The Operating Theatre Journal - Journal - Page 24
One-stage hip revisions are as good as 2-stage surgery
to replace infected artificial hips
Most people recover well after a hip
replacement, but some will develop an
infection. This can mean the artificial joint
needs to be replaced in one- or 2-stage
surgery. Research found that one-stage
hip revisions were as effective as 2-stage
procedures at relieving pain and improving
hip stiffness and function. One-stage
procedures were also better value for money.
What’s new?
Infection of an artificial joint is a rare but
severe complication. People often need
surgery to remove their artificial hip and
the surrounding infected tissue. The 2-stage
procedure allows surgeons to ensure, as far
as possible, the infection is gone before they
implant a new joint. But the replacement
of the joint can be delayed for weeks or
months. A newer, less common, one-stage
procedure is also available.
After surgery, participants completed
questionnaires about their experiences.
Researchers compared people’s experiences
of one- and 2-stage surgery to replace an
artificial hip following infection. They found
no differences between the procedures
in people’s pain, function, or stiffness 18
months on. Analyses showed that one-stage
procedures were associated with fewer
complications; they were also cheaper
to perform. The researchers recommend
increased use of one-stage surgery wherever
possible.
What’s the issue?
In the UK in 2019, more than 100,000
people had a first hip replacement. Many
hip replacements last for over 25 years.
However, of every 100 people who have a hip
replacement, 1 - 2 develop an infection in
the artificial joint within 2 years. Infection
can cause severe pain or disability and people
sometimes need further surgery.
In revision surgery, infected tissue
surrounding the joint is removed, and the
artificial joint replaced. Typically, this is
carried out in 2 stages: infected tissue and
all joint replacement implants are removed
in the first stage, and, after the infection is
completely cleared, a new artificial joint is
inserted in the second stage. But people may
wait weeks and sometimes months for the
second stage. While they wait, their mobility
and quality of life can be poor. In one-stage
surgery, infected tissue and implants are
removed, and the new joint inserted, in a
single procedure.
Previous studies have shown that rates of
reinfection are similar after one- and 2-stage
hip revisions. However, few studies have
explored people’s experiences of surgery
(their pain, mobility, and how quickly they
return to everyday activities).
In this study, researchers assessed how well
people recovered from one- and 2-stage
surgery to replace an artificial hip after
infection. They also assessed value for
money.
24
The study was carried out at 12 bone and
joint specialist centres in the UK, and 3 in
Sweden. It included 140 people requiring
a surgery to replace an artificial hip after
infection. 65 people were randomly assigned
to one-stage, and 75 to 2-stage surgery. Their
average age was 71; 1 in 3 (36%) were women.
The study found that:
• 18 months after surgery, people’s pain,
stiffness and function (ability to carry out
everyday activities) were similar in the two
groups
• 3 months after surgery, pain, stiffness and
function were better after the one-stage
procedure but from 6 months onwards,
outcomes were similar
It can also happen that a surgeon is unable to
be sure that they have removed all infected
or dead tissue in the first stage. In this case
also, the surgeon might decide to delay the
replacement of the joint.
What’s next for one-stage hip
revisions ?
Surgeons could consider carrying out more
one-stage hip revisions, the researchers
say. They recommend the use of one-stage
surgery whenever possible.
The study team are conducting an NIHRfunded study to explore how to integrate
one-stage surgery into regular practice.
https://fundingawards.nihr.ac.uk/award/
NIHR202943
Further information on the risk of infection
after a hip replacement is available on the
NHS website.
• few people (8%) in the single-stage group
had a complication during surgery (such as
fractures) compared to more (27%) in the
2-stage group.
https://www.nhs.uk/conditions/hipreplacement/risks/
There was no difference in infections after
18 months. The risk of being readmitted
to hospital or needing further surgery was
similar between the two groups.
This Alert is based on: Blom AW, and others.
Clinical and cost effectiveness of single
stage compared with two stage revision
for hip prosthetic joint infection (INFORM):
pragmatic, parallel group, open label,
randomised controlled trial. British Medical
Journal 2022;379:e071281.
One-stage operations were cheaper and
offered better value for money. The onestage group spent less time in hospital, had
fewer visits to emergency departments,
home visits from community nurses, and
nights in residential care homes. This group
had more appointments with primary care
nurses. People also lost more working hours,
but most in the study were older and not
working and the study was not powered to
explain this (secondary) finding.
Why is this important?
The study showed that one-stage revisions
relieve pain, and improve stiffness and
hip function, as effectively as two-stage
procedures. One-stage revisions resulted in
fewer complications during surgery, patients
recovered more quickly, and it was more costeffective.
People in the two-stage group required more
support from district nurses and home care
workers. The researchers say that people who
had one-stage surgery were more able to selfcare and to get out and about after surgery.
One-stage surgery is not always possible.
Sometimes, during the procedure, it becomes
clear that complex reconstruction is needed,
which could require specialist or bespoke
implants. The surgeon might decide to
clear the infection in this first stage and
return to carry out the reconstruction in a
second stage, with the appropriate tools and
implants.
THE OPERATING THEATRE JOURNAL
You may be interested to read
A previous study by the same group on risk
factors for infection of artificial joints: Blom
AW, and others. Infection after total joint
replacement of the hip and knee: research
programme including the INFORM RCT.
Programme Grants for Applied Research 2022;
10: 1-226.
A review on artificial joint infections: Tande
AJ and Patel R. Prosthetic Joint Infection.
Clinical Microbiology Reviews 2013; 27:
302–345.
Funding: This study was funded by an NIHR
Programme Grant for Applied Research.
Conflicts of Interest: Several authors
have received fees and funding from
pharmaceutical companies and orthopaedic
joint manufacturers. Full disclosure of the
authors’ conflicts of interest can be found on
the original paper.
Disclaimer: NIHR Alerts are not a substitute
for professional medical advice. They provide
information about research which is funded
or supported by the NIHR. Please note that
views expressed in NIHR Alerts are those of
the author(s) and reviewer(s) at the time
of publication. They do not necessarily
reflect the views of the NHS, the NIHR or the
Department of Health and Social Care.
MUSCLE AND BONE 25.04.23
doi: 10.3310/nihrevidence_57776
www.otjonline.com