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Meta-Analysis
. 2018 Oct;33(10):933-946.
doi: 10.1007/s10654-018-0377-9. Epub 2018 Apr 5.

One- and two-stage surgical revision of peri-prosthetic joint infection of the hip: a pooled individual participant data analysis of 44 cohort studies

Setor K Kunutsor  1   2 , Michael R Whitehouse  3   4 , Ashley W Blom  3   4 , Tim Board  5 , Peter Kay  5 , B Mike Wroblewski  5 , Valérie Zeller  6 , Szu-Yuan Chen  7 , Pang-Hsin Hsieh  7 , Bassam A Masri  8 , Amir Herman  8 , Jean-Yves Jenny  9 , Ran Schwarzkopf  10 , John-Paul Whittaker  11 , Ben Burston  11 , Ronald Huang  12 , Camilo Restrepo  12 , Javad Parvizi  12 , Sergio Rudelli  13   14 , Emerson Honda  13   14 , David E Uip  13   14 , Guillem Bori  15 , Ernesto Muñoz-Mahamud  15 , Elizabeth Darley  16 , Alba Ribera  17 , Elena Cañas  18 , Javier Cabo  18 , José Cordero-Ampuero  19 , Maria Luisa Sorlí Redó  20 , Simon Strange  3 , Erik Lenguerrand  3 , Rachael Gooberman-Hill  3 , Jason Webb  21 , Alasdair MacGowan  16 , Paul Dieppe  22 , Matthew Wilson  23 , Andrew D Beswick  3 ; Global Infection Orthopaedic Management Collaboration
Affiliations
Meta-Analysis

One- and two-stage surgical revision of peri-prosthetic joint infection of the hip: a pooled individual participant data analysis of 44 cohort studies

Setor K Kunutsor et al. Eur J Epidemiol. 2018 Oct.

Abstract

One-stage and two-stage revision strategies are the two main options for treating established chronic peri-prosthetic joint infection (PJI) of the hip; however, there is uncertainty regarding which is the best treatment option. We aimed to compare the risk of re-infection between the two revision strategies using pooled individual participant data (IPD). Observational cohort studies with PJI of the hip treated exclusively by one- or two-stage revision and reporting re-infection outcomes were retrieved by searching MEDLINE, EMBASE, Web of Science, The Cochrane Library, and the WHO International Clinical Trials Registry Platform; as well as email contact with investigators. We analysed IPD of 1856 participants with PJI of the hip from 44 cohorts across four continents. The primary outcome was re-infection (recurrence of infection by the same organism(s) and/or re-infection with a new organism(s)). Hazard ratios (HRs) for re-infection were calculated using Cox proportional frailty hazards models. After a median follow-up of 3.7 years, 222 re-infections were recorded. Re-infection rates per 1000 person-years of follow-up were 16.8 (95% CI 13.6-20.7) and 32.3 (95% CI 27.3-38.3) for one-stage and two-stage strategies respectively. The age- and sex-adjusted HR of re-infection for two-stage revision was 1.70 (0.58-5.00) when compared with one-stage revision. The association remained consistently absent after further adjustment for potential confounders. The HRs did not vary importantly in clinically relevant subgroups. Analysis of pooled individual patient data suggest that a one-stage revision strategy may be as effective as a two-stage revision strategy in treating PJI of the hip.

Keywords: Meta-analysis; One-stage; Prosthesis related infection; Re-infection; Reoperation; Revision; Total hip replacement; Two-stage.

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Conflict of interest statement

Bassam A. Masri reports institutional educational support from Zimmer and DePuy. Tim Board reports institutional financial support from DePuy Synthes. Elizabeth Darley reports personal fees from Hereus Medical outside the submitted work. Michael Whitehouse reports grants from National Institute of Health Research, during the conduct of the study; other from DePuy, grants from Stryker, other from Heraeus, outside the submitted work. Jean-Yves Jenny reports other from Aesculap, other from Exactech, other from FH Orthopedics, outside the submitted work. All other authors declare no conflict of interest.

Figures

Fig. 1
Fig. 1
Selection of studies included in the individual pooled data analysis
Fig. 2
Fig. 2
Indications for index implantation by type of revision strategy
Fig. 3
Fig. 3
Type of infecting microorganism after index implantation by type of revision strategy
Fig. 4
Fig. 4
Cumulative hazard curves for re-infection by type of revision strategy
Fig. 5
Fig. 5
Hazard ratios for re-infection by participant level characteristics. Hazard ratios were adjusted for age, sex, previous hip surgery other than index surgery (yes/no), and difficult to treat organism (yes/no); CI confidence interval, HR hazard ratio; *P value for interaction. Analysis was limited to 495 participants (comprising 48 re-infections) with available data
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