The Experts below are selected from a list of 122796 Experts worldwide ranked by ideXlab platform
Pang Hsin Hsieh - One of the best experts on this subject based on the ideXlab platform.
-
Clinical Study Two-Stage Revision Arthroplasty for Periprosthetic Hip Infection: Mean Follow-Up of Ten Years
2020Co-Authors: Szu-yuan Chen, Chun-chieh Chen, Yu-han Chang, Pang Hsin HsiehAbstract:Background. Two-Stage Revision hip arthroplasty is the gold standard for treatment of patients with chronic periprosthetic joint infection (PJI), but few studies have reported outcomes beyond short-term follow-up. Methods. A total of 155 patients who underwent Two-Stage Revision arthroplasty for chronic PJI in 157 hips were retrospectively enrolled in this study between January 2001 and December 2010. The mean patient age was 57.5 years, the mean prosthetic age was 3.6 years, and the interim interval was 17.8 weeks. These patients were followed up for an average of 9.7 years. Results. At the latest follow-up, 91.7% of the patients were free of infection. The mean Harris hip score improved significantly from 28.3 points before operation to 85.7 points at the latest follow-up. Radiographically, there was aseptic loosening of the stem or acetabular components in 4 patients. In the multivariate survival analysis using a Cox regression model, repeated debridement before final reconstruction, an inadequate interim period, bacteriuria or pyuria, and cirrhosis were found to be the independent risk factors for treatment failure. Conclusion. Our data show that Two-Stage Revision hip arthroplasty provides reliable eradication of infection and durable reconstruction of the joint in patients with PJI caused by a variety of pathogens
-
potential clinical role of 18f fdg pet ct in detecting hip prosthesis infection a study in patients undergoing two stage Revision arthroplasty with an interim spacer
The quarterly journal of nuclear medicine and molecular imaging : official publication of the Italian Association of Nuclear Medicine (AIMN) [and] the, 2010Co-Authors: Shihhsin Chen, Pang Hsin Hsieh, Mel S. Lee, T C YenAbstract:AIM We evaluated the potential role of [18F]fluorodeoxyglucose-positron emission tomography/computed tomography ([18F]FDG-PET/CT) to identify latent infections at the site of an interim hip spacer after resection arthroplasty for hip prosthesis infection. METHODS Twelve patients with an interim hip spacer following resection arthroplasty (Group A) were investigated. Twelve patients with painful primary hip prostheses served as controls (Group B). All underwent PET/CT before surgery. Both non-attenuation-corrected (NAC) and attenuation-corrected (AC) images were analyzed. Serum C-reactive protein (CRP) levels were measured in 22 patients. Elevated CRP level was defined as >/=10 mg/L. The diagnosis of infection was based on the results of intraoperative tissue cultures, intraoperative pathology, and clinical follow-up. RESULTS FDG-PET/CT had 100% sensitivity and 100% negative predictive value for detection of latent infection in both groups. However, there were 4 and 3 false positive cases in Group A and Group B, respectively. Specificity improved from 50% to 62.5% in Group A, and from 62.5% to 87.5% in Group B when using NAC instead of AC. Seventeen patients had CRP values >/=10 mg/L, but only 8 were true positive for infection. FDG-PET/CT ruled out infection in 77.8% (7/9) of false-positive cases identified by CRP levels. CONCLUSION FDG-PET/CT is highly sensitive to detect latent infections in prosthetic hips and in interim hip spacers. The high negative predictive value of PET/CT scans is useful to rule out infections in patients with persistently elevated CRP levels. PET/CT might serve as an auxiliary tool to exclude latent infections in patients posing a clinical diagnostic dilemma.
-
liquid gentamicin in bone cement spacers in vivo antibiotic release and systemic safety in two stage Revision of infected hip arthroplasty
Journal of Trauma-injury Infection and Critical Care, 2009Co-Authors: Pang Hsin Hsieh, Kuochin Huang, Chinglung TaiAbstract:Background:Powdered antibiotics are widely used in acrylic bone cement. Liquid antibiotics, however, have rarely been employed. This study investigated the application of liquid gentamicin, a much less costly antibiotic with a broad antimicrobial spectrum, in bone cement to treat musculoskeletal inf
-
high concentration and bioactivity of vancomycin and aztreonam eluted from simplex cement spacers in two stage Revision of infected hip implants a study of 46 patients at an average follow up of 107 days
Journal of Orthopaedic Research, 2006Co-Authors: Pang Hsin Hsieh, Yu-han Chang, Shihhao Chen, Steve W N Ueng, Chun-hsiung ShihAbstract:This study investigated the release of antibiotics in vivo, from an articulating polymethylmethacrylate (PMMA) spacer used in Two-Stage Revision arthroplasty of infected hip implants. Forty-six patients who underwent Two-Stage Revision hip arthroplasty for infections were managed with an interim PMMA spacer loaded with a high dose of vancomycin and aztreonam. Serum and aliquots of drainage collected after the first-stage surgery, and joint fluid obtained at the time of the second-stage surgery were analyzed for antibiotic concentrations by high performance liquid chromatography and bioactivity by tube dilution bioassay. Following implantation, the highest levels of antibiotics were measured in aliquots of drainage on the first day (vancomycin: 1538.0 +/- 243.6 microg/mL; aztreonam: 1003.5 +/- 323.5 microg/mL), decreasing to 571.9 +/- 169.4 microg/mL for vancomycin and 313.6 +/- 88.3 microg/mL for aztreonam after 7 days. Antibiotic concentrations in serum were very low (vancomycin: 0.58 +/- 0.2 microg/mL, range: 0.1-1.6 microg/mL; aztreonam: 0.46 +/- 0.3 microg/mL, range: 0.1-0.9 microg/mL at 24 h) and there was no systemic adverse effect. At a mean 107 days after the first-stage surgery, the concentrations of antibiotics in joint fluid were well above the minimal inhibitory concentration of most common microorganisms. The released antibiotics were bioactive against the test organisms. Based on the observed results, we confirmed the safety and effectiveness of in vivo drug delivery from antibiotic-impregnated PMMA hip spacers.
-
treatment of deep infection of the hip associated with massive bone loss two stage Revision with an antibiotic loaded interim cement prosthesis followed by reconstruction with allograft
Journal of Bone and Joint Surgery-british Volume, 2005Co-Authors: Pang Hsin Hsieh, Mel S. Lee, Wen E. Yang, Chun-hsiung Shih, Yu-han Chang, Hsinnung ShihAbstract:We have carried out in 24 patients, a Two-Stage Revision arthroplasty of the hip for infection with massive bone loss. We used a custom-made, antibiotic-loaded cement prosthesis as an interim spacer. Fifteen patients had acetabular deficiencies, eight had segmental femoral bone loss and one had a combined defect.There was no recurrence of infection at a mean follow-up of 4.2 years (2 to 7). A total of 21 patients remained mobile in the interim period. The mean Merle D’Aubigne and Postel hip score improved from 7.3 points before operation to 13.2 between stages and to 15.8 at the final follow-up. The allograft appeared to have incorporated into the host bone in all patients. Complications included two fractures and one dislocation of the cement prosthesis.The use of a temporary spacer maintains the function of the joint between stages even when there is extensive loss of bone. Allograft used in Revision surgery after septic conditions restores bone stock without the risk of recurrent infection.
Young-min Kwon - One of the best experts on this subject based on the ideXlab platform.
-
elevated esr and crp prior to second stage reimplantation knee Revision surgery for periprosthetic joint infection are associated with increased reinfection rates
Journal of Knee Surgery, 2021Co-Authors: Christian Klemt, Anand Padmanabha, John G Esposito, Samuel Laurencin, Evan J Smith, Young-min KwonAbstract:PURPOSE Although Two-Stage Revision surgery is considered as the most effective treatment for managing chronic periprosthetic joint infection (PJI), there is no current consensus on the predictors of optimal timing to second-stage reimplantation. This study aimed to compare clinical outcomes between patients with elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) prior to second-stage reimplantation and those with normalized ESR and CRP prior to second-stage reimplantation. METHODS We retrospectively reviewed 198 patients treated with Two-Stage Revision total knee arthroplasty for chronic PJI. Cohorts included patients with: (1) normal level of serum ESR and CRP (n = 96) and (2) elevated level of serum ESR and CRP prior to second-stage reimplantation (n = 102). Outcomes including reinfection rates and readmission rates were compared between both cohorts. RESULT At a mean follow-up of 4.4 years (2.8-6.5 years), the elevated ESR and CRP cohort demonstrated significantly higher reinfection rates compared with patients with normalized ESR and CRP prior to second-stage reimplantation (33.3% vs. 14.5%, p < 0.01). Patients with both elevated ESR and CRP demonstrated significantly higher reinfection rates, when compared with patients with elevated ESR and normalized CRP (33.3% vs. 27.6%, p = 0.02) as well as normalized ESR and elevated CRP (33.3% vs. 26.3%, p < 0.01). CONCLUSION This study demonstrates that elevated serum ESR and/or CRP levels prior to reimplantation in Two-Stage knee Revision surgery for chronic PJI are associated with increased reinfection rate after surgery. Elevation of both ESR and CRP were associated with a higher risk of reinfection compared with elevation of either ESR or CRP, suggesting the potential benefits of normalizing ESR and CRP prior to reimplantation in treatment of chronic PJI.
-
elevated esr and crp prior to second stage reimplantation knee Revision surgery for periprosthetic joint infection are associated with increased reinfection rates
Journal of Knee Surgery, 2021Co-Authors: Christian Klemt, Anand Padmanabha, John G Esposito, Samuel Laurencin, Evan J Smith, Young-min KwonAbstract:Purpose Although Two-Stage Revision surgery is considered as the most effective treatment for managing chronic periprosthetic joint infection (PJI), there is no current consensus on the predictors of optimal timing to second-stage reimplantation. This study aimed to compare clinical outcomes between patients with elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) prior to second-stage reimplantation and those with normalized ESR and CRP prior to second-stage reimplantation. Methods We retrospectively reviewed 198 patients treated with Two-Stage Revision total knee arthroplasty for chronic PJI. Cohorts included patients with: (1) normal level of serum ESR and CRP (n = 96) and (2) elevated level of serum ESR and CRP prior to second-stage reimplantation (n = 102). Outcomes including reinfection rates and readmission rates were compared between both cohorts. Result At a mean follow-up of 4.4 years (2.8–6.5 years), the elevated ESR and CRP cohort demonstrated significantly higher reinfection rates compared with patients with normalized ESR and CRP prior to second-stage reimplantation (33.3% vs. 14.5%, p Conclusion This study demonstrates that elevated serum ESR and/or CRP levels prior to reimplantation in Two-Stage knee Revision surgery for chronic PJI are associated with increased reinfection rate after surgery. Elevation of both ESR and CRP were associated with a higher risk of reinfection compared with elevation of either ESR or CRP, suggesting the potential benefits of normalizing ESR and CRP prior to reimplantation in treatment of chronic PJI.
-
one stage Revision is as effective as two stage Revision for chronic culture negative periprosthetic joint infection after total hip and knee arthroplasty
Journal of Bone and Joint Surgery-british Volume, 2021Co-Authors: Janna Van Den Kieboom, Christian Klemt, Venkatsaiakhil Tirumala, Hayden N Box, Ruben Oganesyan, Young-min KwonAbstract:Aims Removal of infected components and culture-directed antibiotics are important for the successful treatment of chronic periprosthetic joint infection (PJI). However, as many as 27% of chronic P...
-
Comparison of one-stage Revision with antibiotic cement versus Two-Stage Revision results for infected total hip arthroplasty.
The Journal of Arthroplasty, 2013Co-Authors: Ho-rim Choi, Young-min Kwon, Andrew A. Freiberg, Henrik MalchauAbstract:Eighty three patients of infected total hip arthroplasty (THA) treated by implant removal and staged Revision were retrospectively analyzed. Clinical characteristics and treatment outcomes were compared between three groups: 17 one-stage Revisions (one-stage group), 44 Two-Stage Revisions with second stage reimplantation (Two-Stage reimplanted group), and 22 planned Two-Stage but no reimplantation (Two-Stage non-reimplanted group). The rate of infection control was 82% (14/17) in the one-stage group, 75% (33/44) in the Two-Stage reimplanted group, and 68% (15/22) in the Two-Stage non-reimplanted group (P=0.60). The mean of latest Harris hip score was 77, 60, and 58 (P=0.14), and the UCLA activity score was 4.0, 4.2, and 3.6 (P=0.74) for each group, respectively. Results of this study suggest that one-stage Revision arthroplasty can be a treatment option in selected cases of infected THA with a satisfactory infection control rate and functional outcomes comparable to those of Two-Stage Revision.
-
utility of tibial tubercle osteotomy in the setting of periprosthetic infection after total knee arthroplasty
International Orthopaedics, 2012Co-Authors: Ho-rim Choi, Henrik Malchau, Dennis W Burke, Young-min KwonAbstract:Purpose This study reports radiographic and clinical treatment outcomes of tibial tubercle osteotomy (TTO) used for Two-Stage Revision total knee arthroplasty (TKA) in the setting of periprosthetic infection.
Chun-hsiung Shih - One of the best experts on this subject based on the ideXlab platform.
-
high concentration and bioactivity of vancomycin and aztreonam eluted from simplex cement spacers in two stage Revision of infected hip implants a study of 46 patients at an average follow up of 107 days
Journal of Orthopaedic Research, 2006Co-Authors: Pang Hsin Hsieh, Yu-han Chang, Shihhao Chen, Steve W N Ueng, Chun-hsiung ShihAbstract:This study investigated the release of antibiotics in vivo, from an articulating polymethylmethacrylate (PMMA) spacer used in Two-Stage Revision arthroplasty of infected hip implants. Forty-six patients who underwent Two-Stage Revision hip arthroplasty for infections were managed with an interim PMMA spacer loaded with a high dose of vancomycin and aztreonam. Serum and aliquots of drainage collected after the first-stage surgery, and joint fluid obtained at the time of the second-stage surgery were analyzed for antibiotic concentrations by high performance liquid chromatography and bioactivity by tube dilution bioassay. Following implantation, the highest levels of antibiotics were measured in aliquots of drainage on the first day (vancomycin: 1538.0 +/- 243.6 microg/mL; aztreonam: 1003.5 +/- 323.5 microg/mL), decreasing to 571.9 +/- 169.4 microg/mL for vancomycin and 313.6 +/- 88.3 microg/mL for aztreonam after 7 days. Antibiotic concentrations in serum were very low (vancomycin: 0.58 +/- 0.2 microg/mL, range: 0.1-1.6 microg/mL; aztreonam: 0.46 +/- 0.3 microg/mL, range: 0.1-0.9 microg/mL at 24 h) and there was no systemic adverse effect. At a mean 107 days after the first-stage surgery, the concentrations of antibiotics in joint fluid were well above the minimal inhibitory concentration of most common microorganisms. The released antibiotics were bioactive against the test organisms. Based on the observed results, we confirmed the safety and effectiveness of in vivo drug delivery from antibiotic-impregnated PMMA hip spacers.
-
treatment of deep infection of the hip associated with massive bone loss two stage Revision with an antibiotic loaded interim cement prosthesis followed by reconstruction with allograft
Journal of Bone and Joint Surgery-british Volume, 2005Co-Authors: Pang Hsin Hsieh, Mel S. Lee, Wen E. Yang, Chun-hsiung Shih, Yu-han Chang, Hsinnung ShihAbstract:We have carried out in 24 patients, a Two-Stage Revision arthroplasty of the hip for infection with massive bone loss. We used a custom-made, antibiotic-loaded cement prosthesis as an interim spacer. Fifteen patients had acetabular deficiencies, eight had segmental femoral bone loss and one had a combined defect.There was no recurrence of infection at a mean follow-up of 4.2 years (2 to 7). A total of 21 patients remained mobile in the interim period. The mean Merle D’Aubigne and Postel hip score improved from 7.3 points before operation to 13.2 between stages and to 15.8 at the final follow-up. The allograft appeared to have incorporated into the host bone in all patients. Complications included two fractures and one dislocation of the cement prosthesis.The use of a temporary spacer maintains the function of the joint between stages even when there is extensive loss of bone. Allograft used in Revision surgery after septic conditions restores bone stock without the risk of recurrent infection.
-
two stage Revision hip arthroplasty for infection comparison between the interim use of antibiotic loaded cement beads and a spacer prosthesis
Journal of Bone and Joint Surgery American Volume, 2004Co-Authors: Pang Hsin Hsieh, Chun-hsiung Shih, Yu-han Chang, Hsinnung Shih, Wen E. YangAbstract:Background: A Two-Stage Revision is a well-accepted method for the treatment of a deep infection of a hip with a joint implant. In the present study, the results associated with the interim use of antibiotic-loaded cement beads were compared with those associated with the interim use of an antibiotic-loaded cement prosthesis. Methods: One hundred and twenty-eight consecutive patients who were managed with a Two-Stage Revision hip arthroplasty for the treatment of an infection were followed clinically and radiographically for an average of 4.9 years. Cement beads were implanted following resection arthroplasty in the first seventy hips, and a custom cement prosthesis was implanted in the subsequent fifty-eight hips. Results: There was no evidence of recurrent infection in 122 patients (95.3%); the infection-free rates in both groups were similar. The use of a spacer prosthesis was associated with a higher hip score, a shorter hospital stay, and better walking capacity in the interim period; a decreased operative time, less blood loss, and a lower transfusion requirement at the time of reimplantation; and fewer postoperative dislocations. Conclusions: The present study supports the safety and efficacy of the routine use of an antibiotic-loaded cement prosthesis in the interim between the stages of a Two-Stage Revision procedure for the treatment of an infection at the site of a hip arthroplasty. Level of Evidence: Therapeutic study, Level III-2 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.
-
Two-Stage Revision hip arthroplasty for infection with a custom-made, antibiotic-loaded, cement prosthesis as an interim spacer
Journal of Trauma - Injury Infection and Critical Care, 2004Co-Authors: Pang Hsin Hsieh, Chi Hwa Chen, Mel S. Lee, Wen E. Yang, Lih-huei Chen, Chun-hsiung ShihAbstract:BACKGROUND: Two-Stage reconstruction is a well-recognized treatment for deep infection of hip joint implants. The purpose of the study was to report the results of our treatment using a standardized protocol. METHODS: Forty-two consecutive patients with deep infection of the hip prosthesis were treated according to a prospective, Two-Stage resection/reimplantation protocol. Between stages, a custom-made, antibiotic-loaded, cement prosthesis was implanted as an interim spacer. RESULTS: Infection was eradicated in 41 patients after the first-stage operation. Thirty-six patients remained with the ability to walk with the interim cement pros-thesis. For 40 patients who underwent reimplantation, recurrence of infection was observed in only 1 patient at an average of 55.2 months' follow-up. CONCLUSION: We have found that our Two-Stage treatment protocol is a reliable approach for the management of infected hip prostheses. It is effective for eradicating infection and for providing a mobile and functional joint through the treatment course.
H Pandit - One of the best experts on this subject based on the ideXlab platform.
-
single or two stage Revision for infected total hip arthroplasty a systematic review of the literature
Clinical Orthopaedics and Related Research, 2014Co-Authors: Hugh A C Leonard, Alexander D Liddle, Orlaith Burke, D W Murray, H PanditAbstract:Background The best approach for surgical treatment of an infected THA remains controversial. Two-Stage Revision is believed to result in lower reinfection rates but may result in significant functional impairment. Some authors now suggest that single-stage Revision may provide comparable results in terms of infection eradication while providing superior functional outcomes.
-
Revision anterior cruciate ligament reconstruction using a 2 stage technique with bone grafting of the tibial tunnel
American Journal of Sports Medicine, 2005Co-Authors: N P Thomas, Raghu Kankate, Felicity Wandless, H PanditAbstract:BackgroundRevision anterior cruciate ligament surgery is often considered a salvage procedure with limited goals. However, this limitation need not be the case. Similar to primary reconstruction, the goal should be to choose an appropriate graft and place it in an anatomical position in a good quality bone. The issue of good quality bone seems to have been ignored.HypothesisA 2-stage anterior cruciate ligament Revision reconstruction with bone grafting of the tibial tunnel and the use of a different femoral tunnel will produce measured knee laxity and International Knee Documentation Committee scores similar to a primary anterior cruciate ligament reconstruction.Study DesignCase control study; Level of evidence, 3.MethodsThis prospective study involved 49 consecutive 2-stage anterior cruciate ligament Revisions (group R) performed by a single surgeon from 1993 to 2000. Two-Stage Revision surgery was performed if the tibial tunnel from a previous reconstruction surgery would overlap (either partially or fu...
Ashley W Blom - One of the best experts on this subject based on the ideXlab platform.
-
one and two stage surgical Revision of infected elbow prostheses following total joint replacement a systematic review
BMC Musculoskeletal Disorders, 2019Co-Authors: Setor K Kunutsor, Michael R Whitehouse, Ashley W Blom, Andrew D BeswickAbstract:Prosthetic joint infection (PJI) is a challenging complication of total elbow replacement (TER). Potential surgical treatments include one- or Two-Stage Revision; however, the best treatment for elbow PJI is not clearly defined. We conducted a systematic review in accordance with PRISMA guidelines to compare the clinical effectiveness of one- and Two-Stage Revision surgery for elbow PJI using re-infection (recurrent and new infections) rates; mortality; clinical measures of function, pain, and satisfaction; and non-infection related adverse events. MEDLINE, Embase, Web of Science, and The Cochrane Library were searched up to June 2019 to identify observational cohort studies and randomised controlled trials (RCTs) that had recruited patients with elbow PJI following TER and treated with one- or Two-Stage Revision. Of 96 retrieved articles, 2 one-stage and 6 Two-Stage Revision studies were eligible. No RCT was identified. Arcsine transformation was used in estimating rates with 95% confidence intervals (CIs). Staphylococcus aureus was the most common causative organism for PJI of the elbow (24 of 71 elbow PJIs). The re-infection rate (95% CI) for one-stage (7 elbows) ranged from 0.0% (0.0–79.3) to 16.7% (3.0–56.4) and that for Two-Stage Revision (87 elbows) from 0.0% (0.0–49.0) to 20.0% (3.6–62.4). Non-infection related adverse event rate for one-stage (based on a single study) was 16.7% (3.0–56.4) and that for Two-Stage ranged from 11.8% (4.7–26.6) to 20.0% (3.6–62.4). There were no mortality events recorded following one- or Two-Stage Revision surgery and postoperative clinical measures of function, pain, and satisfaction could not be effectively compared because of limited data. No strong conclusions can be drawn because of limited data. The one-stage Revision may be potentially at least as clinically effective as Two-Stage Revision, but further data is needed. There are clear gaps in the existing literature and studies are urgently warranted to assess the clinical effectiveness of one- and Two-Stage Revision strategies for PJI following TER. PROSPERO 2018: CRD42018118002 .
-
one and two stage surgical Revision of infected shoulder prostheses following arthroplasty surgery a systematic review and meta analysis
Scientific Reports, 2019Co-Authors: Setor K Kunutsor, Michael R Whitehouse, Andrew D Beswick, Vikki Wylde, Ashley W BlomAbstract:Periprosthetic joint infection (PJI) is a catastrophic complication of shoulder arthroplasty. Commonly used surgical treatments include one- or Two-Stage Revision, but their effectiveness in controlling infection is uncertain. We aimed to compare re-infection (recurrent and new infections) rates; clinical measures of function and pain; and noninfection complication rates of one- and Two-Stage Revision surgery for shoulder PJI using a systematic review and meta-analysis. We searched MEDLINE, Embase, Web of Science, and The Cochrane Library to February 2018. Longitudinal studies conducted in patients with shoulder PJI treated exclusively by one- or Two-Stage Revision were eligible. No clinical trials were identified. Re-infection rates were meta-analysed using random-effect models after arcsine transformation. The re-infection rate (95% CI) in pooled analysis of eight one-stage studies (147 participants) was 5.3% (1.4–10.6). The corresponding rate for 27 Two-Stage studies (351 participants) was 11.5% (6.0–18.1). Postoperative clinical measures of function and pain were not significantly different between the two Revision strategies. The pooled noninfection complication rate (95% CI) for one-stage and Two-Stage Revision was 12.1% (6.1–19.5) and 18.9% (8.4–31.9) respectively. New evidence suggests one-stage Revision is at least equally as effective as the Two-Stage in controlling infection, maintaining joint function, and improving complications in shoulder PJI.
-
managing uncertainty surgeons decision making for one stage and two stage Revision arthroplasty for prosthetic joint infection
Orthopaedic Proceedings, 2018Co-Authors: Andrew Moore, Michael R Whitehouse, Ashley W Blom, Rachael GoobermanhillAbstract:Around 1% of total hip replacements are follow by prosthetic joint infection (PJI). There is uncertainty about best treatment method for PJI, and the most recent high quality systematic reviews in unselected patients indicates that re-infection rates following one-stage and Two-Stage Revision arthroplasty are relatively similar. In the absence of evidence randomised controlled trials will help to identify the most clinically and cost-effective treatment for PJI. Before such trials are conducted, there is a need to establish reasons for current practice and to identify whether trials are feasible. This study aimed to deliver research that would inform trial design. Specifically, we aimed to characterise consultant orthopaedic surgeons' decisions about performing either one-stage or Two-Stage exchange arthroplasty for patients with PJI after hip replacement and to identify whether a randomised trial comparing one-stage with Two-Stage Revision would be possible.Semi-structured interviews were conducted with ...
-
Managing uncertainty - a qualitative study of surgeons' decision-making for one-stage and Two-Stage Revision surgery for prosthetic hip joint infection.
BMC musculoskeletal disorders, 2017Co-Authors: Andrew Moore, Michael R Whitehouse, Ashley W Blom, Rachael Gooberman-hillAbstract:Approximately 88,000 primary hip replacements are performed in England and Wales each year. Around 1% go on to develop deep prosthetic joint infection. Between one-stage and Two-Stage Revision arthroplasty best treatment options remain unclear. Our aims were to characterise consultant orthopaedic surgeons' decisions about performing either one-stage or Two-Stage Revision surgery for patients with deep prosthetic infection (PJI) after hip arthroplasty, and to identify whether a randomised trial comparing one-stage with Two-Stage Revision would be feasible. Semi-structured interviews were conducted with 12 consultant surgeons who perform Revision surgery for PJI after hip arthroplasty at 5 high-volume National Health Service (NHS) orthopaedic departments in England and Wales. Surgeons were interviewed before the development of a multicentre randomised controlled trial. Data were analysed using a thematic approach. There is no single standardised surgical intervention for the treatment of PJI. Surgeons balance multiple factors when choosing a surgical strategy which include multiple patient-related factors, their own knowledge and expertise, available infrastructure and the infecting organism. Surgeons questioned whether it was appropriate that the Two-Stage Revision remained the best treatment, and some surgeons' willingness to consider more one-stage Revisions had increased over recent years and were influenced by growing evidence showing equivalence between surgical techniques, and local observations of successful one-stage Revisions. Custom-made articulating spacers was a practice that enabled uncertainty to be managed in the absence of definitive evidence about the superiority of one surgical technique over the other. Surgeons highlighted the need for research evidence to inform practice and thought that a randomised trial to compare treatments was needed. Most surgeons thought that patients who they treated would be eligible for trial participation in instances where there was uncertainty about the best treatment option. Surgeons highlighted the need for evidence to support their choice of Revision. Some surgeons' willingness to consider one-stage Revision for infection had increased over time, largely influenced by evidence of successful one-stage Revisions. Custom-made articulating spacers also enabled surgeons to manage uncertainty about the superiority of surgical techniques. Surgeons thought that a prospective randomised controlled trial comparing one-stage with Two-Stage joint replacement is needed and that randomisation would be feasible.
-
managing uncertainty surgeons decision making for one stage and two stage Revision arthroplasty for prosthetic joint infection
Journal of Bone and Joint Surgery-british Volume, 2017Co-Authors: Andrew Moore, Michael R Whitehouse, Ashley W Blom, Rachael GoobermanhillAbstract:Around 1% of total hip replacements are follow by prosthetic joint infection (PJI). There is uncertainty about best treatment method for PJI, and the most recent high quality systematic reviews in unselected patients indicates that re-infection rates following one-stage and Two-Stage Revision arthroplasty are relatively similar. In the absence of evidence randomised controlled trials will help to identify the most clinically and cost-effective treatment for PJI. Before such trials are conducted, there is a need to establish reasons for current practice and to identify whether trials are feasible. This study aimed to deliver research that would inform trial design. Specifically, we aimed to characterise consultant orthopaedic surgeons' decisions about performing either one-stage or Two-Stage exchange arthroplasty for patients with PJI after hip replacement and to identify whether a randomised trial comparing one-stage with Two-Stage Revision would be possible. Semi-structured interviews were conducted with 12 consultant surgeons from 5 high-volume National Health Service (NHS) orthopaedic departments in the UK. Surgeons were sampled on the basis that they perform Revision surgery for PJI after hip arthroplasty and final sample size was justified on the basis of thematic saturation. Surgeons were interviewed face-to-face (n=2) or via telephone (n=10). The interview study took place before design of a multicentre prospective randomised controlled trial comparing patient and clinical outcomes after one-stage or Two-Stage Revision arthroplasty. Data were audio-recorded, transcribed, anonymised and analysed using a thematic approach, with 25% of transcripts independently double-coded. Results: There is no standard surgical response to the treatment of PJI and surgeons manage a complex balance of factors when choosing a surgical strategy. These include multiple patient-related factors, their own knowledge and expertise, available infrastructure and the infecting organism. Surgeons questioned whether evidence supports the emergence of Two-Stage Revision as a method. They described the use of loosely cemented articulating spacers as a way of managing uncertainty about best treatment method. All surgeons were supportive of a randomised trial to compare one-stage and Two-Stage Revision surgery for PJI after hip replacement. Surgeons reported that they would put patients forward for randomisation when there was uncertainty about best treatment. Surgeons highlighted the need for evidence to support their choice of Revision. Some surgeons now use Revision methods that can better address both clinical outcomes and patients' quality of life, such as loosely cemented articulating spacers. Surgeons thought that a randomised controlled trial comparing one-stage and Two-Stage exchange joint replacement is needed and that randomisation would be feasible. The next stage of the work was to design a multi-centre randomised controlled trial, this has been achieved and the trial is now ongoing in the UK.
