Infection After Total Hip Replacement Therapy

Infection After Total Hip Replacement Therapy

A total hip replacement is a surgical procedure involving replacing a damaged hip joint with prosthetic substitutes (Kremers et al., 2015). The first procedure was first done in the 60s and was acclaimed as among the most successful procedures in the past few decades. It was referred to as the Operation of the Century because of the excellent outcomes that were achieved from the operation (Ferguson et al., 2018). Most hip replacements are expected to be functional for between 10 and 15 years. During the surgical procedure, the head of the femur is replaced with a prosthetic one and placed on a shaft with the acetabulum surface lined with a bowl-shaped synthetic joint surface. It is possible to have a partial replacement done where the neck of the femur is fractured, and the femoral part is all that is replaced.

The last decade has witnessed major advances in hip replacement but activity status, hip disease, medical problems, age, and possible characteristics of fractures should be considered when a patient is contemplating a total hip replacement surgery (Kremers et al., 2015). Recovery time after a hip replacement varies from one person to another. Most patients will walk with some assistance on the day of or the day after the surgery. Some patients will resume their normal routines between 10 and 12 weeks following hip surgery. A patient will fully recover from surgery after 6 to 12 months, with replacement lasting up to 20 years.

Overview of the Problem

Total hip replacement is a procedure that is done frequently. Although it is an effective procedure in most cases, it is also used in hip fractures’ management, specifically, femur fractures displaced neck that result from pathological processes’ trauma. Some significant factors are osteomalacia and osteoporosis, which are responsible for the high rates of hip fractures among elderly patients. Arthritis is a degenerative disease of the joints and is also common among older adults, with the most common variety being osteoarthritis. Because of the high success rate at independence reinstating, a well-accepted hip degeneration treatment modality is hip replacement. It is also used in the treatment of juvenile rheumatoid arthritis, but this is only done when all other options have proven not to work (Ferguson et al., 2018).

According to Wolford et al. (2015), early hip replacement patients need a different duration of time to recover, with most people fully recovering within a few months to a year. Similar to all surgical procedures, hip replacement has its level of risk. Approximately 1 in every 100 patients that undergo a total joint replacement will have an infection following the operation. The infections of joint replacement occurs in the deep wound or wound around the artificial implants. The infection can occur as soon as when a patient is still in the hospital or after the patient goes home. Additionally, joint infection can occur a year after the surgical procedure. The joint infections after a replacement are caused by bacteria. However, the joint replacements are made from plastic or metal, thus making it difficult for the bacteria to be attacked by the immune system. Once the bacteria gain access to the implants, they can continue to multiply, resulting in an infection. Even with preventive treatments and antibiotics, patients whose joints are infected need to have a second surgery for the infection to be cured (Wolford et al., 2015). The most common ways the body gets infected after surgery include cuts or breaks on the skin, during major dental procedures such as root canals and tooth extraction, and through other surgical procedures via wounds. Some people tend to be at higher risk for infection development than others. The factors that increase this infection rate risk include diabetes; immune deficiencies such as HIV or lymphoma; immunosuppressive treatments such as corticosteroids or chemotherapy; and obesity. The signs and symptoms of an infected joint include fatigue; fever, night sweats, and chills; wound drainage; redness and warmth around the wound; swelling; and increased stiffness or pain in well-functioning joints (Lopez et al., 2017).

This study will seek secondary sources; highlight the risk factors of hip joint replacement. The second goal is to discuss the strategies for minimizing infection rates. Based on the findings from the literature, the current study will summarize the prevention and minimizing factors. The findings will also answer the PICOT question.

Project Purpose Statement

Total hip replacement surgery is resource-consuming both for the patient and the healthcare system. When infections occur after surgery, the procedure must be re-done, which means increased expense on all fronts for the patient and care facility. Comparing the duration it takes to recover after a hip replacement with and without infection is necessary to highlight the need for preventive measures.

Background and Significance

Health services have seen an exponential rise in the number of procedures involving lower limb arthroplasty among the aging populace. Thus, increasing numbers means that a slight infection rate of prosthetic joints can result in concerns. This is more so with the financial burden associated with a single revision surgery. The picture becomes grimmer because of the continuously metamorphosing bacteria that cause sepsis as well as rare organism infections. It is not possible to eliminate the possibility of contamination of the surgical site despite the standard practice of using prophylaxis antibiotics during surgery (Lopez et al., 2017). The use of prophylaxis, however, minimizes the risk of developing a deep infection to a significant extent. Nonetheless, the use of prophylaxis has its own direct and indirect side effects and the increased concern for bacterial resistance. Further, local guidelines and protocols direct antibiotic prophylaxis, and there still lacks a common consensus on the best regimen to follow.

Despite the efforts to reduce infection rates, they still occur, and diagnosing such an infection can prove difficult. The main symptom is often a pain in the hip, accompanied by other systemic symptoms such as rigors, malaise, and fever are variable. Farther, there may be local inflammation at the surgical site as well as reduced motion range within the specific joint. The diagram below summarizes the steps taken following the manifestation of hip joint infection (Lopez et al., 2017).

Source: Own Construction

The potential impact of this project will be to accurately diagnose hip joint infection and aid treatment in the shortest time possible. The duration it takes for a patient with an infection to recover will also be examined against those without infection. The difference in recovery duration will inform the healthcare industry of the need to take immediate action as well as other necessary measures to minimize the possibility of infection occurrence. The project also hopes to highlight the patient and healthcare costs associated with infection after a total hip replacement, and this may, in turn, propel policymakers to come up with a standard protocol that can be used in surgical procedures to ensure a reduction in infection rates if not totally eliminating the infections altogether.

PICOt Formatted Clinical Project Question(s)

The PICOT question: What is the duration for recovery (O) for patients with total hip replacement (P) who develop a post-operation infection (I) compared to those who do not develop any infection (C) within the first six weeks of recovery (T)?

Literature Review

The key terms used in searching the five articles were hip replacement, infection after hip replacement, duration of recovery after hip replacement, prosthetic joint infection, and risk factors of PJI.

Critical Appraisal of Literature 

The study by Marrmor and Kerroumi (2016) looked at the patient-specific risk factors for infection following an arthroplasty procedure. The author noted that 80 percent of patients have a modifiable infection risk factor, while the remainders are non-modifiable. The article is useful in directing the current research on the types of patients to include in the study; for example, those that have diabetes, renal infection, or are obese, among others, as high-risk patients for PJI. However, the authors did not mention the infection rates for the PJI risk patients for the modifiable risks.

The second study is by Moore et al. (2015), who did qualitative research on the deep joint infection impact on patients and the experiences the patients had with revision surgery. The authors pointed out that approximately 1 percent of patients had a PJI following a hip replacement. PJI treatment involves the use of antibiotics and 1 stage revision or more than one operation. The researchers sought to analyze the experience and impact of PJI treatment after stage 1 and 2 revision. The study did not show how long it took for a patient to recover after the PJI though it noted that some patients had up to 15 revisions to rectify the impact of a PJI.

The third study was by the National Institute for Health Research (2018), which highlighted some of the modifiable risk factors that could be addressed before a patient has a total hip replacement, including weight loss. This may, in turn, support decision-making between the patient and the physician. Patients’ data were analyzed, including the surgical and patient risk factors for infection, and stratified by the surgical units. The study found that men were at a higher risk than women due to increased infection risk. Although the absolute risk was below two infections for every 1,000 persons per annum in most subgroups, other significant associations were identified: a younger age, BMI of 30kg/m² or above, diabetes, and previous septic arthritis. Risk factors related to surgery included previous femoral neck surgery and lateral rather than a posterior approach to surgery. Additionally, the researchers showed that using ceramic components- either ceramic-on-ceramic or ceramic-on-polyethylene- reduced the risk of infection compared to metal-on-polyethylene. However, the study’s main weakness was that the data collected was incomplete in recording patient characteristics, illnesses, and complications.

The fourth literature review is that by Soffin and YaDeau (2016), which discussed the individual components of ERAS efficacy in hip and knee replacement. These included early mobilization after joint arthroplasty; postoperative analgesia; intraoperative anesthetic techniques; preoperative education. The authors identified interventions that lacked high-quality evidence, which was followed by recommendations for further research. Thus, based on the available evidence, the researchers created a model of the ERAS pathway applicable to perioperative care patients undergoing knee and hip replacement. Although this research showed the treatment options that can be applied and which can be used in the current research search criteria, the duration it takes to recover was not discussed. For this current research, the treatment option will be used in searching for studies that have implemented the same and the duration it takes to recover from PJI.

Lastly, Evans et al., 2019) discussed how total hip replacement is a highly effective operation that is common and how all operations would fail in-situ hence the need for patients to understand when such an occurrence would occur. The authors aimed to answer the question of how long a hip replacement can last. The study did not show the duration of a hip replacement following an infection and whether the PJI called for a repeat surgery and, with that, determine the length of hip replacement.

Development of an EBP Standard

Hip replacement surgery is often elective unless it becomes an emergency following an infection or major trauma. Patient involvement is vital in the procedure to ensure better outcomes. Early surgery is beneficial to a patient as it improves outcomes, as delays can result in mortality in elderly patients. The patient preferences’ evaluation involves the interpretation of the relative value that patients associate with the different yet relevant variables, which nuclides supervision by the consultant; timeliness of the operation; cancellation of the surgery after-hours operation; length of hospital stay, and prolonged fasting.

Based on the literature reviewed, an ideal Evidence-Based Practice that would minimize infection rates after a total hip replacement involves an ERAS. These include mobilization after joint arthroplasty; postoperative analgesia; intraoperative anesthetic techniques; preoperative education after the surgery. Additionally, some of the modifiable risk factors for infection need to be addressed before the surgery. These include weight loss for patients that are obese and regulation of blood glucose for patients with diabetes. Also, because hip replacement is elective, patients need to be given relevant information, including the risk of mortality following a joint infection, and this information aids in making an informed decision. Although infection after a hip replacement surgery occurs in 1 in every 1000 patients, this rate is still significant enough as the patient a physician advises may fall in this latter category.

Lastly, the operation time should be very short, with very minimal traffic in the operating room. While prophylaxis antibiotics are used during the surgical procedure, the patient may become resistant; hence, less time should be spent at the OR. The patient should also be advised to adhere to their antibiotic medication regimen after surgery. Non-adherence to medication risks the patient to infection. The patient should also be screened for any nasal bacterial infection before the surgical procedure commences.

Implications and Conclusion

Hip replacement among older adults has the potential to negatively impact the healthcare system, especially when infections set in and require revision surgeries. Infections are costly both to the patient and to the healthcare system. Although 1 in 1000 patients have an infection after surgery, it is possible to reduce this number even further, if not eliminate it altogether. To determine the impact of infection rates, this study proposed assessing the duration it takes for patients to recover with and without an infection following a hip replacement surgery. The recovery rates are expected to differ greatly, with those getting infections expected to take longer recovery times. The results will offer evidence of the need for an EBP to be implemented that can counter these higher numbers. This paper has discussed what an ideal EBP would entail. When physicians are aware of the costs of hip replacement revisions, they will more than likely be vigilant in minimizing these risks, including involving patients in the decision-making process and treatment plans.

References

Evans, J. T., Evans, J. P., Walker, R. W., Blom, A. W., Whitehouse, M. R., & Sayers, A. (2019). How long does a hip replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up. The Lancet, 393(10172), 647-654.

Ferguson, R. J., Palmer, A. J., Taylor, A., Porter, M. L., Malchau, H., & Glyn-Jones, S. (2018). Hip replacement. The Lancet, 392(10158), 1662-1671.

Kremers, H. M., Larson, D. R., Crowson, C. S., Kremers, W. K., Washington, R. E., Steiner, C. A., … & Berry, D. J. (2015). Prevalence of total hip and knee replacement in the United States. The Journal of bone and joint surgery. American volume, 97(17), 1386.

Lopez, D. J., Leach, I., Moore, E., & Norrish, A. R. (2017). Management of the infected total hip arthroplasty. Indian Journal of Orthopaedics, 51, 397-404.

Marmor, S., & Kerroumi, Y. (2016). Patient-specific risk factors for infection in arthroplasty procedure. Orthopaedics & Traumatology: Surgery & Research, 102(1), S113-S119.

Moore, A. J., Blom, A. W., Whitehouse, M. R., & Gooberman-Hill, R. (2015). Deep prosthetic joint infection: a qualitative study of the impact on patients and their experiences of revision surgery. BMJ open, 5(12).

National Institute for Health Research (2018). Joint infection after hip replacement is linked to some risk factors that could be modified. https://evidence.nihr.ac.uk/alert/joint-infection-after-hip-replacement-is-linked-to-some-risk-factors-that-could-be-modified/

Soffin, E. M., & YaDeau, J. T. (2016). Enhanced recovery after surgery for primary hip and knee arthroplasty: a review of the evidence. BJA: British Journal of Anaesthesia, 117(suppl_3), iii62-iii72.

Wolford, M. L., Palso, K., & Bercovitz, A. (2015). Hospitalization for Total Hip Replacement Among Inpatients Aged 45 and Over: United States, 2000-1010 (No. 2015). US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics.

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Infection After Total Hip Replacement Therapy

The purpose of the signature assignment is for students to apply the research and EBP concepts they have learned in this course and develop a framework for the initial steps of the student’s capstone project. The assignment allows the student to initiate the steps for planning, researching and developing an evidence-based practice intervention project proposal.

On or before Day 7, of week eight each student will submit his or her final proposal paper to the week eight assignment link in D2L. This formal paper will include and expand upon work completed thus far in prior assignments.

Essential Components of the Final Project Proposal will include:

1. Introduction– Provide an introduction to your topic or project. The introduction gives the reader an accurate, concrete understanding what the project will cover and what can be gained from implementation of this project.
2. Overview of the Problem – Discuss the problem, why the problem is worth exploring and the potential contribution of the proposed project to the discipline of nursing.
3. Project Purpose Statement – Provide a declarative sentence or two which summarizes the specific topic and goals of the project.
   

   Infection After Total Hip Replacement Therapy

4. Background and Significance – State the importance of the problem and emphasize what is innovative about your proposed project. Discuss the potential impact of your project on your anticipated results to the betterment of health and/or health outcomes.
5. PICOt formatted Clinical Project Question(s)– Provide the Population, Intervention, Comparison, Expected Outcomes and Timeframe for the proposed project.
6. Literature Review – Provide the key terms used to guide a search for evidence and discuss at least five (5) summaries of relevant, credible, recent, evidence-based research studies to support the project proposal.
7. Critical Appraisal of Literature – Discuss the strengths and weaknesses of the evidence, what is known from the evidence and what gaps in evidence were found from the appraisal of evidence-based research studies.
8. Develop an EBP Standard – Describe two to three interventions (or a bundle of care) from the evidence and discuss how individual patient preferences or the preferences of others will be considered.
9. Implications – Summarize the potential contributions of the proposed project for nursing research, education and practice.