Perspective

Similar efficacy seen for one-stage revision THR, two-stage revision THR for PJI

Results published in the European Journal of Epidemiology showed one-stage revision total hip replacement to treat periprosthetic joint infection was as effective as two-stage THR revision performed for this indication.

“The one-stage revision strategy for treating an infected hip replacement is as effective as the two-stage strategy, if not better,” Setor K. Kunutsor, BSc(Legon), MBChB(Legon), MPhil(Cantab), PhD(Cantab), lead author of the study, told Orthopedics Today. “The one-stage strategy may also be a suitable procedure for patients with certain types of infection or problems that were previously thought not to be appropriate for this type of surgery.”

One- vs two-stage revision

Setor K. Kunutsor

Using Medline, Embase, Web of Science, The Cochrane Library and the WHO International Clinical Trials Registry Platform, Kunutsor and his colleagues analyzed data for 1,856 patients with periprosthetic joint infection (PJI) of the hip who underwent either one-stage (n=884) or two-stage (n=972) revision surgery. The study’s primary outcome was re-infection, which was defined as recurrence of infection by the same organism(s) or re-infection with a new organism.

Results showed 10% and 13.8% of patients in the one-stage and two-stage group, respectively, experienced a re-infection. Patients who underwent two-stage revision had a greater risk of re-infection vs. patients who underwent one-stage revision, the cumulative hazard curves showed. Researchers noted the re-infection rate per 1,000 person-years of follow-up was 16.8 for the one-stage revision group and 32.3 for the two-stage revision group. They also found a 1.69 age-adjusted hazard ratio for re-infection when comparing survival data for two-stage revision to one-stage revision.

“With these new findings and subsequent adoption of the one-stage strategy by surgeons and hospitals, quality of life could be improved, unnecessary deaths averted, and this could all be achieved at a lower cost,” Kunutsor said.

Comparing strategies

Since these results are based on observational data, Kunutsor said they “cannot prove cause and effect.” Furthermore, the results cannot be generalized to specific patient populations since investigators could not “evaluate if the results will be the same in different populations and in people with different body mass indices,” he said.

“Ideally, to compare which is the better of the two strategies in treating infection, it will require evidence from a clinical trial,” Kunutsor said, noting such a study will be difficult to conduct as it would require including thousands of patients with a hip infection.

However, the research team has begun a comparative study in which the key outcomes of patient-reported pain and function will help determine whether one-stage or two-stage revision surgery is better for treatment of infected THRs.

“While we await results of this trial and in the absence of any further evidence, we encourage surgeons and policy makers to consider the current evidence in their practice and guidelines,” Kunutsor said. “We will work with patients, surgeons, nurses and other health professionals, and the [National Health Service] NHS to ensure the results of the study have an appropriate impact on future practice.” – by Casey Tingle

Disclosure: Kunutsor reports no relevant financial disclosures.

Results published in the European Journal of Epidemiology showed one-stage revision total hip replacement to treat periprosthetic joint infection was as effective as two-stage THR revision performed for this indication.

“The one-stage revision strategy for treating an infected hip replacement is as effective as the two-stage strategy, if not better,” Setor K. Kunutsor, BSc(Legon), MBChB(Legon), MPhil(Cantab), PhD(Cantab), lead author of the study, told Orthopedics Today. “The one-stage strategy may also be a suitable procedure for patients with certain types of infection or problems that were previously thought not to be appropriate for this type of surgery.”

One- vs two-stage revision

Setor K. Kunutsor

Using Medline, Embase, Web of Science, The Cochrane Library and the WHO International Clinical Trials Registry Platform, Kunutsor and his colleagues analyzed data for 1,856 patients with periprosthetic joint infection (PJI) of the hip who underwent either one-stage (n=884) or two-stage (n=972) revision surgery. The study’s primary outcome was re-infection, which was defined as recurrence of infection by the same organism(s) or re-infection with a new organism.

Results showed 10% and 13.8% of patients in the one-stage and two-stage group, respectively, experienced a re-infection. Patients who underwent two-stage revision had a greater risk of re-infection vs. patients who underwent one-stage revision, the cumulative hazard curves showed. Researchers noted the re-infection rate per 1,000 person-years of follow-up was 16.8 for the one-stage revision group and 32.3 for the two-stage revision group. They also found a 1.69 age-adjusted hazard ratio for re-infection when comparing survival data for two-stage revision to one-stage revision.

“With these new findings and subsequent adoption of the one-stage strategy by surgeons and hospitals, quality of life could be improved, unnecessary deaths averted, and this could all be achieved at a lower cost,” Kunutsor said.

Comparing strategies

Since these results are based on observational data, Kunutsor said they “cannot prove cause and effect.” Furthermore, the results cannot be generalized to specific patient populations since investigators could not “evaluate if the results will be the same in different populations and in people with different body mass indices,” he said.

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“Ideally, to compare which is the better of the two strategies in treating infection, it will require evidence from a clinical trial,” Kunutsor said, noting such a study will be difficult to conduct as it would require including thousands of patients with a hip infection.

However, the research team has begun a comparative study in which the key outcomes of patient-reported pain and function will help determine whether one-stage or two-stage revision surgery is better for treatment of infected THRs.

“While we await results of this trial and in the absence of any further evidence, we encourage surgeons and policy makers to consider the current evidence in their practice and guidelines,” Kunutsor said. “We will work with patients, surgeons, nurses and other health professionals, and the [National Health Service] NHS to ensure the results of the study have an appropriate impact on future practice.” – by Casey Tingle

Disclosure: Kunutsor reports no relevant financial disclosures.

    Perspective
    Jonathan M. Vigdorchik

    Jonathan M. Vigdorchik

    Infection is one of the most common causes of failed THR, which is an otherwise successful procedure. Currently, the standard of care for treating chronic PJI is a two-stage exchange. As it is being driven by high-volume European centers, a one-stage exchange has been proposed with similar success rates in specifically selected patients and with specific surgical techniques. The Global Infection Orthopaedic Management collaboration was set up to help increase numbers of patients and answer questions regarding these topics. In brief, they analyzed 44 unique studies including 1,856 patients who had either a one- or two-stage exchange for PJI and found hazard ratios for re-infection and revision surgery were similar in both groups. While this is certainly promising for a one-stage exchange, it is important to note it is extremely difficult to standardize patients across all these different studies, and at this time, one-stage exchange surgery should be recommended only for patients who are class A hosts and who have an organism that is easy to treat through meticulous surgical debridement using two OR set-ups with clean draping and clean instruments as described in the original studies.

    Editor’s note: As of May 22, Dr. Vigdorchik’s location has been updated.

    • Jonathan M. Vigdorchik, MD
    • Hip and knee surgeon
      Hospital for Special Surgery
      New York

    Disclosures: Vigdorchik reports no relevant financial disclosures.