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Should microbiological samples be taken routinely when performing revision surgery for post-surgical hematoma after hip or knee replacement? Retrospective study of 78 cases of surgically drained hematoma with a minimum follow-up of 2 years - 20/05/23

Doi : 10.1016/j.otsr.2023.103585 
Lucie Charles a, b, c, , Pierre Martinot a, b, c, Julien Dartus a, b, c, Eric Senneville a, c, d, Gilles Pasquier a, b, c, Sophie Putman a, b, c, Julien Girard a, b, c, e, Marie Titecat a, c, f, Henri Migaud a, b, c
a University of Lille, Hauts de France, 59000 Lille, France 
b Service d’Orthopédie, Hôpital Salengro, Place de Verdun, CHU Lille, 59000 Lille, France 
c Northwest Reference Center for Complex Bone and Joint Infections (CRIOAC-G4 Lille-Tourcoing), Centre de Référence pour le traitement des Infections Ostéo-Articulaires Complexes Lille-Tourcoing, rue Emile Laine, 59000 Lille, France 
d Service des Maladies Infectieuses et du Voyageur, CH Dron, rue du Président Coty, 59208 Tourcoing, France 
e University of Lille, University of Artois, University Littoral Côte d’Opale, EA 7369–URePSS–Unité de Recherche Pluridisciplinaire Sport Santé Société, 59000 Lille, France 
f Institute of Microbiology, Lille University Hospital, Centre de Biologie-Pathologie, Rue du Pr. Jules Leclercq, 59037 Lille, France 

Corresponding author. Service de chirurgie orthopédique, Hôpital Roger Salengro, place de Verdun, 59037 Lille, France.Service de chirurgie orthopédique, Hôpital Roger Salengroplace de VerdunLille59037France

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Abstract

Introduction

The relationship between the occurrence of a periprosthetic hip or knee joint infection, a post-surgical hematoma and the time to surgical revision, along with the need to take samples for microbiology analysis has not been clearly defined. This led us to perform a retrospective study to: 1) define the rate of infected hematoma and subsequent infection after surgical revision for hematoma and 2) analyze in which time frame the hematoma was likely to be infected.

Hypothesis

The more time elapsed before the postoperative hematoma is drained surgically after hip or knee replacement, the higher the hematoma infection rate and the late infection rate.

Patients and methods

Between 2013 and 2021, 78 patients (48 hip and 30 knee replacements) who had a postoperative hematoma without signs of infection upon draining were included in the study. Surgeons decided whether samples for microbiology were collected (33/78 patients (42%)). The data compiled consisted of the patient's demographics, the risk factors for infection, number of infected hematomas, number of subsequent infections at a minimum follow-up of 2 years, and the time to revision surgery (lavage).

Results

Of the 27 samples collected from the hematoma during the first lavage, 12/27 (44%) were infected. Of the 51 that did not have samples collected initially, 6/51 (12%) had them collected during the second lavage; 5 were infected and 1 was sterile. Overall, 17/78 (22%) of the hematomas were infected. Conversely, there were no late infections at a mean follow-up of 3.8 years (min 2, max 8) after the hematoma was drained in any of the 78 patients. The median time to revision was 4 days (Q1=2, Q3=14) for non-infected hematomas that were drained surgically versus 15 days (Q1=9, Q3=20) for hematomas that were found to be infected (p=0.005). No hematoma was infected when it was drained surgically within 72hours post-arthroplasty (0/19 (0%)). The infection rate went up to 2/16 (12.5%) when it was drained 3 to 5 days later and 15/43 (35%) when it was drained after more than 5 days (p=0.005). We believe this justifies collecting microbiology samples immediately when the hematoma is drained more than 72hours after the joint replacement procedure. Diabetes was more prevalent in patients who had an infected hematoma (8/17 [47%] versus 7/61 [11.5%], p=0.005). The infection was due to a single bacterium in 65% of cases (11/17); S. epidermidis was found in 59% (10/17) of infections.

Conclusion

The occurrence of a hematoma after hip or knee replacement that requires surgical revision is associated with increased risk of infection, since the hematoma infection rate was 22%. Since hematomas drained within 72hours are less likely to be infected, samples do not need to be collected for microbiology at that time. Conversely, any hematomas being drained surgically beyond this time point should be considered as infected, thus microbiology samples should be collected, and empirical postoperative antibiotic therapy initiated. Early revision may prevent the occurrence of late infections. The standard treatment of infected hematomas appears to resolve the infection at a minimum follow-up of 2 years.

Level of evidence

Level IV Retrospective study.

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Keywords : Hip replacement, Knee replacement, Periprosthetic joint infection, PJI, Hematoma, Total hip arthroplasty, Total knee arthroplasty


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Vol 109 - N° 4

Article 103585- juin 2023 Retour au numéro
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