Changing Surgical Approach During Infection Treatment Does Not Increase Failure Risk

Surgical Flexibility in the Management of Infected Hip Arthroplasty

Periprosthetic joint infection remains a debilitating complication of total hip arthroplasty, frequently requiring two-stage exchange procedures that result in a 74.2% mean infection eradication rate and significant patient morbidity [1]. Clinical data regarding the impact of the initial surgical approach on infection risk remain inconsistent, as some meta-analyses suggest the direct anterior approach may increase risk with an odds ratio of 1.404, while others indicate it may reduce infection incidence compared to posterior or lateral techniques [2, 3]. High-risk populations, particularly the morbidly obese with a body mass index of 40 kg/m² or greater, face 4.3 times higher odds of infection alongside increased rates of dislocation and mechanical failure [4]. In the setting of chronic infection, surgeons must choose between maintaining the original surgical corridor or transitioning to a new approach to optimize debridement and soft tissue management. A recent multicenter study now examines whether this intraoperative decision impacts long-term eradication success and mechanical stability.

Analyzing Approach Discordance in a Large Multicenter Cohort

The researchers conducted an ethics-approved, multicenter, consecutive-case series involving 517 primary total hip arthroplasties specifically treated for periprosthetic joint infection. This cohort represented a broad clinical demographic with a mean age of 65 years (range, 20 to 94 years) and was nearly evenly distributed by sex, as women comprised 52.6% of the participants. From a metabolic perspective, the mean body mass index was 31, though the range extended from 16.7 to 58.7, capturing the high-risk, often obese patients frequently managed in revision settings. To ensure robust longitudinal data, the outcome analyses focused on 431 patients who reached a minimum one-year follow-up, with a mean follow-up duration of five years and a maximum of 17.2 years. At the time of the initial primary surgery, the index surgical approaches were varied: the posterior approach was the most common, utilized in 302 cases (58.4%), followed by the lateral approach in 111 cases (21.5%) and the anterior approach in 104 cases (20.1%). By establishing this baseline of initial surgical corridors, the researchers could effectively measure the impact of approach discordance (the decision to use a different surgical path during infection treatment than the one used in the original surgery) on subsequent clinical outcomes.

Patterns of Surgical Transition and Clinical Presentation

The clinical presentation of periprosthetic joint infection within the study cohort varied significantly, necessitating diverse management strategies tailored to the timing of the infection. Acute periprosthetic joint infection accounted for 37% of cases, while the remaining majority represented chronic infections. To address these infections, surgeons employed several initial treatment modalities based on the nature of the presentation. The most frequent intervention was debridement, antibiotics, and implant retention (61.9%), a strategy typically reserved for acute cases where the components are stable. For more complex or chronic presentations, physicians opted for first-stage revision in 30.4% of the cohort, while single-stage revision was performed in 5.4% of patients. A central focus of the analysis was the incidence of approach discordance (the decision to utilize a different surgical corridor during infection treatment than the one used during the index primary arthroplasty). The researchers found that a change of surgical approach occurred in 23.8% of cases. This transition in surgical access was not typically a delayed decision; rather, most approach changes occurred at the first surgical intervention (19.9%). By identifying these patterns, the study highlights that nearly one in four surgeons chooses to deviate from the original surgical path when managing the complexities of an infected total hip arthroplasty.

Predictors and Frequency of Approach Changes

The likelihood of a surgeon opting for approach discordance was heavily influenced by the specific corridor used in the initial procedure. The researchers found that approach discordance was significantly more common with the anterior approach, occurring in 62.1% of cases, compared to a 51% discordance rate for the lateral approach. In stark contrast, the posterior approach was rarely abandoned, with a discordance rate of only 0.7% (P < 0.001). These data suggest that while surgeons often feel compelled to switch from anterior or lateral entries when managing an infection, they almost universally maintain the posterior corridor if it was the original path of access. The specific type of surgical intervention also served as a major predictor for switching corridors. Approach discordance was more common with first-stage revisions (36.3%) than with other management strategies. Specifically, surgeons changed the approach in 17.2% of debridement, antibiotics, and implant retention procedures and in only 10.7% of single-stage revisions (P < 0.001). This higher rate in two-stage protocols likely reflects the need for more extensive exposure during the explantation of components in chronic infection cases. Notably, the decision to change the surgical corridor appeared to be driven by technical requirements rather than patient characteristics. The study found that no patient factors, such as age or body mass index, were associated with approach discordance, indicating that the surgeon's choice to switch is likely based on the clinical demands of the infection rather than individual patient demographics.

Eradication Success and Mechanical Stability

The primary clinical objective in managing periprosthetic joint infection is the successful eradication of the pathogen while maintaining a functional, stable joint. In this multicenter series, the researchers defined treatment success according to the Musculoskeletal Infection Society tiers 1 to 2 (a standardized classification system where tier 1 represents infection control with no further surgery and tier 2 indicates successful reimplantation after a planned two-stage procedure). Secondary outcomes focused on aseptic complications, specifically looking for postoperative dislocation, periprosthetic fracture, and aseptic loosening of the components. At the latest follow-up, which averaged five years, the overall success rate for infection treatment was 87.2% (376 of 431 patients). Crucially, the data demonstrated that periprosthetic joint infection treatment success was not associated with a change in surgical approach (P = 0.73), suggesting that the decision to use a different surgical corridor does not compromise the surgeon's ability to clear the infection. Beyond infection control, the study evaluated whether switching surgical approaches increased the risk of mechanical failure or instability. Aseptic complications occurred in 4.4% of the total cohort, with dislocation identified as the most common aseptic complication at a rate of 2.6%. When comparing patients who underwent a concordant approach to those with a discordant approach, the researchers found no significant difference in overall complication or dislocation rates (P = 0.33 to 0.73). These findings indicate that the theoretical risks of increased instability or soft tissue compromise associated with utilizing a new surgical path do not manifest as higher rates of dislocation in clinical practice. For the practicing orthopedic surgeon, these results provide evidence that the surgical corridor can be selected based on the technical requirements of the revision rather than a perceived need to adhere to the primary incision site.

References

1. Piuzzi N, Yost L, Putnam WT, et al. Outcomes following planned two-stage exchange arthroplasty for periprosthetic joint infections in the United States: a systematic review of the literature. Archives of Orthopaedic and Trauma Surgery. 2025. doi:10.1007/s00402-025-05955-0

2. Acuña AJ, Do MT, Samuel LT, Grits D, Otero JE, Kamath AF. Periprosthetic joint infection rates across primary total hip arthroplasty surgical approaches: a systematic review and meta-analysis of 653,633 procedures.. Archives of orthopaedic and trauma surgery. 2022. doi:10.1007/s00402-021-04186-3

3. Dockery DM, Allu S, Glasser J, Antoci V, Born CT, Garcia DR. Comparison of periprosthetic joint infection rates in the direct anterior approach and non-anterior approaches to primary total hip arthroplasty: a systematic review and meta-analysis.. Hip international : the journal of clinical and experimental research on hip pathology and therapy. 2023. doi:10.1177/11207000221129216

4. Rubin J, Potluri AS, Jan K, Dandamudi S, Levine BR. A Systematic Review and Meta-Analysis of Periprosthetic Joint Infection Rates in Morbidly Obese Patients Undergoing Total Hip Arthroplasty.. Journal of the American Academy of Orthopaedic Surgeons. Global research & reviews. 2025. doi:10.5435/JAAOSGlobal-D-24-00306