Guidelines
The INFORM best practice guidelines are based on high quality evidence from the six-year INFORM Research programme. They were developed through a rigorous expert consensus method, with a national panel of clinical experts in orthopaedics, primary care, rehabilitation, and healthcare commissioning
The guidelines are for surgeons, doctors, physiotherapists, nurses, and healthcare professionals involved in the treatment and care of patients who have had a hip replacement.
Each section of the guidelines is explained in more detail as follows:
Increased vigilance and monitoring
- Hip replacement patients with post-operative complications such as slow wound healing or unexplained pain should prompt high suspicion of infection.
- Modifiable risk factors should be optimised (e.g., diabetes control).
Diagnosing infection
- All patients with persistent fluid discharge, worsening erythema or worsening pain arising from the joint should be investigated for infection.
- Any patient within the first four weeks of primary joint replacement, with increasing discharge or reduction in function or worsening erythema should prompt discussion with a specialist orthopaedic colleague within 48 hours.
- A patient with a previously well performing hip replacement, who develops symptoms consistent with infection (such as fluid discharge, new or worsening erythema and new or worsening pain) which persist for more than 48 hours, should prompt discussion with an arthroplasty specialist within 72 hours from presentation.
- Improve education and patient and clinician information to enable earlier recognition of signs and symptoms of infection.
- Increase vigilance amongst primary and secondary care for patients at high risk of periprosthetic joint infection. This includes optimising an open-door policy to allow patients to be referred back to the treating orthopaedic team promptly.
Treatment (Debridement, antibiotics and implant retention (DAIR))
- When infection is diagnosed with well-fixed implants, and DAIR is considered, it should be performed promptly. This consists of a radical debridement with exchange of modular components where possible, and NOT a wound wash-out.
Revision surgery
- Single stage revision should be performed whenever surgeons believe it is feasible, and within the bounds of a well-established dialogue with the patient, characterised by a plain language explanation of treatment options, with adequate time for the patient’s questions to be answered.
- Surgeons should consider the use of standard components fixed with antibiotic loaded bone cement as an articulating spacer.
Postoperative management
- Patients need appropriate levels of patient-centred rehabilitation as determined through assessment from early on in their journey.
- Patients with infection should be asked about their need for psychological and social support and this offered from the point of diagnosis onwards to long-term recovery.
- Patients should be assessed and provided with appropriate aids and equipment to support their recovery and rehabilitation.
- Patients should remain under the care of an infection multidisciplinary team whilst on antibiotics and monitored for side-effects and tolerance.