INFECTION WITH

AFTER

SPECIAL

REFERENCE V.

V.

The risk factors

associated

analysed Absence of

using

discharge associated The

mechanisms

regression

analysis

the

controversy

consider of the

associated

whether

late deep infection Aglietti etal. 1974; this

deep

FROM

L.

Hospital,

infection

deep

Franco, whereas discharge

from

The follow-up

infection

a consecutive

total

involved

hip

room or arises some authors source et al.

Salvati and Wilson 1973; etal. 1977; Wilson 1977). In we

were

extensively discharge

unable

to find

the association from the wound

any

between and the

infection.

in the

healing

PATIENTS

of the

AND

the risk factors infection after focused on the

operative

wound.

803 total hip in our clinic

replacements between

31

age

of the Most intervals.

patients patients A final

V. V. Surin, K. Sundholm, Ortopediska Sweden.

MD, Orthopaedic Surgeon MD, Orthopaedic Surgeon Kliniken, Centrallasarettet,

,

1977,

METHODS

December

were

chosen

for this

study.

Box

850,

5-501

97 total the study living to The primary

for reprints British

The

mean

15

Bor#{225}s,

Development,

should

Editorial $2.00

be sent

Society

to Dr V. V. Surin.

of Bone

and

Joint

Surgery

Fack,

5-462

interrelated

risk

together,

in

71

and

other

of the hip or epiphyseolysis in 55, post-traumatic changes

diagnoses

in

eight.

In

on the indications 33 failed hemiarthroplasties procedures.

without

first 1 1 3 total hip antibiotic prophylaxis;

phylaxis Lidgren

according to the method and Lindberg (1977)

defined (Lidwell

Multiple

their effect

answered by 609 patients with We also registered all revision joint for the 86 patients with

dislocation arthritis

previously operated replacement were failed extra-articular The

factors.

potentiate

hip replacements who had died in the course of period. The shortest follow-up for all patients the end of the study was three years. diagnoses for the hip operation were as follows: osteoarthritis in 587 hips, osteoarthritis second-

ary to congenital in 82, rheumatoid

replacements routine described was used

the for

145

hips

total joint and 1 12

were antibiotic

done pro-

by Carlsson, in the 690

operations. infection after total hip replacement was as periprosthetic sepsis which led to reoperation et al. 1982). The most important criteria

considered for the assessment of the presence of sepsis were isolation from the joint of potentially pathogenic micro-organisms (isolated in 28 cases), pus in the joint (observed

in

23

cases),

a

sinus

(17

cases),

raised

erythrocyte sedimentation rate when previously not raised (30 cases) and suggestive histological findings (in 21 out of the 24 cases with stained specimens available). Data analysis. To avoid statistical problems arising from the

Surgeon and System

V#{228}nersborg, Sweden.

030l-620X834071

412

performed on 695 March 1, 1970, and

was 64 years (range 32 to 8 1 years). were being followed up at regular review was made early in 1981 and

L. B#{228}ckman, MBA, Orthopaedic Department of Organisational

1983

hip replacements

total

3 to 10 years.

questionnaires were then 706 total hip replacements. procedures of the implanted

Deep

,

of803

from

when acting

subsequent

Requests

series

ranged

multiple

risk factors,

Baer and Enneking 1977; others did not observe any from the wound and the

(Aglietti, Freeman

controversy,

complications

01

WOUND

Bor#{226}s,Sweden

methods.

that these

after

The purpose of this paper is to study associated with the deep periprosthetic total hip replacement with the interest

The first patients

THE

BACKMAN

infections

wound as an important infection (McLauchlan

report studying more the early superficial late

with

in the operating of cross-infection,

the discharging late periprosthetic

of

actuarial

indicated of the deep infection.

is acquired as a result

1976; Muller 1976; Andrews et al. 1981), correlation between

spite

with 34 deep

standard

REPLACEMENT

DISCHARGE

SUNDHOLM,

the Central

of our data

on the development In

K.

A

HIP

prophylactic antibiotics, complications after operation, discharging wounds, previous and remote infection were related to the development of deep periprosthetic infection. An early from the wound with growth of micro-organisms, though superficial in appearance, proved to be with a high risk of developing late deep infection.

operations

replacement in the ward

TO

SURIN,

From

have been

TOTAL

differences

in the

length

of follow-up

of individual

total hip replacements we used standard actuarial methods for the statistical analysis (Breslow 1975 ; Dobbs 1980). The survival was measured from the date of insertion to the

date

of the THE

first

revision

JOURNAL

procedure. OF

BONE

AND

Life JOINT

tables

SURGERY

INFECTION Table I. Micro-organisms (percentages)

AFTER isolated

TOTAL

from

the

HIP wound

related

No prophylaxis

Micro-organism

were

computed

divided

into

The estimated ratio

of

observed The infection

ratio

presence The

Superficial discharge (n=31)

Deep infection (n=18)

Superficial

Deep

discharge (n=84)

infection (n=l6)

39

61

10

19

Staphylococcus

a/bus

19

22

17

6

Gram-negative

16

11

31

25

Other

23

6

14

31

Nogrowth

35

40

25

whole

deep risk (0)

of the factor significance

prosthetic

version

II

population

infection in a subgroup rate which was simply

to

organisms were cultivated Staphylococcus a/bus grew

to the risk factors.

expected

(E)

was the

number

of having

deep

infection

of

to that in the absence of the risk ratio

in the

of the factor. was tested by

means ofthe log rank test (Peto et a!. 1977). The program used for computations of regression and survival data was the Proportional Hazard Linear Procedure from the Statistical Analysis Inc.,

computer analysis General System,

79.5.

periprosthetic

infection

hip replacements.

In 10 cases

in the first three early deep infections

months started

haematomata, By definition, the fascia, heal during

in seven all nine

diagnosed

the infection

in 34 total was diagnosed

(early deep infection). Nine as spontaneously discharging

cases with haematomata

initially sterile extended

needed extensive surgical the first three weeks.

therapy

culture. beneath

and did not

annual

probability

slightly

of

from

the

during

the

for deep infection (Fig. 1).

seven were

for

of hips years

carried

deep

aureus

found in the discharging

varied

studied.

No

out after

the seventh

without

proven

None

of

periprosthetic

association

with

deep

infection The patient’s age and sex, cortisone treatment, diabetes, operation time, blood loss, perioperative complications, urethral catheterisation for more than 24 hours, temperature rise over 38 degrees day, extreme obesity, the surgeon operation did not show any with

deep

associated

discharge

was

periprosthetic

with

periprosthetic infection Early discharge from observed

infection.

the development

the operative

a

Celsius on the seventh and the indication for statistically significant

of deep

wound.

in 1 15 wounds.

A superficial By definition, all

these wounds were completely healed before first day without active surgical therapy. pathogenic micro-organisms were cultivated

the twentyPotentially from the

draining material in 70 wounds 45 wounds the draining material

(infected discharge). was sterile. According

to the surgeons’ assessment only of superficial inflammation. The hips which developed

32 wounds a superficial

showed

In

signs

discharge

year

was

the

most

deep infections wounds with

common as well positive

microas in the cultures.

time

the

or late) was Bacteriological

were taken during hip replacements 65-B,

factors

recovered.

developed

only

(Table

VOL.

never

18 wounds: 1 1 wounds,

reoperations

of the isolation of Staphylococcus aureus only by the use ofprophylactic antibiotics

I);

was

hip replacements

from from

infection,

at risk,

The frequency was influenced (early

Investigated

in samples in samples

2.0

Staphylococcus organism superficially

reoperation

number

aureus

these 160 total infection.

Factors was

In most of the 24 cases of late deep infection the symptoms developed insidiously and we were unable to find any certain date for the start of symptoms. The calculated

Staphylococcus

association RESULTS

Deep

regime

aureus

according

risk

prophylactic

Flucloxacilin

association between any risk factor and was estimated by the risk ratio, defined

of the

to the

Staphylococcus

the

risk of having as a relative

infections. the deep as the

for subgroups

413

REPLACEMENT

of manifestation

of deep

without influence. samples (opening the operations with antibiotic

No. 4, AUGUST

1983

infection

ILa LJ

cx

La

0

1.0

0 YEARS

and

closing

of 160 consecutive prophylaxis.

Fig.

swabs) total Micro-

5 SINCE OPERATION

The annual versus time

1

probability ofreoperation for deep infection as a percentage since operation. Bars represent standard error (the positive element only being shown).

10

414

V. V. SURIN, Table

II. Observed

numbers

of deep

infections

Factor

K. SUNDHOLM, and

risk

ratios

factor

Prophylactic

antibiotics

Complication Wound

after

discharge

Previous

operations

Remote

infection

Metal-on-plastic

prosthesis

Significance: These

5P