|Year : 2019 | Volume
| Issue : 1 | Page : 67-71
Microbiological profile and outcomes of two-stage revision hip arthroplasty
TD Hariharan1, VJ Chandy1, Jerry George1, Ajit Joseph Mathew1, John Premnath1, Agila Kumari Pragasam2, John Jude Prakash2, Anil Thomas Oomen1, Pradeep Mathew Poonnoose1
1 Department of Orthopaedic Surgery, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Web Publication||16-Aug-2019|
Dr. V J Chandy
Department of Orthopaedic Surgery, Christian Medical College, Vellore, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: Prosthetic joint infection (PJI) is one of the most challenging cases that confront modern orthopaedics. Two-stage revision, which is the standard of care for PJI, is the preferred mode of treatment for these infections. Aims and Objectives: To study the microbiological profile of prosthetic joint infections (PJI) in the hip and to assess the efficacy of a two stage revision surgery for PJI. We also aimed to study the sensitivity and specificity of ESR and CRP in the diagnosis of PJI. Materials and Methods: The microbiological profile, clinical and radiological outcomes of 22 patients who had a two-stage revision for PJI of the hip between 2013 and 2017 were retrospectively analysed. PJI was defined using the criteria provided by the International Consensus Statement on PJI 2013. Results: Staphylococcus aureus was found to be the most common organism in PJI. Debridement was successful in removing the organism in 74% of PJI. At the time of re-implantation (second stage), six joints grew organisms that were different from that isolated at the index debridement - coagulase-negative staphylococci (3cases) and enterococci (3cases). Other infection parameters for these patients were negative. None of the patients who had two-stage revision surgery had clinical evidence of reinfection or radiological evidence of loosening at a mean of 2-year follow-up. An ESR cut off of >30mm/hr had a sensitivity of 75% and specificity of 88% in predicting PJI. A CRP >10mg/L had a sensitivity of 75% and specificity of 69%. The sensitivity and specificity of using both ESR and CRP cut-offs in the diagnosis of infection were 57% and 94%, respectively. The positive predictive value was 94% and negative predictive value was 56%. Conclusion: The outcomes of the study justify a two-stage revision arthroplasty for PJI of the hip. The use of ESR and CRP as screening tests for the success of debridement has value - but should be interpreted with caution.
Keywords: Arthroplasty, C-reactive protein, diagnosis, erythrocyte sedimentation rate, microbiological profile, prosthetic joint infection
|How to cite this article:|
Hariharan T D, Chandy V J, George J, Mathew AJ, Premnath J, Pragasam AK, Prakash JJ, Oomen AT, Poonnoose PM. Microbiological profile and outcomes of two-stage revision hip arthroplasty. Indian J Med Microbiol 2019;37:67-71
|How to cite this URL:|
Hariharan T D, Chandy V J, George J, Mathew AJ, Premnath J, Pragasam AK, Prakash JJ, Oomen AT, Poonnoose PM. Microbiological profile and outcomes of two-stage revision hip arthroplasty. Indian J Med Microbiol [serial online] 2019 [cited 2020 Jun 6];37:67-71. Available from: http://www.ijmm.org/text.asp?2019/37/1/67/264494
| ~ Introduction|| |
The incidence of deep infection associated with primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) ranges from 0.3% to 2.9% (2, 3) and from 1% to 2%, respectively.,, The risk of infection in revision surgeries ranges from 2.1% to 15%. The annual utilisation rate of THA and TKA in India is around 70,000 joints per year with a projected growth rate of around 27% every year. Prosthetic joint infections (PJIs), therefore, play a significant role in determining the overall outcomes of both primary and revision arthroplasties in the future.
Two-stage revision remains the standard of care for infected THA and TKA in most instances. Single-stage revision is successful when the infection involves a THA rather than a TKA; the infection is not polymicrobial; the causative bacteria are Gram-positive, sensitive to the first-line antibiotics and patient factors are optimal (e.g., adequate soft tissue and bone stock, no immunosuppression or significant comorbidities)., [Table 1] summarizes the diagnostic criteria for PJI's recommended by the International consensus meeting on prosthetic joint infections in 2013.,,,
In this study, we reviewed the patients who had two-stage revision arthroplasty of the hip. This study aimed to profile the microbial flora seen in PJIs – both at the time of the first presentation for the first-stage debridement, as well as at the time of the revision surgery when the final implant was inserted. The aim was to assess the usefulness of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) in predicting the success of the second revision surgery. In addition, we audited the success of treatment of two-stage revision arthroplasty performed.
| ~ Materials and Methods|| |
We reviewed the hospital database to identify patients who underwent two-stage revision hip arthroplasty in our unit. All patients who presented with PJI from 2013 to 2017 were included in the study. Patients who underwent a single-stage revision or those who stopped with the first-stage debridement were excluded. Twenty-two patients who had revision hip arthroplasty fulfilled the inclusion criteria [Figure 1].
The patients were diagnosed to have a prosthetic infection based on the criteria as defined by the International Consensus Meeting on PJI [Table 1]. Any patient with one major criterion or 3 out of 5 minor criteria was considered positive for prosthetic infection. The two major criteria were (a) a sinus tract communicating with the prosthesis and (b) a pathogen is isolated by culture from two separate tissues or fluid samples obtained from the affected prosthetic joint. Minor criteria included (a) elevated serum ESR (30 mm/h) or CRP levels (10 mg/L), (b) elevated synovial fluid white blood cell count (>3000 cells/μL), (c) elevated synovial neutrophils' percentage (80%), (d) isolation of a microorganism in one culture of periprosthetic tissue or fluid and (e) >5 neutrophils per high-power field in five high-power fields observed for histologic analysis of periprosthetic tissue at ×400 magnification.
The consensus group also stated that PJI might be present without meeting these criteria, specifically in the case of less virulent organisms (e.g., Propionibacterium acnes). Thus, the clinicians are urged to exercise their judgement and clinical acumen in reaching the diagnosis of PJI.,
All patients had ESR and CRP assessed before both stages of revision. All had an ultrasonographic screening to look for fluid to aspirate prior to surgery. Tissue from the surgical site was sent for histopathological examination at the time of surgery, and the role of histopathological examination (>5 polymorphs/high-power field) was studied. Frozen section was done in 19 of the 22 patients prior to the second-stage reimplantation. Only 2 of the 19 patients had >5 neutrophils/high-power field. The two were clinically found to be free of infection, and cultures were negative; hence, it was decided to proceed with revision total hip replacement. Seven patients had fluid aspirated prior to the second stage, whereas the rest had no fluid on ultrasonographic screening and hence not aspirated. The microbiological profile of the organisms cultured from the tissue was assessed. Cultures were taken from at least five areas at the time of the surgery for both the stages.
Following the first-stage debridement, all patients were treated with appropriate antibiotics for 6-week intravenous where possible. Where oral equivalents were available, it was changed to oral drugs after 3 weeks of intravenous drugs. If the culture at the second surgery, i.e., at the time of replantation, was positive, the patient was given appropriate antibiotics for 6 weeks; and if it was negative, he/she was given antibiotics only for 10 days post-operatively, based on the first culture report.
Patients were followed up with X-rays at each visit to look for any loosening and clinically assessed for any signs of infection or increased pain. A good clinicoradiological outcome was defined as the absence of loosening of the implant and no recurrence of infection. For the purpose of statistics, all patients taken up for the first stage of revision arthroplasty were considered infected, whereas patients with a positive culture at the second stage were considered potentially infected, despite ESR, CRP and fluid counts being normal.
| ~ Results|| |
From 2013 to 2017, 22 patients underwent two-stage revision hip arthroplasty. The median age of the patients was 48 years (range: 20–83 years). Of these, 21 were male and 1 was female. All cases of periprosthetic-infected joints operated on, had their primary surgery done elsewhere. The mean period between the first- and second-stage debridement was 9 months (range: 3–29). The mean follow-up after the second stage was 30 months (range: 14–70 months, standard deviation (SD±14)). Two patients had well-controlled diabetes mellitus, whereas five patients had hypertension, for which they were taking medication. Seven patients had a sinus at the time of presentation. Seven of the cases needed a redo debridement; three soon after the first stage and four were done 16, 24, 28 and 29 months after the first stage, due to persistently high ESR and positive aspirate from the joint.
Erythrocyte sedimentation rate and C-reactive protein
All 22 patients had ESR and CRP done pre-operatively, both before the first-stage debridement and before the second-stage revision. The median ESR prior to the first-stage revision surgery was 39 mm/hr (interquartile range [IQR]: 28–44) and median ESR prior to replantation was 23 mm/hr (IQR: 12–36). The ESR was >30 mm/hr, the cut-off for the diagnosis of infected joint, in 17 of the 22 cases (77%) prior to the first stage. ESR decreased following the first-debridement surgery in 17 out of the 22 patients (77%). In the remaining 5 patients, the ESR showed a downward trend in 3 and a marginal increase in 2 patients [Figure 2]. The sensitivity of ESR in predicting infection was 75%, specificity was 88%, positive predictive value of 91% and negative predictive value of 67% [Table 2].
|Figure 2: (a) Comparison of erythrocyte sedimentation rate before the first-stage debridement (erythrocyte sedimentation rate 1) and before the two-stage implantation surgery (erythrocyte sedimentation rate 2) in 22 patients (b) comparison of C-reactive protein before first-stage debridement (C-reactive protein 1) and before the two-stage reimplantation surgery (C-reactive protein 2) in 22 patients|
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|Table 2: Sensitivity, specificity, PPV and NPV of ESR >30 mm/h and CRP >10 mg/L in predicting infection|
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The median CRP prior to the first-stage debridement was 18 mg/L (IQR: R 7–47). The median CRP at the time of reimplantation was 5 mg/L (IQR: 3–11). The CRP was >10 mg/L, the cut-off for the diagnosis of infected joint, in 18 (82%) of the cases prior to the first stage. It was noted that CRP has decreased in 21 patients (96%), and it had increased only in one patient following the first-stage debridement [Figure 2]. CRP had a sensitivity of 75%, specificity of 69%, positive predictive value of 81% and negative predictive value of 61% in predicting infection. When patients with both ESR >30 mm at 1 h and CRP >10 mg/L were considered as a cut-off for infection, the combination was found to have a sensitivity of 57%, specificity of 93.8%, positive predictive value of 94.1% and negative predictive value of 55.6% in predicting infection [Table 2].
The bacteriological profile
Prior to the first-stage debridement, 14 (64%) had positive cultures from the joint. If the aspirate did not yield any fluid, the tissue was sent from the joint at the time of debridement. The bacteriological profile of the organisms at the first-stage of revision is seen in [Figure 3]. The most common organism at the first-stage revision was Staphylococcus aureus (four cases). Only one of the patients who grew S. aureus was methicillin resistant, whereas all other strains were methicillin sensitive. Two of the infections were polymicrobial comprising Gram-negative bacilli, Klebsiella spp., Escherichia coli and Pseudomonas aeruginosa. One of these two patients achieved complete eradication of infection by the second stage, whereas the others had enterococci growth at the final cultures. Eight patients had no growth on culture but had three other minor criteria or perioperative findings necessitating a two-stage revision. Tissue for the culture was sent from the operated site in all patients. The most common organisms isolated from cultures at the second stage were coagulase-negative Staphylococcus spp.(3 cases) and enterococci(3 cases). All the isolated strains of coagulase-negative staphylococci were susceptible to teicoplanin but resistant to oxacillin and erythromycin.
|Figure 3: (a) The microbiological profile at the first-stage revision, (b) microbiological profile at reimplantation|
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Of the eight patients who had a negative culture at the first stage, two turned positive at the second stage. One grew coagulase-negative Staphylococcus spp. and the others grew enterococci. Overall, only 6 out of 22 patients had a positive culture at the second-stage replantation. None of the 6 had any other minor criteria other than a single-positive culture. Enterococci (n = 3) and coagulase-negative Staphylococcus (n = 3) were the organisms identified.
All patients with positive cultures at the second stage were continued on antibiotics for 6 weeks as per se nsitivity pattern. All patients with positive cultures have been followed up for a mean of 32 months (SD±10.4, range: 16–49 months). None had a poor clincoradiological outcome as assessed by the absence of pain and absence of loosening in the follow-up X-rays. None of the patients had a recurrence of infection or worsening of the clinical status.
| ~ Discussion|| |
THA achieves durable pain relief and restoration of function in most patients with arthritis of the hip, but infection does occur in a small percentage of these patients and remains one of the most devastating complications of THA. Treatment of infection poses an increased risk to the patient as well as increased resource use and institutional cost. Two-stage treatment of infected THA with high-dose antibiotic-laden cement spacers before reimplantation is commonly performed with infection control rates often better than 80%.,
This study outlines our experience in our unit with 22 patients. About 27% (6/22) of the patients had positive cultures at the end of the second stage. None of them had any other minor criteria that classified them as infected. As the cultures were reported only after the second-stage replantation, these patients were treated with 6 weeks of appropriate intravenous antibiotics. They continued to do well with no recurrence of infection or sinus with a mean follow-up of over 2 years.
S. aureus was the main organism isolated in primary cultures, and this is in keeping with the international studies., This is possibly due to the biofilm-forming capabilities of these organisms. Many studies report increased difficulties in eradicating multi-resistant organisms. A two-stage revision is still recommended for these patients. Higher morbidity and mortality is also associated with these patients.,
In this study, ESR and CRP did seem to be useful in predicting the absence of infection, especially at the second stage. The specificity and positive predictive value of the combined ESR and CRP with cut-offs at 30 mm/hr at 1 h and 10 mg/L, respectively, were found to be 94%; highlighting the fact that they are extremely useful in confirming the absence of infection. Not all investigators concur in the value of ESR and CRP prior to the second stage. Parvizi et al. opined that there is little value in checking ESR and CRP prior to the second stage. Lindsey et al., however, reported a better predictive value with a combination of ESR and CRP at the second stage, though a definitive cut-off value could not be identified. Although the negative predictive value of ESR and CRP was moderate, it should be noted that there was a decrease in the ESR values in 77% and CRP values in 96% of the cases, following the first-stage debridement.
The use of an aspiration prior to the second stage could not be assessed in this study, as very few of the patients had fluid in the joint that could be removed for testing at the time of the second stage. Hence, the value of assessing the polymorphs percentage and number of polymorphs/mm3 in the aspirate could not be assessed. Hence, the criteria used to diagnose infection at the second stage need to be revisited. While fluid aspiration does not seem to play a role, a frozen section could probably have a larger role to play in predicting the absence of microbes at the second-stage surgery.
| ~ Conclusion|| |
In conclusion, two-stage revision arthroplasty in infected joints has a good outcome. In 74% of the infected joints, the debridement yielded a culture-negative surgical field where the implant could be inserted at the second stage. Despite their limitations, serum ESR and CRP may have utility as 'rule-out' tests in the interim period between stages of a two-stage revision. More information from larger studies is needed to identify optimal cut-off values. A lowering of these values too may have a significant role in clinical decision-making. Till more evidence to the contrary is available, we continue to recommend ultrasonography screening of the joint to look for fluid for aspiration; and routine frozen section at the time of the revision implantation surgery.
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Conflicts of interest
There are no conflicts of interest.
| ~ References|| |
Cooper HJ, Della Valle CJ. The two-stage standard in revision total hip replacement. Bone Joint J 2013;95-B: 84-7.
Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007;89:780-5.
Kurtz SM, Ong KL, Lau E, Widmer M, Maravic M, Gómez-Barrena E, et al.
International survey of primary and revision total knee replacement. Int Orthop 2011;35:1783-9.
Aynardi M, Jacovides CL, Huang R, Mortazavi SM, Parvizi J. Risk factors for early mortality following modern total hip arthroplasty. J Arthroplasty 2013;28:517-20.
Parvizi J, Sullivan TA, Trousdale RT, Lewallen DG. Thirty-day mortality after total knee arthroplasty. J Bone Joint Surg Am 2001;83-A: 1157-61.
Kunutsor SK, Whitehouse MR, Lenguerrand E, Blom AW, Beswick AD; INFORM Team. Re-infection outcomes following one- and two-stage surgical revision of infected knee prosthesis: A systematic review and meta-analysis. PLoS One 2016;11:e0151537.
Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckelberg JM, et al.
Executive summary: Diagnosis and management of prosthetic joint infection: Clinical practice guidelines by the infectious Diseases Society of America. Clin Infect Dis 2013;56:1-10.
Parvizi J, Zmistowski B, Berbari EF, Bauer TW, Springer BD, Della Valle CJ, et al.
New definition for periprosthetic joint infection: From the workgroup of the musculoskeletal infection society. Clin Orthop Relat Res 2011;469:2992-4.
Parvizi J, Gehrke T, Chen AF. Proceedings of the international consensus on periprosthetic joint infection. Bone Joint J 2013;95-B:1450-2.
Parvizi J, Tan TL, Goswami K, Higuera C, Della Valle C, Chen AF, et al.
The 2018 definition of periprosthetic hip and knee infection: An evidence-based and validated criteria. J Arthroplasty 2018;33:1309-1400.
Kuzyk PR, Dhotar HS, Sternheim A, Gross AE, Safir O, Backstein D. Two-stage revision arthroplasty for management of chronic periprosthetic hip and knee infection: Techniques, controversies, and outcomes. J Am Acad Orthop Surg 2014;22:153-64.
Silva M, Tharani R, Schmalzried TP. Results of direct exchange or debridement of the infected total knee arthroplasty. Clin Orthop Relat Res 2002;404:125-31.
Aggarwal VK, Rasouli MR, Parvizi J. Periprosthetic joint infection: Current concept. Indian J Orthop 2013;47:10-7.
] [Full text]
Tornero E, García-Oltra E, García-Ramiro S, Martínez-Pastor JC, Bosch J, Climent C, et al.
Prosthetic joint infections due to Staphylococcus aureus
and coagulase-negative staphylococci. Int J Artif Organs 2012;35:884-92.
Klouche S, Leonard P, Zeller V, Lhotellier L, Graff W, Leclerc P, et al.
Infected total hip arthroplasty revision: One- or two-stage procedure? Orthop Traumatol Surg Res 2012;98:144-50.
Wolf CF, Gu NY, Doctor JN, Manner PA, Leopold SS. Comparison of one and two-stage revision of total hip arthroplasty complicated by infection: A Markov expected-utility decision analysis. J Bone Joint Surg Am 2011;93:631-9.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]