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Hip: J. P. Whittaker, R. E. Warren, R. S. Jones, and P. A. Gregson Is prolonged systemic antibiotic treatment essential in two-stage revision hip replacement for chronic Gram-positive infection? J Bone Joint Surg Br 2009; 91-B: 44-51 [Abstract] [Full text] [PDF]

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Prolonged systemic antibiotics in revision hip surgery

Ian Stockley, Robert Kerry   (13 February 2009)

Prolonged systemic antibiotics in revision hip surgery

Samer S Morgan, United Kingdom   (5 February 2009)

Prolonged systemic antibiotics in revision hip surgery 13 February 2009
Ian Stockley, Consultant Orthopaedic Surgeon Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Robert Kerry Send letter to journal: Re: Prolonged systemic antibiotics in revision hip surgery ian.stockley{at}sth.nhs.uk Ian Stockley, et al.	Sir, We read this paper with interest. In the introductory section, the authors refer to three articles from our unit in Sheffield, all previously published in the JBJS, and appear to have misinterpreted our results using a technique of radical debridement, local depot and no prolonged systemic antibiotics. In their paper, Whittaker et al say, "others…have reported poor results with no systemic treatment in combination with an antibiotic eluting system" and reference four papers: · The first is from the Endo Klinik1 and refers to single-stage procedures for infection. Whittaker et al were managing their patients by a two-stage procedure so the comparison is not applicable. · The second paper, by Hoad-Reddick et al2, quotes a success rate for eradication of infection of 89% in 59 patients. · The third paper, by Stockley et al3, quotes success in 88% of 114 patients. · Finally, Taggart et al2, quote success in 32 of 33 patients (97%). We find it difficult to see how the authors regard our results from these three series as being poor. We see no evidence that their technique using adjuvant intravenous antibiotics with a success rate of 93% in 41 cases gives superior results. Surely these results are essentially the same? We look forward to a response. I. Stockley, Consultant Orthopaedic Surgeon, R.M. Kerry, Northern General Hospital, Sheffield, UK. 1. Buchholz HW, Elson RA, Engelbrecht E, et al. Management of deep infection of total hip replacement. J Bone Joint Surg [Br] 1981;63-B:342-53. 2. Hoad-Reddick DA, Evans CR, Norman P, Stockley I. Is there a role for extended antibiotic therapy in a two-stage revision of the infected knee arthroplasty? J Bone Joint Surg [Br] 2005;87-B:171-4. 3. Stockley I, Mockford BJ, Hoad-Reddick A, Norman P. The use of two-stage exchange arthroplasty with depot antibiotics in the absence of long-term antibiotic therapy in infected total hip replacement. J Bone Joint Surg [Br] 2008;90-B:145-8. 4. Taggart T, Kerry RM, Norman P, Stockley I. The use of vancomycin-impregnated cement beads in the management of infection of prosthetic joints. J Bone Joint Surg [Br] 2002;84-B:70-2.
Prolonged systemic antibiotics in revision hip surgery 5 February 2009
Samer S Morgan, Orthopaedic Registrar Worthing Hospital, United Kingdom Send letter to journal: Re: Prolonged systemic antibiotics in revision hip surgery samermogan{at}yahoo.com Samer S Morgan, et al.	Sir, I read this paper interest. This is an important topic and very relevant to our practice. Three of the 14 patients who had a history of alterations in their immune status developed infection following the second stage. Do the authors think that those patients with altered immune status require a prolonged period of systemic antibiotics? Salvati et al1 showed that it is very difficult to eradicate gram negative organisms and will require an intensive course of IV antibiotics for six weeks. In their paper the authors mentioned that successful elimination of organisms occurred in 38 hips. Three patients required further debridement after the initial operation because of persistent elevation of the inflammatory markers. The authors included those patients among those who had a successful outcome and in my opinion they should be included among the unsuccessful ones. The mean pre-operative Merle D’Aubigné and Postel score was improved from 7.2 (4 to 16) to 11.4 (8 to 16) at a median follow-up of 49 months (25 to 83). No statistical tests were used to show the significance of this improvement. I think a shortened course of systemic antibiotics in revision surgery should be used with caution, particularly in the immune-compromised patients. S.S. Morgan, Orthopaedic Registrar, Worthing Hospital, Worthing, West Sussex, UK. 1. Salvati EA, Chekofsky KM, Brause BD, Wilson PD Jr. Reimplantation in infection: a 12-year experience. Clin Orth 1982;170:62-75.