Single-stage Surgery With Antibiotic-loaded Hydrogel Coated Implants Versus Two Stage Surgery for Secondary Prevention of Complex Chronic Periprosthetic Hip Joint Infection (SINBIOSE-H)

Single-stage Surgery With Antibiotic-loaded Hydrogel Coated Implants Versus Two Stage Surgery for Secondary Prevention of Complex Chronic Periprosthetic Hip Joint Infection SINBIOSE-H.

Each year, around 1500 infected Total Hip Arthroplasties (THA) need non-conservative surgery, remaining an issue for patients and healthcare units. The recommended treatment, relying on cohort reviews and international consensus follows a two-stage protocol. This protocol implies a first surgery to remove all infected implants and at least 6 weeks of antibiotic treatment without implant, then usually an antibiotic-free period and only then a second surgery to put back new implants and start the rehabilitation protocol, with usually more than a week of a second hospital stay. Between both surgeries, full-weight bearing is prohibited and joint stiffness and/or pain are rather usual complications. Failure rate is estimated at 10% in this two-stage strategy. The single-stage procedure (i.e. implanting back a new prosthesis during the same surgery after implant removal, synovectomy and lavage) is thought to be less susceptible to late functional complications (i.e. pain, stiffness and muscle deficiency) with a shorter, single hospital stay.

Although, with single-stage surgery, infection control could be less efficient because most pathogens produce during the first hours of infection an antibiotic-resistant layer called biofilm, allowing them to colonize and adhere to foreign objects like implants. This single-surgery protocol thus highly relies on antibiotics and has a list of contra-indications (based on experts' consensus): the presence of damaged soft tissues or a sinus tract, unknown pathogens, difficult to treat micro-organisms, severe immunosuppression and for many surgeons, each time a bone graft is necessary. Most of these contra-indications are directly related to the biofilm.

As no randomized control trial has ever compared single-stage versus two-stage surgery, the level of evidence for recommending one procedure over the other is low.

We conducted a survey that showed that most of the French reference centers have already switched to single stage surgery for single-stage non contra-indicated cases.

An antibiotic-loaded hydrogel coating (Defensive Antiadhesive Coating®, Novagenit SRL), has been proven to mechanically prevent the biofilm formation, while allowing a prolonged intraarticular antibiotic release, in a randomized controlled trial in primary prevention of infection in THA.

The addition of this biofilm inhibitor to a single-stage surgery might stand as a promising strategy for secondary prevention of peri-prosthetic hip joint infection. Moreover, using this device to prevent biofilm formation could expand one stage surgery to patients that are "normally" contra-indicated to one stage surgery.

Study Overview

• Status: Active, not recruiting
• Conditions: Hip Prosthesis Infection
• Intervention / Treatment: Device: Defensive Antiadhesive Coating DAC®, Novagenit SRL

• Study Type: Interventional
• Enrollment (Actual): 39
• Phase: Not Applicable

Contacts and Locations

Study Locations

• France
  • Amiens, France
    • CHU Amiens
  • Bordeaux, France
    • CHU Bordeaux
  • Caen, France
    • CHU Caen
  • Clermont-Ferrand, France
    • CHU Clermont-Ferrand
  • Dijon, France
    • Chu Dijon
  • Lille, France
    • Chu Lille
  • Lyon, France
    • HCL - Hôpital Edouard Herriot
  • Lyon, France
    • HCL - Hôpital de la Croix Rousse
  • Marseille, France
    • CHU Marseille
  • Nancy, France
    • CHU Nancy
  • Nantes, France
    • Chu Nantes
  • Nice, France
    • CHU Nice
  • Saint-Etienne, France
    • Chu Saint-Etienne
  • Toulouse, France
    • Chu Toulouse

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 14 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Social security affiliation
• Signed informed consent
• Chronic periprosthetic hip joint infection defined according to the Musculoskeletal Infection Society criteria :
• Two positive periprosthetic cultures with phenotypically identical organisms
• or a sinus tract communicating with the joint,

• or having 3 of 5 minor criteria:

  • Elevated serum C-reactive protein (CRP) and Erythrocyte Sedimentation Rate (ESR);
  • Elevated synovial fluid White Blood Cell (WBC) count or change of ++ on leukocyte esterase test strip;
  • Elevated synovial fluid Polymorphonuclear Neutrophil Percentage (PMN%);
  • Positive histological analysis of periprosthetic tissue;
  • A single positive culture.

Exclusion Criteria:

• Patients with hypersensitivity to hydrogel components (hyaluronic acid and/or poly-lactic acid) known of Defensive Antibacterial Coating (DAC)®
• Pregnancy or positive pregnancy test (performed in women of childbearing age before inclusion)
• Life expectancy < 3 months
• Expected use of a cemented implant by the surgical team (for the treatment surgical protocol)
• Unable to give informed consent
• Patients under guardianship or curators
• Refusal to participate

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Single-stage surgery + DAC® + topical antibiotics; Experimental group is composed of single-stage procedure associated to the use of biofilm inhibitor (Defensive Antibacterial Coating® DAC®) and topical antibiotics=new strategy	Device: Defensive Antiadhesive Coating DAC®, Novagenit SRL; DAC gel, mixed with topical antibiotics is applied on the surface of the implants before implantation, in a sterile environment in the operating room. The topical antibiotics will be added to the reconstituted DAC® gel preparation, at the discretion of the physician, on the basis of pre-operative culture.
No Intervention: control group : two-stage surgery; Control group is composed of two-stage procedure without biofilm inhibitor (standard protocol)

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Recurrence of clinically diagnosed infection relapse of the periprosthetic joint	The periprosthetic joint infection is defined according to the Musculoskeletal Infection Society criteria: Two positive periprosthetic cultures with phenotypically identical organisms; or a sinus tract communicating with the joint,; or having 3 of 5 minor criteria:Elevated serum C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR);Elevated synovial fluid white blood cell (WBC) count;Elevated synovial fluid polymorphonuclear neutrophil percentage (PMN%);Positive histological analysis of periprosthetic tissue;A single positive culture.	Years : 2

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Harris Hip Score (HHS) results	Harris Hip Score (HHS) contains 10 items with maximum score at 100 for a perfect hip and minimum score at 0 for a very bad result.	Years : 2
Postel-Merle d'Aubigné (PMA) results	Postel-Merle d'Aubigné (PMA) contains 3 items (pain, mobility and functional hip) with maximum score at 18 for a perfect hip and minimum score at 0 for a very bad result.	Years : 2
Hip dysfunction and Osteoarthritis Outcome Score (HOOS) results	Hip dysfunction and Osteoarthritis Outcome Score contains 6 items (symptoms, stiffness, pain, function and daily life, sport and leisure activities, quality of life) and measure everyday activities with score from 0 to 4.	Years : 2
Oxford-12 results	Oxford-12 allows to know the feelings of the patient during the last 4 weeks felt from 1 to 5 (satisfaction score).	Years : 2
Death rate (%)	Analysis of death rate by group.	Years : 2
Post-operative complications	Analysis of post-operative complications by group.	Years : 2
Revision surgery for any cause other than infection	Analysis of revision surgery for any cause other than infection.	Years : 2

Collaborators and Investigators

• Sponsor: Centre Hospitalier Universitaire de Saint Etienne
• Collaborators: Ministry of Health, France
• Investigators: Principal Investigator: Bertrand BOYER, MD, Centre Hospitalier Universitaire de Saint Etienne

Publications and helpful links

General Publications

• Boyer B, Cazorla C, Carricajo A, Labruyere C, Chapelle C, Presles E, Zufferey P, Botelho-Nevers E. Single-stage surgery with antibiotic-loaded hydrogel-coated implants versus two-stage surgery for chronic periprosthetic hip joint infection in French tertiary referral hospitals: the SINBIOSE-H non-inferiority, randomised, controlled trial study protocol. BMJ Open. 2025 Feb 25;15(2):e085146. doi: 10.1136/bmjopen-2024-085146.

Study record dates

Study Major Dates

• Study Start (Actual): September 30, 2021
• Primary Completion (Actual): May 30, 2024
• Study Completion (Estimated): December 1, 2026

Study Registration Dates

• First Submitted: January 30, 2020
• First Submitted That Met QC Criteria: January 30, 2020
• First Posted (Actual): January 31, 2020

Study Record Updates

• Last Update Posted (Actual): May 6, 2026
• Last Update Submitted That Met QC Criteria: May 5, 2026
• Last Verified: May 1, 2026

More Information

Terms related to this study

• Keywords: Surgery; Hip Prosthesis; Biofilm inhibitor; Chronic infections; Total Hip Arthroplasties (THA); Defensive Antibacterial Coating (DAC®); Novagenit®
• Additional Relevant MeSH Terms: Pathologic Processes; Disease Attributes; Infections; Pathological Conditions, Signs and Symptoms; Persistent Infection; Limb Deficiencies, Distal, with Micrognathia
• Other Study ID Numbers: 18PH222; ANSM (Other Identifier: 2026-A00172-49)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No