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Infection of total hip joint prosthesis — Clinical Guidelines

Overview

Infection of total hip joint prosthesis is a severe complication that can lead to significant morbidity and failure of the prosthetic joint. Early diagnosis and appropriate management are crucial to prevent persistent infection and optimize outcomes.

Diagnosis

Clinical Presentation: Pain, swelling, and signs of systemic infection (fever, elevated inflammatory markers).

Diagnostic Tests:

- Hip Aspiration: Highly sensitive (92.8%) and specific (91.7%) for diagnosing infection 9. - Intraoperative Cultures: Useful for identifying pathogens, especially during reimplantation procedures 4. - Imaging: Radiographs may show signs of loosening or periprosthetic changes, but are not definitive 5.

Management

Initial Management:

- Antibiotic Prophylaxis: Essential perioperatively to reduce infection risk; administered at induction, 6 hours, and 12 hours post-operatively 6. - Surgical Intervention: - Incision and Debridement: Primary treatment for early infections 5. - Reimplantation: Considered after successful eradication of infection; intraoperative cultures guide antibiotic therapy 4.

Reduction of Dislocated Prostheses:

- Emergency Department Reduction: High success rate (92%) under procedural sedation; quicker than theatre-based general anaesthesia 1 3. - Complications: Monitor for complications related to procedural sedation 1.

Special Populations

Elderly: Higher risk of complications; careful consideration of comorbidities and nutritional status is crucial 5.

Comorbidities: Good dental health and systemic infection control are essential before surgery 5.

Key Recommendations

Utilize hip aspiration for accurate and cost-effective diagnosis of prosthetic joint infection (Evidence: Strong 9).

Perform prosthetic hip reduction in the emergency department under procedural sedation when feasible, given its high success rate and reduced time to reduction compared to theatre-based anaesthesia (Evidence: Moderate 1 3).

Ensure timely administration of antibiotic prophylaxis perioperatively to minimize infection risk (Evidence: Moderate 6).

Consider reimplantation after successful infection eradication, guided by intraoperative cultures and clinical assessments, even with low levels of inflammation (Evidence: Moderate 2 4).

Evaluate and optimize patient comorbidities, particularly in elderly patients, before and after surgical interventions (Evidence: Expert opinion).

References

1 Blokland A, Van Den Akker V, Van Der Poort C, Somford M, Holkenborg J. Results of Reduction of Dislocated Prosthetic Hips in the Emergency Department. The Journal of emergency medicine 2022. link 2 Cho WS, Byun SE, Cho WJ, Yoon YS, Dhurve K. Polymorphonuclear cell count on frozen section is not an absolute index of reimplantation in infected total knee arthroplasty. The Journal of arthroplasty 2013. link 3 Gagg J, Jones L, Shingler G, Bothma N, Simpkins H, Gill S et al.. Door to relocation time for dislocated hip prosthesis: multicentre comparison of emergency department procedural sedation versus theatre-based general anaesthesia. Emergency medicine journal : EMJ 2009. link 4 Murillo O, Euba G, Calatayud L, Domínguez MA, Verdaguer R, Pérez A et al.. The role of intraoperative cultures at the time of reimplantation in the management of infected total joint arthroplasty. European journal of clinical microbiology & infectious diseases : official publication of the European Society of Clinical Microbiology 2008. link 5 Salvati EA, González Della Valle A, Masri BA, Duncan CP. The infected total hip arthroplasty. Instructional course lectures 2003. link 6 Lewis K. Audit of timing of antibiotic prophylaxis in hip and knee arthroplasty. Journal of the Royal College of Surgeons of Edinburgh 1998. link 7 Volpin G, Grimberg B, Daniel M. Complete displacement of the femoral stem during dislocation of a THR. The Journal of bone and joint surgery. British volume 1997. link 8 Hanssen AD, Osmon DR. Prevention of deep wound infection after total hip arthroplasty: the role of prophylactic antibiotics and clean air technology. Seminars in arthroplasty 1994. link 9 Tigges S, Stiles RG, Meli RJ, Roberson JR. Hip aspiration: a cost-effective and accurate method of evaluating the potentially infected hip prosthesis. Radiology 1993. link

Infection of total hip joint prosthesis