Reports From the Field

Reducing Deep Joint Infection in Hip Hemiarthroplasty—A Quality Improvement Project

Journal of Clinical Outcomes Management. 2018 March;25(3)

Author(s):

Brendan J. Gallagher

Samuel E. McMahon

Katie Henderson

Sunil Zachariah

Darrin S. Wilson

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References

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From the Department of Trauma and Orthopaedics, Royal Victoria Hospital, Belfast, N. Ireland.

Abstract

Objective: To improve the deep wound infection rate in patients undergoing hip hemiarthroplasty in our regional trauma center.
Methods: We conducted a retrospective audit of patients who had undergone hip hemiarthroplasty between January 2013 and July 2014 and found that in 750 hip hemiarthroplasties performed, 20 (2.7%) developed a deep infection, a figure in excess of the literature standard. In line with international consensus recommendations, 4 changes to our perioperative practice were implemented: standardized draping of the affected extremity, improved skin preparation using a 2% chlorhexidine gluconate solution, change of incision drapes to iodophor-impregnated adhesive film drapes, and the use of interactive wound dressing. We conducted staff education to highlight the impact of deep wound infection, introduce the changes, and underscore the importance of strict adherence to intraoperative sterility.
Results: One year after introducing the changes, we audited the period April 2015 to March 2016, during which time 457 hip hemiarthoplasties were performed. Five (1.1%) deep infections were identified.
Conclusion: Improvement in the perioperative care of our hip hemiarthroplasty patients has resulted in a reduced risk of the development of deep wound infection. This improvement was maintained in a third audit period, with continued implementation of these changes in practice.

Keywords: deep infection; hip hemiarthroplasty; quality improvement; proximal femoral fracture; risk reduction strategies.

Deep wound infection following hip hemiarthroplasty is a catastrophic outcome for the patient, resulting in a prolonged stay in hospital, a poor outcome and increased costs. There is limited evidence in the literature reporting early deep infection rates specific to hip hemiarthroplasty. A number of studies describe the incidence of deep infection in proximal femur fractures treated by arthroplasty and fixation [1], with only a single study reporting on solely hip hemiarthroplasty [2]. The reported incidence of early deep infection following hip hemiarthroplasty specifically varies from 1.6% [1] to 4.9% [2,3]. These figures are primarily provided by retrospective, descriptive studies, with variable lengths of follow-up.

Early deep infection occurs more frequently in hip hemiarthroplasty for trauma than elective total hip arthroplasty. This is thought to be due to several factors including the advanced age of hip hemiarthroplasty patients and their comorbid status, in addition to the shorter time frame in which to medically optimize trauma patients, including less opportunity to address nutritional elements known to impact recovery.

A number of prognostic factors have been identified as increasing the chance of developing a deep periprosthetic infection following hip hemiarthroplasty. Although these are debated they include cognitive impairment, high body mass index, development of wound hematoma post-operatively and increased operating time [8].

Many of the measures taken to reduce the risk of deep infection in arthroplasty have a limited evidence base, with a significant amount of practice based on expert opinion [10]. This is due to the difficulty in designing robust randomized controlled trials with sufficient numbers to identify significant trends. It is generally accepted that parenteral antibiotic prophylaxis [4] and antibiotic-loaded cement reduce the incidence of infection [5]. Increased theatre traffic has long been accepted as increasing bacterial counts in theatre [6]. Sterile skin preparation and draping with impermeable drapes and an iodophor-impregnated adhesive skin drape have been shown to reduce bacterial contamination and recolonization rates in vitro [4], although this has not resulted in a clinical reduction in deep periprosthetic joint infections. Other practices such as the use of laminar flow theatres are less well evidenced [7].

Following concerns regarding a perceived spike in infection rates in our hip hemiarthroplasty patients, the senior author, who is the training liaison officer for trauma and orthopedics in the hospital, convened a meeting with the first 2 authors regarding how best to investigate this potential issue. It was decided that an audit of practice should be conducted, as well as a literature review to assess acceptable infection rates within the literature and any potential areas for improvement.

Setting

The Royal Victoria Hospital in Belfast is one of the UK’s largest dedicated trauma units, treating over 900 proximal femur fractures per year. Of these, approximately 500 are displaced intracapsular neck of femur fractures requiring hip hemiarthroplasty. Patients are managed on dedicated trauma wards, and in accordance with British Orthopaedic Association guidelines there is a focus on multidisciplinary rehabilitation including a fully integrated orthogeriatric service [8]. We routinely use a modular Exeter trauma stem (Stryker, Kalamazoo MI) prosthesis with gentamycin-loaded cement and an antibiotic prophylaxis regimen of flucloxacillin and gentamicin prior to incision, followed by 2 further doses of flucloxacillin over 24 hours. A preoperative checklist is conducted to ensure that antibiotics are administered prior to skin incision and that there are no concerns regarding equipment sterility. Four trauma theatres are run each weekday, prioritizing medically optimized proximal femoral fracture patients.