The use of physical methods in the comprehensive strategy of the sanitation stage of revision arthroplasty for deep periprosthetic infection of the hip joint

Authors:

Linnik Stanislav Antonovich – Grand PhD in Medical sciences (Dr. Med. Sci.), Professor of the Department of Traumatology, Orthopedics and Military Field Surgery, North-Western State Medical University named after I.I. Mechnikov, 47 Piskarevsky Ave, 195067 St. Petersburg, Russian Federation; e-mail: stanislavlinnik@mail.ru; https://orcid.org/0000-0002-1360-6971.

Korshunov Dmitry Yuryevich – Head of the Department of Traumatology and Orthopedics N 1, Federal State Budgetary Institution “Federal Center for Traumatology, Orthopedics and Endoprosthetics”, 29 Stroiteley Ave, 214019 Smolensk, Russian Federation; e-mail: dmi02041976@yandex.ru; https://orcid.org/0009-0005-9819-0598.

Ovsyankin Anatoly Vasilievich –PhD in Medical sciences (Cand. Med. Sci.), Chief Physician, Federal State Budgetary Institution “Federal Center for Traumatology, Orthopedics and Endoprosthetics”, 29 Stroiteley Ave, 214019 Smolensk, Russian Federation, e-mail: dmi02041976@yandex.ru.

Sokurova Alla Mikhailovna – PhD in Biological sciences (Cand. Bio. Sci.), Associate Professor, Associate Professor of the Department of Microbiology, Virology and Immunology, Saint Petersburg State Pediatric Medical University of the Ministry of Health of the Russian Federation, 2 Litovskaya St., 194100 St. Petersburg, Russian Federation; e-mail: amsokurova@gmail.com.

Orishak Elena Aleksandrovna –PhD in Medical sciences (Cand. Med. Sci.), Associate Professor, Department of Medical Microbiology, North-Western State Medical University named after I.I. Mechnikov, Ministry of Healthcare of the Russian Federation, 47 Piskarevsky Ave, 195067 St. Petersburg, Russian Federation; e-mail: Elena.Orishak@szgmu.ru; https://orcid.org/0000–0002–4562–4402.

Tsololo Yaroslav Borisovich – Assistant, Department of Traumatology, Orthopedics and Military Field Surgery, North-Western State Medical University named after I.I. Mechnikov, Ministry of Healthcare of the Russian Federation, Piskarevsky Prospekt, 47, 195067 St. Petersburg, Russian Federation; e-mail: yaroslav.tsololo@gmail.com; https://orcid.org/0000-0001-7744-0002.

Sergeeva Marina Borisovna – PhD in Medical sciences (Cand. Med. Sci.), Head of the Department of Traumatology and Orthopedics, Albrecht Federal Scientific Center for Medical and Social Expertise and Rehabilitation, 50 Bestuzhevskaya Street, 195067 St. Petersburg, e-mail: marina.hairulova@yandex.ru. Metalichenko Egor Sergeevich– student, North-Western State Medical University named after I.I. Mechnikov, 47 Piskarevsky Ave, 195067 St. Petersburg, Russian Federation; e-mail: window1246@mail.ru; https://orcid.org/0009-0008-7837-9467.

Bubnov Valery Valerievich – resident of the Department of Emergency Medical Care, North-Western State Medical University named after I.I. Mechnikov, 47 Piskarevsky Ave, 195067 St. Petersburg, Russian Federation; e-mail: super.homerlo2012@yandex.ru; https://orcid.org/ 0009-0005-5751-2255.

Likhachev Yan Valerievich – student, North-Western State Medical University named after I.I. Mechnikov, Ministry of Healthcare of the Russian Federation, Piskarevsky Prospekt, 47, 195067 St. Petersburg, Russian Federation; e-mail: stanislavlinnik@mail.ru.

Annotation:

Introduction. Currently, there is no unified approach to the management of periprosthetic joint infection. The gold standard for treating patients with periprosthetic joint infection is a two-stage revision proposed by J.N. Insall in 1983. The success rate of this two-stage approach ranges from 89 % to 100 %. Considering that recently the causative agents of PJI are often multidrug-resistant microorganisms, new physical wound sanitation methods—such as high-temperature argon plasma and ultrasonic wound cavitation—are gaining importance in treatment.

Aim. To improve the outcomes of the sanitation stage of revision arthroplasty by using physical wound sanitation methods and targeted long-acting antibacterial therapy.

Materials and methods. We analyzed the treatment of 154 patients with hip periprosthetic joint infection aged 37 to 81 years. The study included patients with confirmed signs of deep periprosthetic hip infection. Diagnosis of periprosthetic joint infection involved clinical, laboratory, and radiographic evaluations in two projections, with additional CT, MRI, microbiological, hematological, and cytological tests as needed. All patients underwent the sanitation stage of revision arthroplasty. Depending on soft tissue condition, bone defects, and the patient’s general status, patients underwent two-stage revision arthroplasty with placement of either an articulating or block-type spacer, or hip arthrodesis. Based on the type of sanitation stage performed, patients were divided into three groups. In Group 1 (49 out of 154 patients, 31.8 %), the sanitation stage was performed using the traditional technique: removal of prosthesis components and placement of manually molded cement spacers with gentamicin. All patients in Groups 2 and 3 underwent the sanitation stage with the use of a long-acting antimicrobial composition for spacer fabrication, as well as physical wound treatment using a plasma scalpel, VERSAJET device, and ultrasonic wound cavitation.

Results. We analyzed the outcomes of the sanitation stage of revision arthroplasty over a follow-up period of 3 to 9 months. The data demonstrated the antibacterial efficacy of physical methods during the sanitation stage. For example, primary wound healing in Group 1 patients was significantly lower (p<0.05) at 59.2 % compared to 78.2 % in Group 3 and especially 86.0 % in Group 2. Conversely, recurrence of PJI in Group 1 was significantly higher (p<0.05) at 26.5 % compared to 12.7 % in Group 3 and 6.0 % in Group 2, indicating the effectiveness of using a plasma scalpel and ultrasonic cavitation during the sanitation stage.

Discussion. According to most authors, two-stage revision arthroplasty for hip periprosthetic joint infection is the treatment of choice, with an effectiveness of up to 90 %. Using articulating spacers achieves sustained infection remission rates of 80 % to 96 % and facilitates the definitive stage of reimplantation. However, recurrence of periprosthetic joint infection after the sanitation stage prompts surgeons to develop new spacer designs and antimicrobial compositions.

Conclusion. An individualized approach to the sanitation stage of revision arthroplasty for periprosthetic joint infection – taking into account bone defects, spacer selection, sanitation strategy, and patient condition – allows for a positive outcome in 96 % of cases, with satisfactory limb function restoration.

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