Orthopaedic Surgery for Infected Knee and Hip Joints

<p dir="ltr">Background: The infected joint is a devastating orthopaedic condition with significant morbidity and is potentially life-threatening. The knee and hip are the most commonly affected large joints in children and adults and these joints may be native or prosthetic. Various surgical options exist to treat them, each with differing outcomes. Literature directly comparing surgical treatments has been scarce or often confounded. Furthermore, comparisons frequently lack patient-centred outcomes, particularly joint function. The primary aim of this thesis was to directly compare the surgical treatments for infected knee and hip joints from childhood to adulthood.</p><p dir="ltr"><br></p><p dir="ltr">Materials and Methods: In section I, surgery for native joint infections is examined. Due to the low incidence of native joint infections, surgical treatments are assessed with retrospective comparative methodology for knees in children and adults. The paediatric patients with infected hip or knee joints were followed up to assess their long-term outcomes. In section II, surgery for prosthetic joint infections is compared. Treatments were compared using both retrospective comparison and then by application of a novel desirability of outcome ranking in a prospective analysis. Key outcomes throughout comparisons included joint function, infection cure and mortality.</p><p dir="ltr"><br></p><p dir="ltr">Results: Arthroscopic treatment had earlier functional recovery and less reoperations than open treatment for native joint infections in children. The long-term functional outcomes were similar following knee or hip septic arthritis in children. Arthroscopic surgery required less reoperations and had better postoperative range of motion than open surgery for native knee joint infections in adults. Conversely, for prosthetic knee joint infections, open debridement, antibiotics and implant retention (DAIR) was more effective than arthroscopic DAIR. The desirability of outcome ranking (DOOR) for prosthetic joint infections (PJI) was established by our international working group. Applying the DOOR showed that for early PJI, DAIR was superior to 2-stage exchange whilst for late PJI, 2-stage was superior to DAIR.</p><p dir="ltr"><br></p><p dir="ltr">Conclusion: When compared, the better surgical treatment for patients with acute native or prosthetic joint infection was the opposite. Patients with native joint septic arthritis had better surgical and functional outcomes following arthroscopic surgery. For patients with prosthetic joint infection, open surgery was superior. In the paediatric and adult population, arthroscopic surgery was more effective than open surgery. Long-term outcomes were similar for children with infected knee or hip joints. For prosthetic joint infections, the better surgical and functional outcomes again were opposite; the less extensive surgery, DAIR, was superior in early PJI while for late PJI, a complete 2-stage exchange was better than DAIR. This research provides evidence that the surgery which achieves the best patient outcomes differs depending on the type of joint infection throughout the different stages of life.</p>