CHARLOTTE, NC (OCRI) – New research out of OrthoCarolina Research Institute (OCRI) gives more treatment options to patients by changing how doctors approach periprosthetic joint infection (PJI), a rare, yet serious complication of joint replacement surgery.
“In orthopedic surgery, we’re largely dealing with quality-of-life problems. When infection is involved, it’s really a life and death problem,” OrthoCarolina’s Dr. Jesse Otero explains.
For the one to two percent of patients who develop this debilitating infection around an artificial joint, treatment has traditionally involved two surgeries referred to as a “two-stage” surgery. The infected implant is removed, the area is washed out, antibiotics are prescribed, and a second surgery is performed months later to place a new implant.
The latest research from the OrthoCarolina Hip and Knee Center and Prosthetic Joint Infection Center is expanding treatment options for these patients with a “one-stage” procedure.
Reflecting on the results of the decade-long study, OrthoCarolina’s Dr. Tom Fehring says, “I think it’s going to change care around the world.”
For years, the standard surgical intervention for PJI in the United States consists of those two-stage surgeries. One surgery to remove the joint and treat the infection and a second to replace the prosthetic joint three grueling months later. About ten years ago, physicians in Europe said they were performing this procedure in one, long surgery.
Dr. Fehring, having gone through two-stage surgery himself, started wondering alongside his peers, “If the results are about the same, why not do a one-stage?”
To figure out if the one-stage procedure stacked up to the respected two-stage standard of care, Dr. Fehring and OCRI put the two procedures to the test with support from an Orthopaedic Research and Education Foundation (OREF) grant.
Since a two-stage procedure was about 85-90% successful, physicians were hesitant to change their ways. “When we first started this, we were all nervous about it because we’d been trained to do two stages,” Fehring explains.
But in a first-of-its-kind prospective, randomized, and controlled research study to compare the success of one-stage vs two-stage exchange in treating and managing PJI the results were clear.
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OCRI’s results showed a 97% success rate with one-stage. In contrast, the two-stage was 91%.
Researchers designed the study to reflect real-world patients. That meant including various infection types and severity of complications. The findings were published in the Journal of Bone and Joint Surgery (JBJS) after extensive peer review.
With the research study going through 15 reviewers before going to print and eventually claiming the prestigious front cover of JBJS, Fehring says, “It’s one of the most scrutinized articles in orthopedics, and it survived that.”
“I think it’s going to change care around the world.”
By publishing an evidence-based study showing one-stage can save a patient from undergoing an unnecessary surgery, OCRI researchers hope this research saves patients valuable recovery time and financial strain that comes along with major surgery.
“It’s not so difficult to have those challenging discussions with patients anymore.” Dr. Otero explains. “I still talk to them about two-stage, but then I say, ‘listen, we’ve got this alternative option that’s brand new. We’ve got data to support it, and the results are phenomenal.’ I haven’t had a single patient who said, ‘I’ll take the two-stage, not a single one.’ And so patients really appreciate that effort as well.”
Treating a prosthetic joint infection requires more than surgery. Patients may need to receive care from a team of surgeons, infectious disease specialists, internists, nurses, rehabilitation care, and specialized operating-room teams.
Countries in Europe have designated infection centers for joint infection patients. OrthoCarolina was inspired by this specialized approach and founded the OrthoCarolina Periprosthetic Joint Infection Center. That team treats more infection patients, through referrals, than anyone else in the Southeast. With that volume of patients, researchers put groundbreaking treatment plans to the test daily.
But they aren’t stopping with just one center in Charlotte. The team hopes to train and encourage physicians in every state across the United States to open their own specialized centers as well.
“A majority of the patients that we see had attempted care somewhere else,” Otero says. “And it sure would be nice to have a network of centers with formalized, standardized, evidence-based treatment algorithms to get patients the best care.”
“We’ve got data to support it, and the results are phenomenal. I haven’t had a single patient who said, ‘I’ll take the two-stage, not a single one.’ And so patients really appreciate that effort as well.”
Specialized centers also have the opportunity to treat more patients with complex infections and participate in research that can improve future care.
At OrthoCarolina, the Prosthetic Joint Infection Center built a registry database of thousands of patients, helping physicians study outcomes and identify better ways to diagnose and treat challenging infections.
“There’s a real opportunity for collaborative research,” Dr. Fehring projects. “Fifty prosthetic joint infection centers across the country all (using standardized infection protocols) the same way. So we’ll be able to make significant advances in research, better for patient care with doctors treating patients who have a lot of experience treating infection because it is different.”
For someone facing a painful, infected joint, the possibility of treating the infection and replacing the implant during a single operation is significant.
“We need better options for patients.” Otero says compassionately. “And so if you’ve ever been in that moment and you’ve experienced the hardship, you’ve had a family member who suffered from an orthopedic problem, you understand what it’s like to need better care. With the research that we’re doing here, we really are providing better care, and that’s measurable, and it’s published. We’re proud of it.”
Continued research will expand patient’s treatment options even further as new evidence-based treatments are found to eliminate infection and restore mobility and quality of life.
The future of orthopedic medicine is taking shape with every patient visit, procedure, and test in a biomechanics lab.
“You’re helping people around the world because we’re publishing papers that affect people that we’ll never meet,” Fehring says. “And that’s kind of cool, you know, because that’s what research does.”
Making a contribution to OCRI allows our team of researchers to challenge the status-quo, improve orthopedic treatments, and help your loved ones get back to the activities they love that much sooner.
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