncated)