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The use of antibiotic prophylaxis in hip arthroscopy is under-reported and lacks evidence-based guidelines: a systematic review and survey
  1. Seper Ekhtiari1,
  2. Chloe E Haldane2,
  3. Darren de SA3,
  4. Nicole Simunovic4,
  5. Ivan H Wong5,
  6. Forough Farrokhyar2,4,
  7. Olufemi R Ayeni1
  1. 1 Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
  2. 2 Michael G Degroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
  3. 3 Division of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
  4. 4 Department of Clinical Epidemiology and Biostatistics, Centre for Evidence Based Orthopaedics, McMaster University, Hamilton, Ontario, Canada
  5. 5 Division of Orthopaedic Surgery, Dalhousie University,Capital District Health Authority, Halifax, Nova Scotia, Canada
  1. Correspondence to Dr Olufemi R Ayeni, Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON L8N20 3Z5, Canada; ayenif{at}mcmaster.ca

Abstract

Importance Hip arthroscopy is an increasingly common orthopaedic procedure with postoperative infection rates<5%. With the growing challenge of antibiotic resistance and rising healthcare costs, it is important to establish whether antibiotic prophylaxis is routinely used in hip arthroscopy, and whether it is necessary.

Objective The objectives of this review were to (1) report current practice patterns with regard to antibiotic prophylaxis for hip arthroscopy and (2) present the available evidence regarding the use of antibiotic prophylaxis in hip arthroscopy.

Evidence review The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed in the execution and reporting of this study. The databases MEDLINE, EMBASE and PubMed were searched and screened in duplicate. Data regarding patient demographics, surgical indications, surgical techniques, use of antibiotic prophylaxis and adverse events were collected. Study quality was assessed in duplicate using Methodological Index for Non-Randomised Studies criteria. A survey was distributed to high-volume hip arthroscopists to gauge their practice patterns. Data were analysed and presented using descriptive statistics.

Findings Nine studies of primarily level IV evidence (78%) and of fair quality were included. Overall, 592 patients (652 hips; 56.2% male) were included in the review, with a mean age of 40.6 years. Notably, 1069 otherwise eligible studies were excluded from this review because they did not report on their use (or lack thereof) of prophylactic antibiotics. Overall, 390 patients received routine antibiotic prophylaxis, 160 patients did not and 42 patients received prophylaxis only if an implant was used. Only three infections were reported among 652 operations, with all infections from studies that routinely used antibiotic prophylaxis. The survey had a 60% response rate (21/35), and revealed that 81% of respondents routinely provide prophylactic antibiotics, most commonly preoperative intravenous cefazolin (66.7%). The most common postoperative antibiotic was cephalexin.

Conclusions and relevance Antibiotic prophlyaxis use in hip arthroscopy is very under-reported. Routine prophylaxis was the most common practice pattern in both the literature and the survey. Overall, postoperative infection rates are extremely low. Future studies are required to prospectively assess the role of antibiotic prophylaxis in hip arthroscopy.

Level of evidence Level IV, systematic review of level III and IV studies

  • hip
  • arthroscopy

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What is already known

  • Antibiotic resistance is a growing and dangerous problem in healthcare.

  • There are currently no guidelines regarding the use of antibiotic prophylaxis in hip arthroscopy.

What are the new findings

  • The majority of high-volume hip arthroscopy surgeons routinely prescribe prophylactic antibiotics for patients undergoing hip arthroscopy.

  • Practice patterns regarding the use of prophylactic antibiotics in hip arthroscopy are not well reported, making it difficult to draw conclusions about their effectiveness or necessity.

Introduction

Hip arthroscopy is a safe, cost-effective treatment with good clinical outcomes and a number of applications, particularly in the context of femoroacetabular impingement.1–3 The complication rates of hip arthroscopy are quite low, reported to be between 1% and 8%.4–7 Infection as a complication of hip arthroscopy appears to be quite rare—superficial wound infections are reported at rates of between 0.7% and 2.7%,8–11 and there have at least two reported cases of deep wound infections.4 5

The use of antibiotic prophylaxis in hip arthroscopy has not been well studied, and there are no current evidence-based guidelines.12 Recent reviews recommend a preoperative dose of intravenous, broad-spectrum antibiotics, more due to a lack of clear guidelines rather than any evidence of benefit.12 13 Previously, routine prophylactic antibiotics were also standard of care in knee arthroscopy.14 Since then, a number of large case series and retrospective comparative studies have cast doubt on the efficacy and necessity of antibiotic prophylaxis in knee arthroscopy.14–17 Given the growing threat of antimicrobial resistance,18 it is important that all physicians play a role in antimicrobial stewardship, and that the prescription and use of antibiotics is as targeted and evidence-based as possible.18

No clear guidelines exist on the use of antibiotic prophylaxis in the context of hip arthroscopy. According to The American Society of Health-System Pharmacists (ASHP), antimicrobial prophylaxis is not recommended for patients undergoing certain orthopaedic surgeries, including arthroscopy, without the implantation of foreign material (strength of evidence=C, level VII recommendation based on expert opinion or data extrapolated from evidence for general principles and other procedures).19 Given the rapid rise in the use of hip arthroscopy combined with the aforementioned concerns regarding antibiotic resistance, this presents an important issue, and there is a need for clearer and more specific evidence-based guidelines.20 21 The purpose of this systematic review was to (1) report current practice patterns, based on documentation within available literature, with regard to antibiotic prophylaxis for hip arthroscopy, and (2) present the current available evidence regarding the use of antibiotic prophylaxis in hip arthroscopy.

Materials and methods

Search strategy

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were considered and followed in the execution and reporting of this study. Two reviewers searched three online databases (EMBASE, MEDLINE and PubMed) for literature discussing the use of antibiotic prophylaxis in hip arthroscopy. The search was performed on 4 July 2017, and the databases were searched from database inception to the search date. Inclusion criteria were (1) all levels of evidence; (2) patients of all demographics; (3) studies available in English; (4) human studies; and (5) clinical studies reporting whether or not they used prophylactic antibiotics. Exclusion criteria were (1) non-operative studies and (2) studies where outcomes for the exact same patients were reported in more than one study (most recent used). The key terms used in the search were ‘hip’ and ‘arthroscopy’ see online appendix for the details of search strategy.

Supplementary file 1

Study screening

Two reviewers independently screened the titles, abstracts and full texts of all search results. In order to ensure thoroughness, any disagreements at the title and abstract stages resulted in automatic inclusion. Disagreements at the full-text stage were resolved by consensus, or by a third, senior reviewer if agreement could not be reached. Finally, to ensure completeness, the references of all included studies were screened.

Quality assessment of included studies

Using the Methodological Index for Non-Randomised Studies (MINORS) Criteria, two reviewers independently assessed the quality of included studies.22 MINORS is a validated assessment tool for non-randomised studies. The criteria consist of 12 items, each scored 0, 1 or 2, with a maximum score of 16 for non-comparative studies and a maximum score of 24 for comparative studies. The MINORS score was categorised a priori as follows: 0<MINORS score<6 to indicate very low quality evidence, 6≤MINORS score<10 to indicate low quality of evidence, 10≤MINORS score<14 to indicate fair quality of evidence and MINORS score >14 to indicate a relatively good quality of evidence for non-randomised studies.

Data abstraction

Data were independently abstracted by two reviewers from the full texts of included articles. Collected data were entered into a Microsoft Excel (2013) spreadsheet, designed a priori. Data included study characteristics, patient demographics, antibiotic prophylaxis use and the occurrence of postoperative complications. Also, disclosures and funding sources of the included studies were assessed to evaluate the risk of bias.

Survey

Given that the available data were limited and sporadically reported, a decision was made post hoc to add a small survey component. The primary purpose of this survey was to identify any major or glaring differences between the data that were retrieved and actual practice patterns. With Institutional Review Board approval (HiREB #3114), a brief survey was designed to ask high-volume hip arthroscopy surgeons about their practice patterns when it comes to antibiotic prophylaxis. The high-volume hip arthroscopists were identified by one of the authors, who is themself a high-volume hip arthroscopy surgeon. Those surveyed were identified from an international pool of those known to perform high-volume hip arthroscopy based on personal correspondence or academic publications. In total, 35 surveys were sent out to surgeons practicing in North America (n=22), Europe (n=11), Australia (n=1) and Asia (n=1). All data were collected voluntarily, anonymously and with informed consent. The survey was disseminated using the SurveyMonkey platform via email. A reminder email was sent out 1 week after the initial email.

Statistical analysis

For each screening stage, a kappa (κ) value was calculated to assess inter-reviewer agreement. Based on previous literature, agreement was categorised a priori as follows: substantial agreement: κ >0.60; moderate agreement: 0.21≤ κ ≤0.60; slight agreement: κ <0.21.23 Inter-reviewer agreement for MINORS scores was assessed using an intraclass correlation coefficient (ICC). Descriptive statistics, such as means, ranges and measures of variance (eg, SD, 95% CI), were presented where applicable. No meta-analysis was performed, as the included studies were of low quality and the outcomes were highly heterogeneous.

Results

Study characteristics

Nine studies met the inclusion and exclusion criteria for this review (figure 1). The initial search yielded 6683 studies. Of the nine included studies, published between 2013 and 2016, there was one case–control study, seven case series and one case report (table 1).

Table 1

Characteristics of included studies

Figure 1

Outline of systematic screening strategy.

Study quality

There was substantial agreement among reviewers at the title (κ=0.74; 95% CI: 0.71 to 0.76), abstract (κ=0.78; 95% CI: 0.76 to 0.81) and full-text screening stages (κ=0.87; 95% CI:. 70 to 1.00). Two included studies were of level III evidence, while the remaining seven studies were of level IV evidence (table 1). There was substantial agreement among quality assessment scores using the MINORS criteria (ICC=0.92, 95% CI: 0.69 to 0.98). The included studies had a mean MINORS score of 12.2±4.9, which indicates fair quality among inherently low-quality evidence. Analysis of disclosures and funding sources did not reveal any clear sources of bias relevant to antibiotic use.

Patient demographics

A total of 619 patients underwent hip arthroscopy across the included studies, of whom 592 (652 hips) were included in final data analysis (94.0%)—the remaining patients were lost to follow-up or had declined participation in the studies (table 1). These patients had a mean age of 40.6 years (range=16–68 years), and were followed for a mean of 20.8 months (range=6–72 months). There were a total of 327 male patients (56.2%). The included studies were conducted in the USA (three studies), Sweden (two studies), Canada (one study), Germany (one study), Turkey (one study) and the UK (one study) (table 1).

Indications and surgical technique

The most common indication for hip arthroscopy was femoroacetabular impingement (six studies),24–29 followed by labral tear (two studies),4 30 and a cotyloid fossa lesion in one study (table 2).31 Patient positioning was reported in seven studies, with 534 patients (six studies) operated on in supine position4 26 28–31 and only one patient in a single study operated on in the lateral decubitus position.31 Mean operative time was reported for 217 patients at 69.6 min (four studies).24 25 29 31 Eight studies reported on portal placement, with six studies (294 patients) reporting the use of two portals24 25 28–31 and two studies (254 patients) using three portals.4 27

Table 2

Descriptive statistics

Antibiotic prophylaxis

Of the 592 patients included in this review, 390 patients (six studies) received routine antibiotic prophylaxis,4 24–27 31 42 patients (one study) received antibiotic prophylaxis only if an implant was used30 and 160 patients (two studies) did not routinely receive prophylactic antibiotics.28 29 Four studies reporting routine antibiotic prophylaxis reported on the medication used: 57 patients (two studies) received cephalexin (500 mg four times a day orally x7 days),24 25 79 patients (one study) received cefuroxime (dose and course unspecified)26 and one patient (one study) received 1.5 g of an intravenous cephalosporin.31 Also, 211 patients (one study) received intravenous prophylactic antibiotics, though the medication and dosing regimen were unspecified.4 Importantly, 1069 otherwise eligible studies were excluded from this review specifically because they did not report on their use (or lack thereof) of antibiotic prophylaxis.

Adverse events

Overall, postoperative infections were exceedingly rare. A total of three infections were reported among 652 operations, including two superficial wound infections treated with oral antibiotics, and a single case of septic arthritis and osteomyelitis requiring irrigation, debridement and intravenous antibiotics. All three infections were from studies using antibiotic prophylaxis.4 25 Among studies reporting the use of prophylactic antibiotics, no adverse effects (eg, Clostridium difficile infection) associated with antibiotic administration were reported.

Survey results

The survey was distributed to 35 high-volume hip arthroscopy surgeons. Twenty-one participants (60%; 95% CI: 43.6% to 74.4%) returned the survey, all of whom fully completed the survey. Of those responding, 81.0% (95% CI: 60.0% to 92.3%) of surgeons (17/21) reported that they routinely provide antibiotic prophylaxis. Among those who did provide antibiotic prophylaxis, 88.2% (95% CI: 65.7% to 96.7%) gave only preoperative antibiotics, while 11.8% (95% CI: 3.3% to 34.3%) gave both preoperative and postoperative antibiotics. Cefazolin was the most commonly used medication for antibiotic prophylaxis, being used by 66.7% (95% CI: 41.7% to 84.8%) of surgeons who routinely administer antibiotic prophylaxis.

All of the surgeons who reported that they did not routinely provide antibiotic prophylaxis indicated that they do provide prophylaxis for special populations, including diabetics, immunocompromised patients and patients with skin conditions. Half of those surgeons who do not routinely provide prophylaxis reported that they do provide prophylaxis for all patients receiving implants.

Discussion

The key finding from this review was that information regarding the use of prophylactic antibiotics in the context of hip arthroscopy is extremely under-reported. Of studies that met all other inclusion and exclusion criteria, <1% reported on the use of prophylactic antibiotics. The reasons for this lack of reporting are likely numerous. Preoperative prophylactic antibiotics are often prescribed (or not prescribed) based on existing institutional and personal practice patterns. As well, with the growing body of hip arthroscopy literature, gaps in the literature continue to be identified and addressed. When antibiotic prophylaxis is prescribed, the type, route, dose, frequency and duration are highly variable. Some surgeons use intravenous antibiotics such as cephalosporins in the operating room, while others use oral antibiotics including cephalexin and cefuroxime postoperatively. At this time, there is insufficient evidence to draw conclusions about the necessity of antibiotic prophylaxis in hip arthroscopy.

Interestingly, the survey results were consistent with the data in the included study, showing that most surgeons use intravenous antibiotic prophylaxis. Thus, despite the lack of explicitly reported data, the findings of this review are likely somewhat a fair, although crude, representation of current practice. Also, the response rate of 60% was consistent with previous physician-targeted email surveys reported in the literature.32

Currently, there is a lack of clear guidelines regarding the use of antibiotic prophylaxis in hip arthroscopy specifically. As previously mentioned, the ASHP clinical practice guidelines recommend the use of prophylaxis in arthroscopic procedures of the knee only if there is a potential for the use of implants. Based on clinical studies in the context of knee arthroscopy, it is likely that antibiotic prophylaxis is not necessary in knee arthroscopy, regardless of implant use.14–17 Given the very low rate of postoperative infections following hip arthroscopy, and the findings of this systematic review, it is possible that, similar to knee arthroscopy, antibiotic prophylaxis is not routinely required in hip arthroscopy. Of course, individual patient characteristics such as smoking, diabetes and immunosuppression must always be considered as they put the patient at higher risk for infection.

In addition to patient safety and clinical efficacy, cost-effectiveness is an increasingly important component of the risk–benefit analysis of any intervention.33 To the authors’ knowledge, there has not been a formal cost-effectiveness analysis of antibiotic prophylaxis in hip arthroscopy. In their retrospective review of nine cases of septic arthritis following various arthroscopic procedures, D’Angelo and Ogilvie-Harris concluded that antibiotic prophylaxis is cost-effective as it is difficult to predict which patients may develop such serious infections.34 In contrast, in a randomised, double-blinded, controlled trial with 437 patients, Wieck et al found no evidence that prophylactic cefazolin was cost-effective or beneficial in preventing postoperative infections.16 There is a need for an updated cost-effectiveness analysis focused specifically on hip arthroscopy in order to determine the incremental cost-effectiveness ratio.

This systematic review has many strengths, including a broad search strategy and lenient inclusion criteria which ensured a thorough search of the available literature and wider generalisability. In addition, duplicate screening of the articles at all stages was undertaken to minimise reviewer bias. Also, the addition of a survey component helps to augment and support the included data. Finally, this review highlights the under-reporting when it comes to antibiotic prophylaxis practice patterns in the context of hip arthroscopy.

This review was primarily limited by the low volume and quality of evidence available on this topic. Also, the substantial lack of reporting of prescription patterns with regard to antibiotic prophylaxis in the context of hip arthroscopy significantly limited the number of studies and patients that could be included in this review. Furthermore, the lack of any studies directly comparing the use of antibiotic prophylaxis with no prophylaxis makes it difficult to draw conclusions about the necessity of routine antibiotic prophylaxis in hip arthroscopy. With regard to the survey, given that it was not a primary source of data for this study, it was not formally validated and had a small sample size. Finally, though the survey was sent to surgeons practicing in four different continents, the limited sample size does not allow us to explore the regional differences regarding prophylactic antibiotics in arthroscopic surgery.

Future hip arthroscopy studies should briefly report whether or not they use antibiotic prophylaxis, as well as consistently reporting postoperative infection rates. In addition, large, prospective, randomised studies aimed specifically at evaluating the efficacy and cost-effectiveness of antibiotic prophylaxis in the context of hip arthroscopy are needed to elucidate whether prophylactic antibiotics are routinely needed in hip arthroscopy, and to identify any specific situations in which they are recommended (eg, in the context of allograft implants, longer operations, and so on).

Conclusions and relevance

Details regarding antibiotic prophylaxis are not consistently reported in hip arthroscopy literature. Routine prophylaxis was the most common practice pattern in both the literature and the survey. Overall, postoperative infection rates are extremely low. Future studies are required to prospectively assess the role of antibiotic prophylaxis in hip arthroscopy.

Acknowledgments

We thank Matthew Skelly and Andrew Duong for their support in the preparation and submission of this manuscript.

References

View Abstract

Footnotes

  • Contributors SE, DdS and ORA conceived the systematic review, and NS conceived the survey component. SE and CEH carried out the search, screening process and assessment of study quality. SE designed, distributed and analysed the survey component. SE drafted the manuscript. CEH edited the manuscript. DdS and ORA provided key expert input and editing throughout the process. IHW edited the manuscript and provided key expert input. NS and FF provided key expert feedback on methodological and statistical aspects. All authors read and approved the final manuscript.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.

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