Surgical Management for Chronic Destructive Septic Hip Arthritis: Debridement, Antibiotics, and Single-Stage Replacement is as Effective as Two-Stage Arthroplasty

Abstract

Objective: To compare the surgical outcomes of debridement, antibiotics, and single-stage total hip replacement (DASR) vs two-stage arthroplasty (two-stage arthroplasty) for chronic destructive septic hip arthritis (SHA).

Methods: Cases of chronic destructive SHA treated by DASR or two-stage arthroplasty in our department from January 2008 to October 2021 were retrospectively reviewed. Patient demographic information, perioperative inflammation markers, intraoperative blood loss, microbial culture, and metagenomic new generation sequencing results were recorded. The perioperative complications, hospital stay, hospitalization cost, infection recurrence rate, and Harris Hip Score (HHS) at the last follow-up were compared between the two groups.

Results: A total of 28 patients were included in the study, including 11 patients who received DASR and 17 patients who received two-stage arthroplasty. There was no significant difference in demographic information, preoperative serum inflammatory markers, synovial fluid white blood cell count, or percentage of polymorphonuclear leukocytes between the two groups. The DASR group demonstrated significantly lower intraoperative blood loss [(368.2 ± 253.3) mL vs (638.2 ± 170.0) mL, p = 0.002], hospital stay [(22.6 ± 8.1) days vs (43.5 ± 13.2) days, p < 0.0001], and hospitalization expenses [(81,269 ± 11,496) RMB vs (137,524 ± 25,516) RMB, p < 0.0001] than the two-stage arthroplasty group. In the DASR group, one patient had dislocation as a complication. There were no cases with recurrence of infection. In the two-stage arthroplasty group, there was one case complicated with spacer fracture, one case with spacer dislocation, and one case with deep vein thrombosis of the lower limbs. There were no cases with recurrence of infection. There were no significant differences in the readmission rate, complication rate, or HHS at the last follow-up between the two groups.

Conclusions: Both DASR and two-stage arthroplasty achieved a satisfactory infection cure rate and functional recovery for chronic destructive SHA, and DASR demonstrated significantly lower intraoperative blood loss, hospital stay, and hospitalization costs than two-stage arthroplasty. For appropriately indicated patients, if microbial data are available and a standardized debridement protocol is strictly followed, DASR can be a treatment option.

Keywords: Debridement; Next generation sequencing; Septic arthritis; Total hip arthroplasty.

Fig. 1

Flow diagram of surgical selection for chronic destructive SHA in our institution. (*: key indication).

Fig. 2

Pathogens of debridement, antibiotics, and the single‐stage replacement (DASR) and two‐stage arthroplasty groups.

Fig. 3

A typical case (Case 3) of debridement, antibiotics, and single‐stage replacement (DASR) for chronic destructive SHA. A 77‐year‐old female patient with a history of venous valve insufficiency of both lower limbs complained of repeated right hip pain for 1 year. Her preoperative CRP was 30.8 mg/L, and her ESR was 76 mm/h. (A) X‐ray showed severe destruction of the superior aspect of the femoral head and adjacent acetabulum. (B) Magnetic resonance imaging (MRI) showed altered signal intensity in the right femoral head and neck and effusion. Aspiration was performed under the guidance of ultrasound before surgery, and the pus revealed WBC of 3616 × 10⁶/L and PMN of 88%, with culture showing Parvimonas micra. (C) After discussion with the patient, the DASR strategy was selected. The tissue culture showed P. micra, which was consistent with the mNGS results. Empirical intravenous vancomycin and meropenem were administered, which was later changed to piperacillin tazobactam, for a total of 2 weeks, followed by oral amoxicillin for a total duration of 8 weeks. (D) The 23‐month follow‐up result showed satisfactory function of the right hip. Inflammatory markers were normal, and X‐ray demonstrated a decent prosthesis position and no sign of infection.

Fig. 4

A typical case (Case 4) of two‐stage arthroplasty for chronic destructive SHA. A 59‐year‐old male patient with a history of diabetes and hypertension complained of recurrent right hip pain for 3 months. His preoperative CRP was 5.1 mg/L, and his ESR was 56 mm/h. (A) X‐ray showed narrowing of the joint space and destruction of the left femoral head and acetabulum. (B) MRI revealed signal changes in the femoral head, with mild effusion. Aspiration was tried but failed to harvest pus under the guidance of ultrasound before surgery. (C) After discussion with the patient, the two‐stage arthroplasty strategy was selected. Thorough debridement and femoral head and neck resection were performed, and an antibiotic‐impregnated cement spacer was implanted. Culture of the synovial fluid and multiple intraoperative tissues showed MSSA, which was consistent with the mNGS results (Staphylococcus). Empirical intravenous vancomycin and meropenem were administered, which was later changed to cefazolin, for a total of 3 weeks, followed by oral levofloxacin for a total of 5 weeks. (D) The second‐stage revision was performed 12 weeks later. (E) At 15 months of follow‐up, the function of the right hip was good, the inflammatory markers were normal, and X‐ray showed satisfactory prosthesis position and no sign of infection.