Early Peri-Prosthetic Joint Infection after Hemiarthroplasty for Hip Fracture: Outcomes of Debridement,Antibiotics,and Implant Retention

Abstract

Background:

There are currently no treatment algorithms specifically for early peri-prosthetic joint infection (PJI) after hemiarthroplasty for hip fracture. Commonly, debridement, antibiotics, and implant retention (DAIR) is attempted as first-line management, despite lack of evidence supporting this strategy in this patient group. The purpose of this study was to evaluate outcomes of DAIR for early PJI after hemiarthroplasty for hip fracture in our unit.

Methods:

The departmental database from December 2008 to January 2019 was searched to identify all patients in our unit who were treated for early PJI after hemiarthroplasty for hip fracture. Data for included patients were collected from electronic healthcare records and analyzed. Primary outcome measure was treatment success, defined as patient survival to discharge, with eradication of infection and implant retention.

Results:

Twenty-six patients were identified and included in the study. Mean age was 84.7 years. All except one patient were American Society of Anesthesiologists (ASA) class 3 or 4. All patients were McPherson host grade B or C. Twenty-three of 26 patients underwent DAIR and three of 26 proceeded directly to excision arthroplasty. Debridement, antibiotics, and implant retention was successful in three of 23 patients (13%) after a single procedure, with success in two additional patients after a second procedure, giving overall success rate of five of 23 patients (22%).

Conclusions:

Debridement, antibiotics, and implant retention has a high failure rate in treating early PJI after hemiarthroplasty for hip fracture. These patients are generally elderly and frail with multiple host and wound compromising factors. Debridement, antibiotics, and implant retention should not be recommended as first-line management for the majority of these patients, for whom getting it right the first time is of vital importance to avoid consequences associated with failed surgical procedures. Further multicenter studies that also explore alternate treatment strategies are required to devise an algorithm specifically for hip fracture patients, to aid decisions on treatment and improve outcomes.

In the United Kingdom approximately 65,000 patients per year are treated for hip fracture with surgical procedures as recommended by the National Institute for Health and Care Excellence (NICE) [1,2]. These procedures involve the implantation of prostheses to allow early restoration of mobility. One of the biggest risks and challenges currently faced in orthopedics is peri-prosthetic joint infection (PJI). Microbes that cause biofilm formation on orthopedic implants are a major factor contributing to the difficulty in eradication of infection [3,4]. Despite the advancements in implants, materials, surgical technique, and a multitude of perioperative preventative measures being utilized, reported incidence rates of PJI after surgery for hip fracture range from <1% to >6% [5 –11]. Studies have shown that PJI is associated with an additional 10%–20% mortality risk, longer hospital stays, and tripled overall costs [11 –14].

Experts have evaluated current practice and evidence in treating PJI in orthopedic patients during International Consensus Meetings in 2013 [15] and 2018 [16]. Surgical strategies currently being utilized include debridement, antibiotics, and implant retention (DAIR), one-stage, and two-stage exchange arthroplasty procedures. There is strong consensus that DAIR can be considered for early infection that occurs within three months of index procedure, with less than three weeks of symptoms [15,16]. In a study of 122 cases of PJI after total hip arthroplasty (THA), Grammatopolous et al. [17] reported that infection eradication was achieved in up to 85% of patients overall, with 68% after a single DAIR. This is currently one of the largest studies supporting the use of DAIR for early PJI after elective primary and revision THA, where patients were treated in specialist bone infection unit.

However, the focus of the International Consensus Meetings and much of the current literature relates to elective arthroplasty. Patients undergoing hemiarthroplasty for hip fracture clearly have different characteristics that those undergoing elective arthroplasty for degenerative joint disease. After hip fracture, NICE recommends offering THA rather than hemiarthroplasty for patients who walk independently outdoors with no more than a cane and are not cognitively impaired [2]. Therefore, those being offered hemiarthroplasty rather than THA are generally those with features of frailty and poor functional status [18]. These frail patients, already in a catabolic state as a result of the initial trauma, have less physiologic reserve to cope with surgical stressors and infection, and are at greater risk of complications [18 –20].

There is currently little evidence supporting use of DAIR for PJI after hemiarthroplasty for hip fracture, and no consensus or treatment algorithms specifically for this patient group exist. A commonly utilized strategy for hip fracture patients, as used in our unit, is an attempt at DAIR as first-line management, followed by excision arthroplasty if DAIR fails. A study by Bergkvist et al. [21] reported DAIR treatment success rate of 19% for PJI after hip fracture, compared with 64% after elective arthroplasty. However, a study by Mellner et al. [22] reported more encouraging outcomes with DAIR success of 82% in patients with hip fractures. Further evaluation is required to determine if DAIR is an appropriate treatment option in this predominantly frail group of patients.

The purpose of this study was to evaluate retrospectively the outcomes of DAIR performed for early PJI after hemiarthroplasty for hip fracture in our district general hospital trauma unit.

Patients and Methods

The National Hip Fracture Database and departmental databases from December 2008 to January 2019 were searched to identify all patients treated in our unit for hip fracture. A further search was performed to identify any of these patients who returned to surgery. Electronic healthcare records including operation notes for each patient were reviewed to establish the reason for return and exact nature of the procedure performed. Only those who met all inclusion criteria were included and data collected and analyzed. Ethical approval was not required.

Inclusion criteria included: the procedure performed during return to surgery was DAIR or excision arthroplasty; the index procedure was hemiarthroplasty for hip fracture; the index procedure was performed within less than three months; and Musculoskeletal Infection Society (MSIS) diagnostic criteria for PJI was met [23].

Patients were all treated for hip fracture and PJI in the same unit utilizing a multidisciplinary team involving orthopedic surgeons, orthogeriatricians, and a single consultant microbiologist with specialist interest in orthopedic infection. The standard hemiarthroplasty was performed through an anterolateral approach using an uncemented hydroxyapatite-coated implant. Gentamicin-loaded cement was used in cemented hemiarthroplasty procedures. All implants were modular and fully compliant with NICE benchmark. Patients received only single-dose intravenous antibiotic prophylaxis (teicoplanin and gentamicin) 30 minutes prior to the procedure. Debridement, antibiotics, and implant retention was considered first-line management for early PJI, followed by excision arthroplasty should DAIR fail to eradicate the infection. One-stage and two-stage exchange arthroplasty procedures have not been utilized in our unit for treating infected hemiarthroplasty.

Pre-operative clinical diagnosis of PJI and return to surgery was based on clinical features including systemic signs and symptoms of infection, local signs of infection such as persistent or purulent wound discharge, and biochemical markers including serum erythrocyte sedimentation rate and C-reactive protein. Pre-operative joint aspiration was not performed. Debridement of all infected and non-viable tissue followed by thorough irrigation with sterile saline using pulsed lavage was performed by the on-call trauma surgeon. Deep tissue samples were obtained and underwent culture and sensitivity and histologic analysis. Local antibiotic agents after debridement were not utilized. Standardized empiric broad-spectrum intravenous antibiotic agents were commenced, followed by organism-specific intravenous antibiotic agents once microbial sensitivities were available. Clinical features and inflammatory markers were monitored for response to treatment and an individualized organism-specific antibiotic regimen continued as directed by our microbiologist.

Data collected included patient demographics, comorbidities, recorded American Society of Anesthesiologists (ASA) class, procedure details, procedure dates, grade of operating surgeon, pathology and microbiology results, date of death or discharge, infection status on discharge, and mortality within one year of infection. A review of tissue histology and causative micro-organisms identified from intra-operative samples confirmed that patients included in this study met MSIS criteria for PJI. For purposes of analysis, micro-organisms were classified based on those generally considered to be high-virulence or low-virulence [24 –26]. Patients were also assigned retrospectively a systemic host grade according to the McPherson staging system, in which grade A is an uncompromised host, grade B is a compromised host with one to two compromising systemic factors, and grade C is a substantially compromised host with more than two compromising systemic factors [27,28].

The primary outcome measure of interest was DAIR treatment success. Successful treatment was defined as patient survival to discharge, with retained implants, with no evidence of ongoing infection, and no evidence of infection recurrence within one year. Failure was defined if excision arthroplasty was performed subsequently because of persistent infection, the patient was discharged with ongoing evidence of PJI, such as a discharging sinus or plan for lifelong suppressive antibiotic agents, or the patient died in hospital. Secondary outcome measures were in-hospital mortality and one-year mortality.

Statistical analysis was performed using IBM SPSS Statistics for Windows, version 25.0 (IBM Corp., Armonk, NY). Normality of distribution for continuous parameter was assessed by inspection of histograms and Q-Q plots and confirmed utilizing the Shapiro-Wilk test. Mean, standard deviation and t-tests were used for normally distributed variables. Median, interquartile range (IQR), and Mann-Whitney U tests were used for non-normally distributed variables. For categorical parameters Fisher exact test and likelihood ratio were used. All p values ≤0.05 were considered statistically significant.

Results

During this 10-year period a total of 1,774 patients underwent hemiarthroplasty for hip fracture. Twenty-six of these patients (1.47%) were treated for confirmed early PJI and were included in the study. Table 1 summarizes a breakdown of all arthroplasty procedures, including THA, performed for hip fracture, and numbers of patients treated for early PJI according to type of procedure performed.

Table 1.

Breakdown of Arthroplasty Procedures Performed in Our Unit for FNF from December 2008 to January 2019, and Numbers of Those Treated for Early PJI

	Procedure	Total performed (n)	Treated for early PJI (n)	Percentage (%)
Hemiarthroplasty	Uncemented HHA	1,718	24	1.40
	Cemented HHA	56	2	3.57
	Total HHA	1,774	26	1.47
Total hip arthroplasty	Uncemented THA	304	1	0.33
	Cemented/Hybrid THA	130	1	0.77
	Total THA	434	2	0.46
Total		2,208	28	1.27

FNF = femoral neck fracture; HHA = PJI = peri-prosthetic joint infection; THA = total hip arthroplasty.

Mean age of included patients was 84.7 years (range, 72–97 years; standard deviation [SD] 6.6), median time from index procedure to DAIR was 22.0 days (range, 6–90 days; IQR = 15) and median length of hospital stay 75.5 days (range, 33–301; days, IQR = 43). With the exception of one patient who was recorded as ASA 2, all other patients were ASA 3 (severe systemic disease) or 4 (severe systemic disease that is a constant threat to life). All patients were McPherson host grade B or C.

The clinical course and outcomes of patients treated for early PJI after hemiarthroplasty for hip fracture is shown in Figure 1. Twenty-three of 26 patients underwent DAIR. Forty-eight percent of initial DAIR procedures were performed by consultants, and the remainder by associate specialists or hip arthroplasty fellows. Debridement, antibiotics, and implant retention was successful in 13% (3/23) of patients (13%) after a single DAIR, with success in two additional patients after second DAIR, giving an overall success rate of 22% (5/23 patients). Treatment failed in the two patients who underwent more than more DAIR procedures. In-hospital mortality was 26% (6/23 patients), and 39% (9/23 patients) at one year.

FIG. 1.

Flowchart illustrating the clinical course and outcomes of patients treated for early peri-prosthetic joint infection (PJI) after hip hemiarthroplasty.

A comparison of characteristics between patients with DAIR success versus failure are summarized in Table 2. There were no statistically significant differences in age, gender, ASA, McPherson host grade, time from index procedure to DAIR, number of DAIR procedures, virulence of micro-organism, or length of hospital stay. Of note, DAIR was successful in the single patient in this study with ASA 2, who was a grade B host.

Table 2.

Comparison of Characteristics Between Patients with Successful versus Failed DAIR for Early PJI after HHA

	Successful DAIR (n = 5)	Failed DAIR (n = 18)	p
Age, mean (SD)	83.4 (5.4)	86.3 (6.5)	0.38
Gender (n = M / F)	0/5	4/14	0.54
ASA class, median (range)	3 (2–4)	3 (3–4)	0.19
McPherson host grade (n = A /B/C)	0/3/2	0/10/8	1.00
Days primary surgery to DAIR, median (IQR)	24.0 (16)	21.0 (16)	0.85
Number of DAIRs, median (range)	1 (1–2)	1 (1–4)	0.44
Virulence of microorganism (n = low/high)	2/3	6/12	1.00
Length of hospital stay, d, mean (SD)	54.8 (17.2)	92.4 (59.4)	0.18
1-year mortality (%)	0 (0%)	9 (50%)	0.12

ASA = American Society of Anesthesiologists; DAIR = debridement, antibiotics, and implant retention; HHA = hip hemiarthoplasty; PJI = peri-prosthetic joint infection; SD = standard deviation.

Three of 26 patients were considered poor candidates for DAIR and proceeded directly to excision arthroplasty. In-hospital mortality was 33%. Sixty-seven percent (2/3) of patients were discharged clear of infection and both alive at one year.

Discussion

The purpose of this study was to evaluate treatment success of DAIR in early PJI after hemiarthroplasty for hip fracture. Overall treatment success of DAIR was only 22%, with either single or multiple DAIR procedures.

The mean age of patients in this study was 84.7 years. With the exception of one patient who was ASA 2, all other patients were ASA 3 or 4 and all patients were McPherson host grade B or C. Increased DAIR failure rates have been associated with higher ASA class (3 or 4) and host grade (B or C) compared with healthy individuals [29 –32]. In a study of 67 patients with acute PJI after hip or knee arthroplasty, Fink et al. [30] reported that ASA correlated independently with DAIR failure, with up to sevenfold increased risk in higher ASA class patients [29]. Interestingly, in our study, DAIR was successful in the single patient with ASA higher than 3. In a study of 90 patients with acute PJI after primary hip arthroplasty, Bryan et al. [31] reported a grade A host was predictive of treatment success, with DAIR failure rate of 8% compared with 44% for grade C hosts. Additionally, these patients all have soft tissue trauma around the joint as a result of an initial fall and hip fracture as a compromising wound factor [27]. Poor host and wound characteristics of patients included in our study may therefore be a major reason for poor outcomes.

There are a few small studies reporting outcomes of DAIR for PJI in similar groups of frail patients. Blomfeldt et al. [33] reported unfavorable outcomes in hip fracture patients with 82% conversion to excision arthroplasty. Kazimoglu et al. [34] reported a DAIR treatment success rate of 41% in a multicenter retrospective study of 39 patients, and similarly, Guren et al. [10] reported a success rate of 43% in a single-center retrospective study of 35 patients. Additionally, studies have reported increased failure rates arthroplasty for hip fracture compared with elective arthroplasty; Bergkvist et al. [21] reported 35% increased failure rate, De Vries et al. [35], 23%, and Del Toro et al. [36], 21%. These results further support the concern that because of different host characteristics, evidence supporting the use of DAIR in elective arthroplasty cannot be extrapolated to apply to hip fracture patients.

A single-center retrospective study of 28 patients by Mellner et al. [22] was the only study that identified reporting favorable outcomes of DAIR in hip fracture patients. A high overall incidence of PJI of 4.5% was reported, with DAIR success rate of 82% after a single DAIR. However, 26 of 28 patients were treated with DAIR within seven days of index procedure. Post-operative incision discharge, elevated inflammatory markers, and pyrexia are frequent findings during the early post-operative stage, particularly in these patients who frequently have associated medical problems [37]. Therefore, these findings would not be reliably diagnostic of PJI during this early post-operative stage, and such an extremely aggressive approach could lead to overdiagnosis of PJI, with overreported DAIR success rate. In busy units in which overall incidence of PJI is much lower, an extremely aggressive surgical approach may lead to unnecessary operations with additional risk to these frail patients.

Staphylococcus aureus and Staphylococcus epidermidis were the most prevalent causative organisms in this study. These are among the most prevalent biofilm-forming organisms reported in current orthopedic literature [3,4,38]. Adherence of micro-organisms to an implant surface is rapid and formation of a complete biofilm can occur within three weeks, allowing organisms to be 1,000 times more resistant to antimicrobial agents [3,4,39]. The overall median time from implantation to DAIR in our study was 22.0 days (range, 6–90 days; IQR = 18). Because early PJI is presumed to occur at time of implantation, the possibility of complete biofilm formation prior to DAIR for many of our patients may have affected treatment success adversely [23,38]. This may also be a factor in the favorable outcomes reported by Mellner et al. [22] where DAIR was performed within seven days of implantation for most patients.

Our study is not without limitations and has inherent weaknesses associated with any single-center retrospective study design. The consistency of surgical technique and antibiotic regimens could not be scrutinized fully in detail because of procedures being performed by different surgeons and varied comprehensiveness of documentation available. Because of the multitude of potential variables that could affect treatment success and rarity of these cases, this would be challenging to control even with a prospective study design, using a single surgeon and operating team following a strict protocol. Although flaws in consistency of DAIR methodology may exist, this is a pragmatic study that accepts the variations in practice that occur in reality, and gives a representation of the overall treatment in an average district general hospital (DGH).

Given the poor success of DAIR in this cohort, alternative strategies need to be explored, including one-stage and two-stage exchange arthroplasty surgery. Two-stage exchange arthroplasty is generally regarded as the gold standard in orthopedics with reported success rates of 80%–100% [15,16,40]. There is a reluctance to consider exchange arthroplasty procedures in hip fracture patients because of the magnitude of surgery. However, should they provide greater chance of treatment success, the benefits could outweigh the risks and be more acceptable than a DAIR strategy with high failure rates. Excision arthroplasty also remains an option and could be considered in high-risk patients or those with poor functional demand, where overall impact on quality of life may be less substantial.

Conclusion

Our study reports overall DAIR success rate of 22% in treating early PJI after hemiarthroplasty for hip fracture, where mean patient age was 84.7 years and all patients McPherson host grade B or C. The majority of patients undergoing hemiarthroplasty for hip fracture are elderly, frail, with cognitive impairment, and poor baseline mobility and functional status. These patients are poor hosts and are less capable of coping with the stresses of trauma, infection, and multiple surgeries than healthy individuals. These high failure rates are unacceptable to this frail patient group and lead to further surgical stresses, as well as further soft tissue trauma and surgical site compromise. For many of these patients, DAIR may do more harm than good and should not be considered first-line management. For previously mobile patients who are medically fit for surgery, a single, rather than multiple DAIR approach is recommended, with earlier conversion to excision arthroplasty should DAIR fail. For immobile and unwell patients, excision arthroplasty should be considered an appropriate first-line management option, avoiding the risks of DAIR. Further multicenter studies that also explore alternate treatment strategies are required to devise an algorithm specifically for hip fracture patients, to aid getting treatment decisions right the first time and improve outcomes.

Footnotes

Funding Information

There is no funding source.

Author Disclosure Statement

The authors declare that they have no conflicts of interest.

This article does not contain any studies with human participants or animals performed by any of the authors.

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National Institute of Health and Care Excellence (NICE). Hip fracture: management. NICE. 2017. https://www.nhfd.co.uk/2018report (last accessed June 9, 2019).

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