TREATMENT OF THE TOTAL HIP INFECTION
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Related issues: |
| TOTAL HIP INFECTIONS |
| TREATMENT OF TOTAL KNEE INFECTIONS |
| BACTERIA CHARACTERISTICS |
| BACTERIA IDENTIFICATION |
| ANTIBIOTIC TREATMENT |
"It is almost impossible, with current methods of treatment, to eradicate implant-associated infections without removing the foreign body (the total hip prosthesis)"
(Garvin 1995)
Once the infection gets hold in the total hip joint, treatment of the infection in the total hip with antibiotic only is not effective. On the contrary, it is dangerous because
it produces antibiotics resistant bacterial strains
it may trigger allergy against antibiotics in the patient.
Once the infecting bacteria landed on the surface of the total joint they produce quickly a slime envelope that protects them effectively against the action of antibiotics. The prosthesis and the soft tissues have slime forming bacteria firmly adherent to them. The surgeon must remove the infected total joint prosthesis with tissues around it to get rid of the slime forming bacteria. First when the the slime forming bacteria have been removed the antibiotic treatment will be effective against the few bacteria that remained scattered in the tissues.
The most often used, and the most often successful method is the staged exchange of the infected prosthesis. This method uses two operations: in the first stage the surgeon removes the infected total hip joint, in the second stage the surgeon implants a new total joint prosthesis.
Staged exchange of an infected total hip prosthesis
Click on the icon for a full size picture
A. The prosthesis bathes in a sea of pus (gray in the picture). The infection has destructed large areas of skeleton around the prosthesis.
B. At "first stage" operation the surgeon removes the total hip prosthesis and all infected tissues and cement rests around it. The surgeon then places a large piece of bone cement, formed as a femoral component of the hip prosthesis (yellow in the picture), in the space after the removed hip joint prosthesis. The wound is then closed.
This piece of cement is called spacer and it is imbibed with potent antibiotics.
The spacer has two functions: First, it keeps the muscles and other tissues around the hip joint at just right tension.
Second, large quantities of antibiotics leak continually from the spacer in the space left after the removed total hip prosthesis. If any bacteria remained in this space after extraction of the infected prosthesis, it will be killed now by the high concentration of antibiotics.
With the spacer in place, the patient can continue to use his/her leg and exercise the muscles. The use of the spacer is a big progress compared with the older practice, when the patient has had a traction through his leg and was confined to bed.
Antibiotic treatment with massive doses of antibiotics continues for several weeks. (Short antibiotic treatment is one of the causes for failure of the staged exchange operation)
C. When laboratory tests show that the infection is eradicated, the surgeon carries out the second stage of this procedure. In the "second stage" operation, the surgeon removes the spacer and puts a special new total hip joint prosthesis in place.
The revision total hip joint prosthesis is bulkier to fill the voids after the destructed tissues. The femoral component has also a longer stem for anchoring in the still healthy part of the thigh bone.
Usually, the surgeon must use a filling material to fill all dead space around the revision prosthesis. The material may be bone cement imbibed with antibiotics, bone grafts, or a mixture of both. (Void space would otherwise collect blood and offer nourishment to new bacteria)
Antibiotic treatment continues after the "second stage" operation.
What other methods of treatment of total hip infection are available?
Treatment with antibiotics only.
This is done in the rare cases, when the bacteriological cultures done during primary total hip replacement revealed presence of bacteria in several (at least two) samples, although there were no other signs of infection. It is recommended to treat these patients six weeks with antibiotics.
Similarly, in the acute wound infection, before the infection bacteria get hold in the tissues and on the surface of the total hip prosthesis, the surgeon removes carefully the infected collected blood (hematoma), flushes the wound surfaces and closes the wound over suction drains (tubes attached to suction device). The drains suction continually the blood that oozes into the closed wound space, and which may become nurture ground for occasional bacteria left in the wound. It is recommended to treat these patients six weeks with antibiotics. The total hip prosthesis is left in place if it is well attached to the skeleton.
One stage exchange.
Has been used be some surgeons in the past. The surgeon opens the infected total hip joint, removes carefully all infected tissues and the infected joint prosthesis, flushes the wound, and then puts a new total hip in place. Also the exchange is done within one operation procedure.The use of bone cement containing antibiotics is almost mandatory.
Nowadays the accepted criteria for such one stage are otherwise healthy patients with well retained skeleton around the prosthesis, the bacteria are well sensitive to common antibiotics. On the other hand, also elderly and infirm patients, who would probably not tolerate two surgeries, may be operated on with one stage exchange.
The indications for the use of one stage exchange as opposed to two stages exchange operation method, vary, however, among the surgeons. See also the Table below.
Results of treatment of infections around the total hip prostheses:
The results depend on
- how early the infection was detected and treated. The infections detected and treated late have worse results than infections detected and treated early
- how widespread was the destruction of bone and soft tissues
- what kind of bacteria caused the infection
Infections caused by the so called Gram- positive bacteria are easier to treat than the infections caused by the so called Gram -negative bacteria.
Infections caused by Tubercles bacteria, rare in the developed countries, need antibiotic treatment both before and after the revision operation. The results of revision operations after Tuberculous infection are not worse than the results of treatment of hip joint infections caused by other bacteria.
In general, about 70% of all total hip infections will heal after the first staged exchange procedure. In 15 % of all staged revision operations the infection will return and a second staged revision procedure will be necessary to eradicate the infection. In about 15 % of all staged revision operations even the second staged operation fails. In some of these patients the total hip joint cannot be saved at all.
The results depend on the right strategy used for the treatment of the infection around the total hip joint. Statistics also demonstrate that clinics specialized on treatment of complications of total hip surgery have better results of treatment of the infection around the total hip.
The importance of the staged exchanged procedure and the use of antibiotic loaded bone cement papers from this excellent statistics:
Success Rates of revision operations for Total Hip Infection Cement One- Stage Revision Two-Stage Revision Antibiotic-loaded cement 82 % 91 % Plain cement 58 % 82 %
(Robbins 2001)
How long should the antibiotic treatment after the revision operation last?
It depends on the "infection parameters", the lab tests indicating the ongoing infection activity. When these tests are negative, the antibiotics are stopped. The length varies also between individual surgeons and hospital
This period lasts usually four to six weeks after the second stage revision operation. Some patients, however, may need very long antibiotic treatment.
This is called "suppressive antibiotic treatment" and such antibiotic treatment may be lifelong. The value of such long antibiotic treatment, however, is discussed.
Patient satisfaction after the staged exchange
The results of the staged exchange operations after total hip infection are worse then the results of revision operations for non-infectious loosening of total hips.
Still, about 80 % of the patient have been satisfied with the result of the operation if the infection has been eradicated.
When the exchange operation fails
"A 28 year - old woman... Patient presented with history of 14 surgical procedures on the right hip and 39 (!) procedures on the left hip (after bilateral total hip arthroplasties) in an attempt to eradicate "a stubborn infection".
Eftekhar 1993
When the exchange operations fail repeatedly the surgeon has then two possibilities:
1) Hip fusion:
The surgeon fixes the upper part of the thigh bone to the pelvic bone with screws and plates. The goal is bone union between them. Because so much skeleton was destructed by the infection, this is an extremely difficult operation, and it fails often.
2) Girdlestone / resection plastic:
The surgeon may let the patient to live without a hip joint. Yes, it is possible to live without a hip joint. This condition has a name: Girdlestone’s plastic - an embellishing term for a difficult terminal state after failed total hip replacement.
The English surgeon Girdlestone proposed and carried out this operation in the 1940's on patients with hips totally destructed by tuberculosis. He simply removed all infected rests of the destructed hip. He himself rarely used it unless the patient's disability was extreme.
Think that this operation was also proposed as a treatment for osteoarthritis of the hip in the 1940's.! (Girdlestone 1945 ) What a progress has the hip surgery made since then!?
Interestingly enough, in poor countries (India), this operation, together with antibiotic treatment, is still being used today as a treatment method of choice for tuberculous hip infection - and accepted by the patients!
The results of Girdlestone plastic in patients with failed total hip joints have not been good:
80% of all such patients need special walking aids, or cannot walk at all,
and even with walking aids they walk worse than people with the leg amputated
> 90 % of all patients have pain in the their "hips" (Kantor GS 1986)
References:
Eftekhar NT Total hip arthroplasty , Mosby 1993, text to radiograph 27-2
Girdlestone GB. Proc R Soc Medicine 1945; 38:363-8
Kantor GS et al: J Arthroplasty 1986;1: 83-89
Robbins et al : J Bone Joint Surg-Am 2001; 83-A: 602-14
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