Title: Infection and Orthopaedic Management (INFORM): Mobilising evidence into practice
Funder: Department of Health and Social Care

Abstract: Total joint replacement is a successful treatment for people with joints damaged by arthritis or injury and can reduce pain and improve physical function. However, about 1% of people have a prosthetic joint infection within two years of their primary hip replacement. If untreated, infection can result in severe pain, disability and death. Most patients are treated with a two-stage revision procedure involving two separate operations. An alternative single-stage procedure is used less commonly. From 2014-2020, we conducted the INFORM research programme (RP-PG-1210-12005) which aimed to identify ways of improving outcomes for prosthetic joint infection. We identified risk factors, effective treatments, patient and surgeon experiences and preferences for treatment. Risk factors include male sex, obesity, diagnoses other than osteoarthritis, co-morbidities including diabetes, liver disease and dementia, and surgical factors such as the lateral approach. Infection has a devastating impact on patients lives, and surgeons also describe a psychological burden. A less radical first-line surgical operation of debridement and implant retention (DAIR) is effective for many patients. For infected hip replacements single- and two-stage revision appear equally efficacious, but single-stage has better early results and is cost-effective. Patients prefer treatments which allow full functional return within 3-9 months and this should be considered when selecting the intervention. Single-stage surgery accounts for a minority of revision procedures and there is scope for increased utilisation. In the INFORM programme we have published 27 peer-reviewed articles, with 2 more under review and 4 more to submit. A Programme Development Grant will enable us to implement the main findings on treatment from INFORM into clinical practice through work with stakeholders, including the NHS and patients, and thereby improve outcomes for patients facing revision for infection. Aim To benefit patients and the NHS by ensuring that evidence from the INFORM programme is effectively implemented into healthcare practice. Objectives: 1) Work with stakeholders to develop a treatment pathway for prosthetic hip infection with best evidence from the INFORM programme (the INFORM treatment pathway ). 2) Using a collaborative learning approach, implement the INFORM treatment pathway into NHS orthopaedic centres. 3) Using co-design and stakeholder engagement, develop an implementation support toolkit to ensure that the pathway can be effectively implemented into practice in a meaningful and sustainable way. Development workplan 1) In-depth work with stakeholders including surgeons, patients and commissioners to develop a treatment pathway for prosthetic hip infection, based on evidence from the INFORM programme. 2) Working with stakeholders, implement the treatment pathway in up to 12 UK orthopaedic centres using learning from this experience to concurrently and iteratively develop an implementation support toolkit designed to increase the likelihood of successful implementation across the NHS in future. Timeline for delivery Two workstreams will be conducted consecutively and will last 24 months in total. Impact and dissemination This work will develop and implement the first nationally recognised evidence-based treatment pathway for prosthetic hip infection. We will also produce peer-reviewed publications, and targeted resources for patients and professionals using evidence-based approaches to raise awareness and change practice respectively.

Lay abstract: People with damaged or diseased joints may have joint replacement to reduce pain and disability. About one in a hundred joint replacements become infected. Infection can cause severe pain, disability and death. Treatment usually requires two operations with antibiotics between surgeries. Some surgeons treat joint infection with one operation. Between 2014 and 2020 we conducted the INFORM Programme to find out why some patients are prone to getting joint infections, how this affects patients, NHS resources, and to evaluate treatments. We reviewed existing evidence, analysed data from large international studies, talked to patients and surgeons about their experiences of infection and treatment, and developed an international network of orthopaedic infection experts. We conducted a randomised controlled trial, where 140 patients with hip infection from 12 UK and 3 Swedish hospitals received either one or two operations to find out which gave the best outcomes. A patient forum supported our research. We found that risk of infection was greater in obese people, men, and people with pre-existing health conditions. Patients and surgeons described the devastating effects of infection and treatment on people s lives. Important patient concerns were recovery time, and ability to engage in valued activities. The research we reviewed showed that treating infection with one or two operations cleared the infection equally. The randomised trial found that recovery was delayed in people receiving two operations, while people who only had one operation had better outcomes for pain, mobility, and quality of life up to a year after surgery, though these were similar at 18 months. NHS costs were lower when patients had one operation. We also found that conservative surgery (called debridement, antibiotics and implant retention, DAIR) performed within three weeks of infection has a far less negative impact on patients and clears infection in over 60% of cases. We will now put important findings from the programme into practice to improve patient outcomes and ensure that the NHS delivers the best possible care. Currently there is no national recommended treatment pathway, because of a lack of good underpinning evidence. Using the evidence from the INFORM programme, we can now develop the pathway. We will do this in two studies: 1) In-depth work with surgeons, patients and commissioners to develop a treatment pathway for infection after hip replacement, based on the INFORM programme evidence. 2) Work with 12 UK orthopaedic centres to deliver the treatment pathway to all patients with hip infection. We will take learning from centres using the treatment pathway to help embed the pathway in other NHS centres. This follow-on work will enable us to use evidence from the INFORM programme to change NHS practice and ensure patients receive the best possible treatment for joint infection.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MUSCULOSKELETAL