Two-stage cementless revision THR after infection. 5 recurrences in 40 cases followed 2.5-7 years

Two-stage revision of infected hip prosthesis after post-operative antibiotic therapy: An observational study

Infection is a major threatening side effect after total hip arthroplasty (THA) that its management is so difficult and is accompanied by different complications. The aim of this study was to determine the outcomes of patients underwent 2-staged THA after a course of antibiotic therapy. It was an observational prospective study performed during 2009 and 2019. We managed 51 patients with infected THA using a method in which antibiotic prophylaxis was performed after THA. We followed the same protocol for treatment of patients included 2-staged revision: in first stage, removal of infected instruments were performed and insertion of a hand-made antibiotic-cement spacer was done until erythrocyte sedimentation rate and CRP were normalized. In second stage, an un-cemented prosthesis was re-implanted in femoral side and post-operative IV antibiotic were administered for a week. Patients were monitored for about 15 months. Data were analyzed. There were 3 patients developed recurrent infection required girdlestone due to the aging. One of them needed to remove implant and 2 other with 3 times of re-infection were treated by antibiotic therapy. Other 10 cases were treated first by re-changing the cement. The rate of successful treatment was 78.4% (40 of 51) after the primary surgery and antibiotic therapy. This rose to 92.1% (47 of 51) following more debridement and antibiotic therapy. The merging of staged surgical debridement, using spacer of cement-antibiotic and re-implant beside 1-week intravenous antibiotic therapy, leaded to appropriate early outcomes in this series.

Articulated bipolar vs. non-articulated conventional spacers: A comparative study of results from two-stage treatment of chronic septic arthritis in prosthetic or native hips

INTRODUCTION

Infection is a serious complication of 0.2-0.7% of primary total hip arthroplasties (THA) and 1-22% of prosthetic revisions. The objective of our study was to compare two types of spacers (unipolar versus bipolar) for two-stage revisions of periprosthetic hip infections. The primary hypothesis was that bipolar spacers have fewer mechanical complications than unipolar spacers. The secondary hypothesis was that bipolar spacers decrease the rate of septic revisions and promote primary prosthesis reimplantation.

MATERIAL AND METHOD

This retrospective, monocentric, multi-operator study was carried out between January 2012 and July 2018, including patients operated on for septic arthritis of the native or prosthetic hip (two-stage procedure). The patients were divided into two groups: group A, including the articulated spacers and group B, including the unipolar spacers. We studied the complications of the spacers and the course of the infection over a minimum of two years. Functional status was assessed by the Postel Merle d'Aubigné (PMA) score, the Harris Hip Score (HHS) and pre- and postoperative patient satisfaction scores.

RESULTS

We collected data for 39 hips from 37 patients (mean age 63, 22 men and 14 women: 16 patients in group A, 21 in group B). We found no mechanical complications in group A versus 12 (52%) in group B. At 2 years, 93.8% of patients in group A no longer had any signs indicative of an active infection, compared with 71.4% in group B. In group A, the median PMA score increased from 5.5 (4-10.5) to 13.5 (12.5-15.5) and the HHS score from 27.5 (17-41.5) to 79 (64.5-89.5), postoperatively. In the final group B, the PMA score increased from 7 (6-9) to 14 (12-16) and the HHS score from 24 (11-41) to 72 (48-82) postoperatively.

CONCLUSION

The use of articulated spacers in THA or septic THA two-stage revision significantly reduces the occurrence of mechanical complications in the short term, as well as the pain between the two procedures.

LEVEL OF PROOF

IV.

The use of augmented antibiotic-loaded cement spacer in periprosthetic joint infection patients with acetabular bone defect

Background

Spacer complications may affect final clinical outcome of the two-stage approach in periprosthetic joint infection (PJI) patients. This study aimed to investigate clinical outcomes and complications of augmented antibiotic-loaded cement spacer in PJI patients with acetabular bone defect.

Methods

Data on PJI patients with acetabular bone defect receiving two-stage revision from January 2009 to December 2016, in our hospital were retrospectively reviewed. Screw-cement-shell was used to improve the stability of the hip with acetabular wall defect. Handmade acetabular spacer could prevent femoral spacer entering into pelvis in patients with acetabular internal wall defect. A total of 26 patients (11 males and 15 females) were included in the current study. Their mean age was 46.7 ± 15.4 years old. Clinical outcomes and complications were measured.

Results

Twenty-one of total 26 hips (21/26, 80.8%) showed positive cultures and 15/26 (57.7%) samples were cultured with staphylococcus. Of enrolled patients, 5/26 (19.2%) developed mixed infection. There was one patient (3.8%) with spacer dislocation and two (7.7%) with spacer fracture. One patient developed acute PJI 5 years after the second-stage revision, so overall success rate among these patients was 96.2%. Differences in Paprosky classifications before the first and second stage did not reach significant level (p > 0.05). Hip Harris score was raised from 40.9 ± 14.0 to 81.2 ± 11.2 (p < 0.05).

Conclusions

Augmented antibiotic-loaded cement spacer could achieve satisfactory clinical outcomes in PJI patients with acetabular bone defect. It provided joint mobility, increased additional joint stability, and decreased iatrogenic bone defect caused by acetabular wear.

Management of the Infected Hip Arthroplasty by Two-Stage Reimplantation

The aim of this study is to present our experience with two-stage reimplantation in the management of the infected hip arthroplasty. Between January 1993 and December 2001 the replacement of the total hip arthroplasty in two stages was performed in 18 patients. There were 7 male and 11 female patients and the average age was 62 years. The mean follow-up after revision was 3.5 years. The mean postoperative Harris Hip Score averaged 78 (50–96) points. None of 18 patients had a recurrence of the infection. Two-stage reconstruction of the infected hip is preferred to one-stage exchange arthroplasty at our department because of higher rate of eradication of the infection.

The Use of a Supra-Acetabular Antibiotic-Loaded Cement Shelf to Improve Hip Stability in First-Stage Infected Total Hip Arthroplasty

BACKGROUND

Antibiotic-loaded cement spacers in first-stage revision total hip arthroplasty (THA) for managing infection are associated with high dislocation and fracture rates. The aim of this study was to report the use of an antibiotic-loaded cemented supra-acetabular roof augmentation to reinforce hip stability after cement spacer insertion for first-stage total hip revision in the treatment of infected THA.

METHODS

We retrospectively reviewed a consecutive series of 50 THAs involving 47 patients with an infected hip requiring staged revisions of THA. We documented dislocation, reinfection, and time for revision and outcome.

RESULTS

There were no cases of hip dislocation, cement fractures, or any other technical complications associated with the use of the roof augmentation lip. Thirteen cases (26%) had a cemented spacer for longer than 120 days. Seven (14%) cases had recurrent infection after staged revision THA.

CONCLUSION

The antibiotic-loaded cemented supra-acetabular roof augment improved femoral head spacer coverage for patients requiring a staged revision THA for infection.

Does cemented or cementless single-stage exchange arthroplasty of chronic periprosthetic hip infections provide similar infection rates to a two-stage? A systematic review

Background

The best surgical modality for treating chronic periprosthetic hip infections remains controversial, with a lack of randomised controlled studies. The aim of this systematic review is to compare the infection recurrence rate after a single-stage versus a two-stage exchange arthroplasty, and the rate of cemented versus cementless single-stage exchange arthroplasty for chronic periprosthetic hip infections.

Methods

We searched for eligible studies published up to December 2015. Full text or abstract in English were reviewed. We included studies reporting the infection recurrence rate as the outcome of interest following single- or two-stage exchange arthroplasty, or both, with a minimum follow-up of 12 months. Two reviewers independently abstracted data and appraised quality assessment.

Results

After study selection, 90 observational studies were included. The majority of studies were focused on a two-stage hip exchange arthroplasty (65 %), 18 % on a single-stage exchange, and only a 17 % were comparative studies. There was no statistically significant difference between a single-stage versus a two-stage exchange in terms of recurrence of infection in controlled studies (pooled odds ratio of 1.37 [95 % CI = 0.68-2.74, I² = 45.5 %]).

Similarly, the recurrence infection rate in cementless versus cemented single-stage hip exchanges failed to demonstrate a significant difference, due to the substantial heterogeneity among the studies.

Conclusion

Despite the methodological limitations and the heterogeneity between single cohorts studies, if we considered only the available controlled studies no superiority was demonstrated between a single- and two-stage exchange at a minimum of 12 months follow-up. The overalapping of confidence intervals related to single-stage cementless and cemented hip exchanges, showed no superiority of either technique.

The Transfemoral Approach for Removal of Well-Fixed Femoral Stems in 2-Stage Septic Hip Revision

BACKGROUND

The value of a transfemoral approach for removal of well-fixed infected hip arthroplasties in 2-stage revision is unclear, especially whether cerclages for closure of the flap in the first step lead to higher reinfection rates and whether reopening of the flap for reimplantation of a hip arthroplasty leads to a lower union rate of the bony flap.

METHODS

Seventy-six septic 2-stage revisions via a transfemoral approach with cerclages for closure of the flap in the first step and reopening of the flap for reimplantation were followed prospectively for a mean period of 51.2 ± 23.2 (24-118) months.

RESULTS

The union rate of the bony flap after reimplantation was 98.7%, and no recurrence of reinfection was recorded in 93.4% of all cases. Subsidence of the stem occurred at a rate of 6.6%, dislocation at a rate of 6.6%, and there was no aseptic loosening of the implants. The Harris Hip Score was 62.2 ± 12.6 points with the spacer and 86.6 ± 15.5 points 2 years after reimplantation. Nine fractures (11.8%) of the flap occurred during the operation because of osteolytic or osteoporotic weakness of the flap itself, but these all healed without further intervention.

CONCLUSION

The transfemoral approach is a safe method for septic revision of well-fixed hip prostheses, and the use of cerclage wires for closing the osteotomy flap in the first stage does not appear to lead to a higher reinfection rate. Similarly, the reopening of the flap does not appear to decrease the union rate of the flap.

Cementless revision for infected hip arthroplasty: an 8.6 years follow-up

OBJECTIVE

To investigate cementless revision for postoperative infection after total hip arthroplasty (THA).

METHODS

From November 1997 to December 2009, 10 patients (10 hips; four males, six females) of mean age 58 years (36-73 years) with infection after THA were treated. Six of the 10 hips underwent revision total hip arthroplasty, two only received new acetabular components and two underwent stem revision. One-stage revision was performed in six cases and two-stage revision in four. Consecutive radiographs were compared to evaluate component conditions. Harris hip scores were determined before surgery and at final follow-up. Erythrocyte sedimentation rate and C-reactive protein were assessed.

RESULTS

All patients were followed up for a mean duration of 8.6 years (6.5-15.6 years). The mean Harris hip score improved from 35 (18-63) points preoperatively to 89 (60-99) points at final follow-up. No re-infection occurred. Femoral component exsertion was occurred in one asymptomatic patient. Hip joint pain resolved in seven cases; three patients had mild pain when walking long distances. At final follow-up, six patients still had slight limps. Heterotopic ossification developed in two hips. Mean polyethylene liner wear was 0.08 mm per year at final follow-up. Deep vein phlebothrombosis and nerve injury did not occur.

CONCLUSION

One- or two-stage revisions using cementless prosthesis can produce satisfactory clinical outcomes in patients with infection after THA. Whether the original prosthesis can be partially retained when attached tightly to the femur or acetabular bone needs further investigation.

Two-Stage Revision Arthroplasty for Periprosthetic Hip Infection: Mean Follow-Up of Ten Years

Background. Two-stage revision hip arthroplasty is the gold standard for treatment of patients with chronic periprosthetic joint infection (PJI), but few studies have reported outcomes beyond short-term follow-up. Methods. A total of 155 patients who underwent two-stage revision arthroplasty for chronic PJI in 157 hips were retrospectively enrolled in this study between January 2001 and December 2010. The mean patient age was 57.5 years, the mean prosthetic age was 3.6 years, and the interim interval was 17.8 weeks. These patients were followed up for an average of 9.7 years. Results. At the latest follow-up, 91.7% of the patients were free of infection. The mean Harris hip score improved significantly from 28.3 points before operation to 85.7 points at the latest follow-up. Radiographically, there was aseptic loosening of the stem or acetabular components in 4 patients. In the multivariate survival analysis using a Cox regression model, repeated debridement before final reconstruction, an inadequate interim period, bacteriuria or pyuria, and cirrhosis were found to be the independent risk factors for treatment failure. Conclusion. Our data show that two-stage revision hip arthroplasty provides reliable eradication of infection and durable reconstruction of the joint in patients with PJI caused by a variety of pathogens.

Is single-stage revision according to a strict protocol effective in treatment of chronic knee arthroplasty infections?

BACKGROUND

The increasing number of patients experiencing periprosthetic total knee arthroplasty (TKA) infections and the cost of treating them suggest that we seek alternatives to two-stage revision. Single-stage revision is a potential alternative to the standard two-stage procedure because it involves only one surgical procedure, so if it is comparably effective, it would be associated with less patient morbidity and lower cost.

QUESTIONS/PURPOSES

We compared (1) the degree to which our protocol of a highly selective single-stage revision approach achieved infection control compared with a two-stage revision approach to TKA infections; and (2) Knee Society scores and radiographic evidence of implant fixation between the single-stage and two-stage patients who were treated for more complicated infections.

METHODS

Between 2004 and 2009, we treated 102 patients for chronic TKA infections, of whom 28 (27%) were treated using a single-stage approach and 74 (73%) were treated using a two-stage approach. All patients were available for followup at a minimum of 3 years (mean, 6.5 years; range, 3-9 years). The indications for using a single-stage approach were minimal/moderate bone loss, the absence of immunocompromise, healthy soft tissues, and a known organism with known sensitivities for which appropriate antibiotics are available. Participants included 38 men and 64 women with a mean age of 65 years (range, 45-87 years). We used the Musculoskeletal Infection Society definition of periprosthetic joint infection to confirm infection control at the last followup appointment. Radiographs were evaluated for signs of loosening, and patients completed Knee Society Scores for clinical evaluation.

RESULTS

None of the patients in the single-stage revision group developed recurrence of infection, and five patients (93%) in the two-stage revision group developed reinfection (p=0.16). Patients treated with a single-stage approach had higher Knee Society scores than did patients treated with the two-stage approach (88 versus 76, p<0.001). However, radiographic findings showed a well-fixed prosthesis in all patients with no evidence of loosening at last followup in either group.

CONCLUSIONS

Our data provide preliminary support to the use of a single-stage approach in highly selected patients with chronically infected TKAs as an alternative to a two-stage procedure. However, larger, multicenter, prospective trials are called for to validate our findings.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Partial two-stage exchange for infected total hip arthroplasty: a preliminary report

BACKGROUND

One common approach to the infected total hip arthroplasty (THA) calls for a staged revision, including removal of all components. However, removal of well-fixed femoral components can result in bone loss and compromised fixation; it is not known whether it is effective to leave a well-fixed femoral component in situ, remove only the acetabular component, débride thoroughly, place a spacer, and delay reimplantation.

QUESTIONS/PURPOSES

The purposes of this study were to determine (1) the frequency of infection recurrence; (2) the frequency of death; and (3) the Harris hip scores of patients treated with a "two-stage partial exchange" approach.

METHODS

A retrospective analysis from 2000 through January 2011 revealed 19 patients with infected THA treated with partial two-stage exchange including complete acetabular component removal, aggressive soft tissue débridement, retention of the well-fixed femoral stem, placement of an antibiotic-laden cement femoral head on the trunnion of the retained stem, postoperative course of antibiotics, and delayed reimplantation. Indications for this treatment included those patients whose femoral component was determined to be well fixed and its removal would result in significant femoral bone loss and compromise of future fixation. During the study period, this represented 7% (19 of 262) of the patients whom we treated for a chronically infected THA. Minimum followup was 2 years (mean, 4 years; range, 2-11 years). None of the 19 patients in this series were lost to followup. We defined failure as recurrence of infection in the same hip or the use of long-term suppressive antibiotics.

RESULTS

Two patients (11%), both with prior failure of two-staged treatment of infection, failed secondary to recurrence of infection at an average of 3.3 years. There were no patient deaths within 90 days. The mean Harris hip score was 68 (range, 31-100; best score is 100).

CONCLUSIONS

Insofar as 89% of patients in this series were clinically free of infection at a minimum of 2 years, we believe partial two-stage exchange may represent an acceptable option for patients with infected THA when femoral component removal would result in significant bone loss and compromise of reconstruction. Further study is required on this approach.

The relationship between microbiology results in the second of a two-stage exchange procedure using cement spacers and the outcome after revision total joint replacement for infection: the use of sonication to aid bacteriological analysis

Patients with infected arthroplasties are normally treated with a two-stage exchange procedure using polymethylmethacrylate bone cement spacers impregnated with antibiotics. However, spacers may act as a foreign body to which micro-organisms may adhere and grow. In this study it was hypothesised that subclinical infection may be diagnosed with sonication of the surface biofilm of the spacer. The aims were to assess the presence of subclinical infection through sonication of the spacer at the time of a second-stage procedure, and to determine the relationship between subclinical infection and the clinical outcome. Of 55 patients studied, 11 (20%) were diagnosed with subclinical infection. At a mean follow-up of 12 months (interquartile range 6 to 18), clinical failure was found in 18 (32.7%) patients. Of the patients previously diagnosed with subclinical infection, 63% (7 of 11) had failed compared with 25% (11 of 44) of those without subclinical infection (odds ratio 5.25, 95% confidence interval 1.29 to 21.4, p = 0.021). Sonication of the biofilm of the surface of the spacer is useful in order to exclude subclinical infection and therefore contributes to improving the outcome after two-stage procedures.

A modified cement spacer technique for infected total hip arthroplasties with significant bone loss

Complications related to femoral spacers are common during addressing infected total hip arthroplasties by 2-stage revision. We evaluated 11 patients who had 2-stage revisions with massive bone loss after removal of the infected components by a trochanteric osteotomy. All femoral cement spacers were assembled on intramedullary nails. Femurs were protected by a plate, whereas acetabuli were augmented by a cage or roof ring depending on the remaining bone stock. This additional hardware was covered with antibiotic-impregnated cement. Infection was eradicated in 10 (90.9%) of 11 patients within 3.5 months in average. None of the patients had spacer fracture, periprosthetic fracture, or dislocation. Augmentation by hardware covered with antibiotic-impregnated cement is effective and may reduce complications until definitive treatment is performed.

Trabecular metal acetabular revision system (cup-cage construct) to address the massive acetabular defects in revision arthroplasty

The increasing number of total hip replacements in the younger clique has added to the demand for revision procedures. Revision situations are often encountered with infection, loss of bone stock and bone defects. There are various methods of reconstruction of acetabular defects. The management options of type 3B Paprosky acetabular defects are limited with allograft and conventional cages. Trabecular metal technology has evolved to address these bone defects. Trabecular metal acetabular revision system (TMARS) cup-cage construct is a new technique to address massive acetabular defects. We describe a case of failed hip reconstruction done for a Giant cell tumour of proximal femur managed by a two stage procedure, initial debridement and second stage reconstruction of acetabulum with TMARS cup-cage construct and femur with allograft prosthesis composite.

Two-stage revision of implant-associated infections after total hip and knee arthroplasty

Septic loosening of total hip and knee endoprostheses gains an increasing proportion of revision arthroplasties. Operative revisions of infected endoprostheses are mentally and physically wearing for the patient, challenging for the surgeon and a significant economic burden for healthcare systems. In cases of early infection within the first three weeks after implantation a one-stage revision with leaving the implant in place is widely accepted. The recommendations for the management of late infections vary by far. One-stage revisions as well as two-stage or multiple revision schedules have been reported to be successful in over 90% of all cases for certain patient collectives. But implant associated infection still remains a severe complication. Moreover, the management of late endoprosthetic infection requires specific logistics, sufficient and standardized treatment protocol, qualified manpower as well as an efficient quality management. With regard to the literature and experience of specialized orthopaedic surgeons from several university and regional hospitals we modified a commonly used treatment protocol for two-stage revision of infected total hip and knee endoprostheses. In addition to the achievement of maximum survival rate of the revision implants an optimisation of the functional outcome of the affected artificial joint is aimed for.

Functional and Emotional Results Differ After Aseptic vs Septic Revision Hip Arthroplasty

BACKGROUND

It is widely believed that a deep implant infection leads to poor functional and emotional outcomes following total hip arthroplasty.

QUESTIONS/PURPOSE

The purpose of this retrospective comparative review was to determine if patients who undergo two-stage, septic revision hip arthroplasty will have decreased emotional and general health scores, in addition to decreased function, compared to the aseptic revision group.

PATIENTS AND METHODS

One hundred forty-five of 195 patients who underwent aseptic total hip revision for aseptic loosening (mean follow-up = 61 months) and 45 of 73 patients who underwent two-stage, septic revision hip arthroplasty (mean follow-up = 48 months) met the inclusion criteria and had a technically successful outcome. All patients were retrospectively evaluated using Harris Hip Scores (HHS), ad hoc questions, and the SF-36 Health Survey.

RESULTS

The average HHS were 73.2 ± 20.5 (aseptic) and 57.4 ± 20.6 (septic). Significant differences in the SF-36 Health Survey were found between the two groups in: physical functioning (p = 0.026) and role limitations due to physical health (p = 0.004). No significant difference in SF-36 scores was seen in: Energy/Fatigue, General Health Perception, Personal or Emotional Problems, Role Limitations due to Emotional Well Being, Social Functioning, and Bodily Pain.

CONCLUSIONS

Two-stage, septic revision produces a poor functional outcome compared to aseptic revision; however, the overall impact of a septic revision emotionally and socially was not significantly different than patients undergoing aseptic revision.

Infectiological, functional, and radiographic outcome after revision for prosthetic hip infection according to a strict algorithm

BACKGROUND AND PURPOSE

Successful treatment of prosthetic hip joint infection (PI) means elimination of infection and restored hip function. However, functional outcome is rarely studied. We analyzed the outcome of the strict use of a treatment algorithm for PI.

PATIENTS AND METHODS

The study groups included 22 hips with 1-stage exchange for PI (group 1), 22 matched hips revised for aseptic loosening (controls), and 50 hips with 2-stage exchange (group 2). Relapse of infection, Harris hip score (HHS), limping, use of crutches, reoperations, complications, and radiographic changes were compared between the groups.

RESULTS

There was 1 relapse of infection, which occurred in group 2. In group 1, the mean HHS was 84; 4 of 19 patients were limping and 2 required 2 crutches, which was similar to the control results. In group 2, scores were lower and complication rates higher. The use of a Burch-Schneider ring and the presence of a deficient trochanter impaired function. There were no differences in radiographic outcome between the groups.

INTERPRETATION

With the algorithm used, infection can be cured with high reliability. With a 1-stage procedure, mobility is maintained. After 2-stage procedures, function was impaired due to there being more previous surgery and more serious infection.

Two stage hip revision in periprosthetic infection: results of 41 cases

BACKGROUND

two-stage revision is considered the best treatment approach for the eradication of chronic joint infection. We report the outcome of 41 consecutive patients with infected hip prostheses, treated between 2000 and 2005, with two-stage revision using an antibiotic-loaded cement spacer.

METHODS

Patients underwent a treatment protocol which included clinical and radiographic evaluation, laboratory investigations, hip aspiration, 99mTc-MDP and 99mTc-leukocyte-labeled scintigraphy and intraoperative assessment. All patients were diagnosed with a late chronic infection and classified as B-host according to the Cierny-Mader classification system. 9 patients out of 41 (22%) required a second interim treatment period, with exchange of the spacer. The proportion of methicillin-resistant Staphylococcus was similar between the one-spacer group and two-spacer group (28% vs 33%), whereas the proportion of patients with three or more risk factors was significantly higher in the two-spacer group than in the one-spacer group (28% vs 55%, respectively).

RESULTS

Forty patients had final reimplantation, one patient had a resection arthroplasty. At an average follow-up of 5.3 years no recurrence of infection occurred. The average post-operative Harris hip score improved from 41 to 80.

CONCLUSIONS

In the treatment of two-stage revision arthroplasty the adherence to the protocol proved to be effective for infection eradication and final reimplantation.

Treatment of infected hip arthroplasty

The clinical outcomes of a consecutive series of deep total joint infections treated with a prosthesis retaining protocol were reviewed. The treatment of deep periprosthetic joint infections is challenging. In recent years, two-stage exchange arthroplasty has emerged as the gold standard for successful elimination of infection. With success rates averaging 82% to 96%, this treatment method has both the highest and most consistent rate of infection eradication. Another alternative in the treatment of the deep periprosthetic infection is the single-stage exchange arthroplasty. Successful eradication of infection after single-stage exchange arthroplasty has been reported to average from 60% to 83% after total hip infections. While both the single and two-stage exchange arthroplasty are viable treatment options, they are associated with negative factors such as they are time consuming, expensive, and may entail a 6- to 12-week period with a minimally functioning extremity after prosthesis removal. This paper reports the general principles of management, the treatment of acute infection occurring in the postoperative period or later, and the treatment of chronic infection by exchange arthroplasty or resection arthroplasty.

Antibiotics-impregnated cement spacers in the first step of two-stage revision for infected totally replaced hip joints: report of ten trial cases

BACKGROUND

Periprosthetic infection is one of the serious complications after total hip arthroplasty (THA). This study analyzed the perioperative and postoperative status of patients who underwent antibiotics-impregnated cement spacer technique in the first step of the two-stage revision.

METHODS

Ten joints of the nine patients (mean age, 65 years; seven women, two men) received two-stage revision as a result of infection that appeared after primary THAs in seven joints, aseptic revision in one, and recurrent type in two. An antibiotics-impregnated cement spacer made by a mold system was applied in the femoral side of all joints. An acetabular spacer was made by hand using a cup gauge in eight joints with extensive tissue loss.

RESULTS

The change of leg length after the first stage was -2.2 mm, and range of hip flexion was 72 degrees on average, respectively. Patients could walk with crutches after the first stage, except one patient with simultaneous infections of both hips and one with fracture of the cement spacer. One fracture of femoral cement spacer, and one dislocation of femoral spacer accompanied by fracture of acetabular cement spacer and curable recurrent infection, were found. In all cases of the second-stage procedure, the acetabular side was reconstructed with allogeneic bone graft with cross plate and that of the femur was by impaction bone grafting method. In the latest follow-up, reconstructed implants were stable. Seven patients could walk without any supportive devices and two could walk with the support of a T-cane.

CONCLUSIONS

An antibiotics-impregnated cement spacer in the first step of the two-stage revision was effective not only to compensate tissue loss after removal of the implants and to minimize discrepancy of leg length, but also to contribute to improvement of perioperative and postoperative daily activities of the patient's life as well as treatment of the infection.

Treatment of infected total hip arthroplasty with a 2-stage reimplantation protocol: update on "our institution's" experience from 1989 to 2003

Infection is a devastating complication of total hip arthroplasty (THA). This study aimed to determine whether 2-stage reimplantation is still effective for treating contemporary pathogens, including multidrug-resistant organisms. Records of all cases of infected THAs from 1989 to 2003 were reviewed for data on organism, presence of drug resistance, use of an antibiotic-impregnated spacer, type of reimplant, and success of treatment. Of the 87 protocol patients with 2 years of follow-up, 94.3% (82) underwent reimplantation. The original infection was eradicated in 80 of the 84 hips (78/82 patients), a success rate of 95%. All 21 multidrug-resistant infections were eradicated. There were no major differences in eradication rates when the period was split into 3 sections. These results support previous studies from our institution which demonstrated the effectiveness of a 2-stage reimplantation protocol with a standard 1:8 minimal bactericidal titer for treating infections after THA, including those due to methicillin-resistant organisms.

Rationale for one stage exchange of infected hip replacement using uncemented implants and antibiotic impregnated bone graft

Infection of a total hip replacement (THR) is considered a devastating complication, necessitating its complete removal and thorough debridement of the site. It is undoubted that one stage exchange, if successful, would provide the best benefit both for the patient and the society. Still the fear of re-infection dominates the surgeons decisions and in the majority of cases directs them to multiple stage protocols. However, there is no scientifically based argument for that practice. Successful eradication of infection with two stage procedures is reported to average 80% to 98%. On the other hand a literature review of Jackson and Schmalzried (CORR 2000) summarizing the results of 1,299 infected hip replacements treated with direct exchange (almost exclusively using antibiotic loaded cement), reports of 1,077 (83%) having been successful. The comparable results suggest, that the major factor for a successful outcome with traditional approaches may be found in the quality of surgical debridement and dead space management. Failures in all protocols seem to be caused by small fragments of bacterial colonies remaining after debridement, whereas neither systemic antibiotics nor antibiotic loaded bone cement (PMMA) have been able to improve the situation significantly. Reasons for failure may be found in the limited sensitivity of traditional bacterial culturing and reduced antibiotic susceptibility of involved pathogens, especially considering biofilm formation. Whenever a new prosthesis is implanted into a previously infected site the surgeon must be aware of increased risk of failure, both in single or two stage revisions. Eventual removal therefore should be easy with low risk of additional damage to the bony substance. On the other hand it should also have potential of a good long term result in case of success. Cemented revisions generally show inferior long term results compared to uncemented techniques; the addition of antibiotics to cement reduces its biomechanical properties. Efficient cementing techniques will result in tight bonding with the underlying bone, making eventual removal time consuming and possibly associated with further damage to the osseous structures. All these issues are likely to make uncemented revisions more desirable. Allograft bone may be impregnated with high loads of antibiotics using special incubation techniques. The storage capacities and pharmacological kinetics of the resulting antibiotic bone compound (ABC) are more advantageous than the ones of antibiotic loaded cement. ABC provides local concentrations exceeding those of cement by more than a 100fold and efficient release is prolonged for several weeks. The same time they are likely to restore bone stock, which usually is compromised after removal of an infected endoprosthesis. ABC may be combined with uncemented implants for improved long term results and easy removal in case of a failure. Specifications of appropriate designs are outlined. Based on these considerations new protocols for one stage exchange of infected TJR have been established. Bone voids surrounding the implants may be filled with antibiotic impregnated bone graft; uncemented implants may be fixed in original bone. Recent studies indicate an overall success rate of more than 90% without any adverse side effects. Incorporation of allografts appears as after grafting with unimpregnated bone grafts. Antibiotic loaded bone graft seems to provide sufficient local antibiosis for protection against colonisation of uncemented implants, the eluted amounts of antibiotics are likely to eliminate biofilm remnants, dead space management is more complete and defects may be reconstructed efficiently. Uncemented implants provide improved long term results in case of success and facilitated re-revision in case of failure. One stage revision using ABC together with uncemented implants such should be at least comparably save as multiple stage procedures, taking advantage of the obvious benefits for patients and economy.

Revision of late periprosthetic infections of total hip endoprostheses: pros and cons of different concepts

Many concepts have been devised for the treatment of late periprosthetic infections of total hip prostheses. A two-stage revision with a temporary antibiotic-impregnated cement spacer and a cemented prosthesis appears to be the most preferred procedure although, in recent times, there seems to be a trend towards cementless implants and a shorter period of antibiotic treatment. Because of the differences in procedure, not only between studies but also within studies, it cannot be decided which period of parenteral antibiotic treatment and which spacer period is the most suitable. The fact that comparable rates of success can be achieved with different treatment regimens emphasises the importance of surgical removal of all foreign materials and the radical debridement of all infected and ischaemic tissues and the contribution of these crucial procedures to the successful treatment of late periprosthetic infections.

Two-stage procedure in the treatment of late chronic hip infections--spacer implantation

Infection after total hip arthroplasties (THA) is a devastating complication with significant consequences for both the patients and the healthcare systems. In recent times, a two stage procedure using antibiotic-impregnated interim spacers has become the most popular treatment for late chronic hip joint infections after THA with success rates over 90%. In this review, we discuss the different types of spacers used in the treatment of chronically infected THA and conclude that hip spacers are effective in the treatment of hip joint infections.

Acetabular revisions using trabecular metal cups and augments

The purpose of this study is to evaluate the efficacy of trabecular metal (TM) shells and augments in acetabular revisions with significant pelvic bone loss. We retrospectively reviewed 97 cases of consecutive loose total hip arthroplasty with a minimum of Paprosky grade IIA pelvic bone loss treated with a TM revision acetabular component with or without modular augments. The average Harris hip score improved from 55 preoperatively to 76 postoperatively. At the most recent radiographic evaluation, 88 cups demonstrated no lucent lines, 1 cup had lucent lines but remained well fixed, and 8 cups underwent resection arthroplasty for infection. One cup was revised for chronic instability. There were no aseptic failures in this series. Trabecular metal acetabular cups and shells with or without the use of modular augments can be effectively used to revise failed acetabular components in patients with substantial pelvic bone loss.

Two-stage cementless revision of infected hip endoprostheses

Cementless two-stage revision of infected total hip prostheses lacks the possibility of local antibiotic protection of the implant at the time of reimplantation, which leads to the concern that this protocol may not sufficiently eradicate periprosthetic infection. Moreover, early implant loosening as much as 18% and stem subsidence as much as 30% have been reported. To determine whether a cementless revision could eradicate infection and achieve sufficient implant stability, we prospectively followed 36 patients with two-stage revisions for septic hip prostheses. We used a uniform protocol of a 6-week spacer interval, specific local and systemic antibiotic therapies, and cementless modular revision stems. The minimum followup was 24 months (mean, 35 months; range, 24-60 months). In one patient, the spacer was changed when the C-reactive protein value failed to normalize after 6 weeks, and the reimplantation was performed after an additional 6 weeks. No infections recurred. There was no implant loosening and a 94% bone-ingrowth fixation of stems. Subsidence occurred in two patients. The Harris hip score increased from a preoperative mean of 41 to 90 at 12 months after reimplantation and later. Using cementless prostheses in two-stage revisions of periprosthetic infections of the hip in combination with a specific local and systemic antibiotic therapy seems to eradicate infection and provide implant stability.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Midterm to long-term followup of staged reimplantation for infected hip arthroplasty

Most reports on two-stage reimplantation have focused on the short-term cure rate of infection, but little is known about long-term reinfection-free survival or mechanical durability. We retrospectively reviewed 168 patients (169 hips) with infected arthroplasty, all of whom had two-stage reimplantation for the treatment of an infected total hip arthroplasty between 1988 and 1998. In the second stage, the femoral component was fixed with antibiotic-loaded bone cement in 121 hips; the remaining femoral components and all acetabular components were uncemented. The minimum followup time was 2 years (mean, 7 years; range, 2-16 years). At most recent followup, 12 hips (7.1%) were reoperated on for reinfection and 13 hips (7.7%) were revised for aseptic loosening or osteolysis. Apparently aseptic loosening occurred on one or both sides of the joint in 24 hips (14.2%). The 10-year survivals free of reinfection and mechanical failure were 87.5% and 75.2% respectively. Nineteen hips dislocated and eight underwent revision surgery for instability. The method of femoral component fixation, either with or without cement, did not correlate with risk of infection, loosening, or mechanical failure. Based on these results, the method of fixation used for the femoral component during two-stage reimplantation surgery should be based on the surgeon's preference for fixation combined with the assessment of femoral bone stock.

LEVEL OF EVIDENCE

Level IV, case series. See the Guidelines for Authors for a complete description of levels of evidence.

One-stage cementless revision arthroplasty for infected hip replacements

We hypothesised that one-stage cementless revision hip arthroplasty may have advantages and a role in the treatment of selected patients with an infected hip replacement. We retrospectively reviewed all patients with an infected hip replacement treated with one-stage revision using cementless implants. Twelve patients were reviewed and followed up for at least three years (average: 7.2 years, range: 3.3-11.3 years) postoperatively. One recurrence of infection and one aseptic stem loosening were detected during follow-up. Grafted bone, which was used in eight patients, appeared to have united to host bone in all patients. The success rate of treatment was 83.3% when infection recurrence or component loosening were regarded as failure. One-stage revision hip arthroplasty using cementless implants appears to have a role in the treatment of carefully selected patients with an infected hip replacement if meticulous débridement is performed and appropriate antibiotics are properly used.

Low relapse with oral antibiotics and two-stage exchange for late arthroplasty infections in 40 patients after 2-9 years

BACKGROUND AND PURPOSE

Exchange surgery in late arthroplasty infection is directed against bacteria adhering to implants. Therapies based on antibiotics that are effective intracellularly have been proposed recently. We have combined both strategies to improve the cure rate.

METHODS

40 consecutive patients (16 hips, 24 knees) were diagnosed with late arthroplasty infection. The organisms isolated were 35 Staphylococcus, 19 of which were methicillin-resistant, 4 Enterococcus, 6 Gram-negative bacilli, and 4 Corynebacterium. The infections were managed by a combined therapy consisting of two-stage exchange surgery and two oral intracellularly-effective antibiotics. The antibiotics were selected according to bacterial sensitivity and intracellular and biofilm effectiveness. Second re-implantation surgery was delayed until clinical and analytical normalization. Patients were in hospital for only 1 week after each surgery, and were followed up prospectively on an outpatient basis (2-9 years). Cure of the infection was defined as absence of clinical, serological, and radiographic signs of infection during the whole follow-up.

RESULTS

The infection was resolved in 38/40 patients (15/16 hips and 23/24 knees).

INTERPRETATION

Oral antibiotics that are effective intracellularly in combination with two-stage exchange surgery is a promising alternative for treating late arthroplasty infections. Oral antibiotics shorten hospitalization and reduce patient discomfort.

Cementless two-stage exchange arthroplasty for infection after total hip arthroplasty

We retrospectively reviewed all patients at one center with an infected total hip arthroplasty treated with 2-stage revision using cementless components for the second stage and the PROSTALAC articulated spacer at the first stage. Twenty-nine patients were reviewed and followed for at least 2 years postoperatively. An isolated Staphylococcus species was cultured in 76% (22/29) of patients. Three (10.3%) of 29 patients had recurrent infection at the site of the prosthesis. One of the 3 patients ultimately underwent a Girdlestone arthroplasty. Another patient was managed with irrigation and debridement, whereas the final patient was treated with intravenous antibiotics alone. Treatment of infection at the site of a hip arthroplasty with 2-stage revision using cementless components and an articulated spacer yields recurrence rates similar to revisions where at least one of the components at the second stage is fixed with antibiotic-loaded cement.

Iontophoresed segmental allografts in revision arthroplasty for infection

Revision arthroplasty after infection can often be complicated by both extensive bone loss and a relatively high rate of re-infection. Using allograft to address the bone loss in such patients is controversial because of the perceived risk of bacterial infection from the use of avascular graft material. We describe 12 two-stage revisions for infection in which segmental allografts were loaded with antibiotics using iontophoresis, a technique using an electrical potential to drive ionised antibiotics into cortical bone.

Iontophoresis produced high levels of antibiotic in the allograft, which eluted into the surrounding tissues. We postulate that this offers protection from infection in the high-risk peri-operative period. None of the 12 patients who had two-stage revision with iontophoresed allografts had further infection after a mean period of 47 months (14 to 78).

Cementless two-staged total hip arthroplasty for deep periprosthetic infection

bTwo-staged exchange with delayed reimplantation of a new prosthesis is considered by many to be the preferred method of treatment for deep periprosthetic infection after total hip arthroplasty. Until recently, most authors of previously published reports of this two-staged exchange procedure have used cemented implants fixed with antibiotic-containing bone cement. In view of the superior results of revision total hip arthroplasties with cementless implants, we reviewed the results of 33 two-staged revision total hip arthroplasties done for deep infection using cementless femoral components. There were no recurrent infections in the 28 patients in this study who had a 2-year minimum followup. Two patients developed a new infection with a different organism after reimplantation of their hip. Three patients with considerable acetabular bone deficiency had acetabular component revision for aseptic loosening; however, there were no cases of femoral component loosening. The overall infection rate of 7% using this approach was comparable to previous reports of two-staged revision total hip arthroplasties done with cemented components fixed with antibiotic-containing bone cement. In addition, cementless femoral component fixation seemed to be more reliable and durable in comparison to previous reports of revision total hip arthroplasty with cemented stems. The results of this study support the continued use of cementless implant fixation for two-staged reconstruction of the infected total hip arthroplasty.

LEVEL OF EVIDENCE

Therapeutic study, Level IV-1 (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Two-stage revision hip arthroplasty for infection with a custom-made, antibiotic-loaded, cement prosthesis as an interim spacer

BACKGROUND

Two-stage reconstruction is a well-recognized treatment for deep infection of hip joint implants. The purpose of the study was to report the results of our treatment using a standardized protocol.

METHODS

Forty-two consecutive patients with deep infection of the hip prosthesis were treated according to a prospective, two-stage resection/reimplantation protocol. Between stages, a custom-made, antibiotic-loaded, cement prosthesis was implanted as an interim spacer.

RESULTS

Infection was eradicated in 41 patients after the first-stage operation. Thirty-six patients remained with the ability to walk with the interim cement pros-thesis. For 40 patients who underwent reimplantation, recurrence of infection was observed in only 1 patient at an average of 55.2 months' follow-up.

CONCLUSION

We have found that our two-stage treatment protocol is a reliable approach for the management of infected hip prostheses. It is effective for eradicating infection and for providing a mobile and functional joint through the treatment course.

Treatment of the infected hip replacement

Selection of the suitable treatment method for an infected hip arthroplasty requires careful assessment of patient-related variables and expected treatment goals. The basic treatment options include antibiotic suppression, open debridement, resection arthroplasty, arthrodesis, reimplantation of another prosthesis, and amputation. Successful treatment of infection requires complete debridement of all infected and foreign material and appropriate antimicrobial therapy. When possible, the preferred treatment approach is insertion of another prosthesis with a delayed reconstructive treatment technique. Patients now are presenting with an increasing incidence of resistant organisms and severe bone loss, which increases the difficulty of treatment.

Detection of biomaterial-associated infections in orthopaedic joint implants

Biomaterial-associated infection of orthopaedic joint replacements is the second most common cause of implant failure. Yet, the microbiologic detection rate of infection is relatively low, probably because routine hospital cultures are made only of swabs or small pieces of excised tissue and not of the surfaces of potentially infected implants. Joint replacements from patients in whom infection was suspected, after clinical, radiologic, and biochemical examinations, were used in this study. The aim of the current study was to compare the detection rate of infection in total joint replacements based on cultures of the excised tissue and scrapings from the biomaterial surface. Joint prostheses were retrieved from 22 patients requiring orthopaedic revision surgery because of suspected infection of their prostheses. Routine hospital culturing of tissue only showed bacterial growth in nine patients (41%). However, after prolonged culturing, bacterial growth was observed in 14 patients (64%), whereas extensive culturing of scrapings from the biomaterial surface indicated bacterial growth in 19 of the 22 patients (86%). In addition, confocal laser scanning microscopy enabled observation of biofilm bacteria on the surfaces of the explanted prostheses. Diagnosis in orthopaedic revision surgery should consider using a microbial or microscopic analysis of the surface of an explanted prosthesis, where the biofilm mode of growth firmly anchors and protects the infecting organisms. Improved detection of infection by analysis of the implant surface is expected to yield ameliorated therapy and a reduced need for revision surgery.

Treatment outcome of two-stage revision total hip arthroplasty for infected hip arthroplasty using antibiotic-impregnated cement spacer

Infected hip prosthesis, a serious complication of primary total hip arthroplasty (THA), can have severe consequences. We report the treatment outcome of two-stage revision THA for infected hip arthroplasty, including hemiarthroplasty, using an antibiotic-impregnated cement spacer for the interval between the first and second stages. Between 1996 and 2000 we performed this procedure on nine hips in eight patients. Cementless revision THA was performed as the second-stage procedure. Bone defects were restored with frozen allografts. The outcome was evaluated using the hip score of the Japanese Orthopaedic Association (JOA hip score). The mean duration of follow-up was 35.7 months (range 10-55 months). The mean JOA hip score at follow-up improved from 30.1 (range 10-74) to 73.2 (24-96). The mean interval between the first and second stages was 10.1 weeks (range 6-19 weeks). Eight of the nine hips achieved a successful outcome. One hip, with methicillin-resistant Staphylococcus aureus infection, experienced recurrence 4 months after revision THA. This patient was successfully treated 14 months after the first revision THA with a second two-stage procedure using a vancomycin- and arbekacin-impregnated cement spacer and beads. These results suggest that two-stage revision THA using an antibiotic-impregnated cement spacer is a useful technique for treating infected hip arthroplasty.

Use of antibiotic-impregnated cement in total joint arthroplasty

The use of antibiotic-impregnated cement in revision of total hip arthroplasty procedures is widespread, and a substantial body of evidence demonstrates its efficacy in infection prevention and treatment. However, it is not clear that it is necessary or desirable as a routine means of prophylaxis in primary total joint arthroplasty. In the management of infected implant sites, antibiotic-impregnated cement used in one-stage exchange arthroplasties has lowered reinfection rates. In two-stage procedures, use of beads and either articulating or nonarticulating antibiotic-impregnated cement spacers also has lowered reinfection rates. In addition, spacers reduce "dead space," help stabilize the limb, and facilitate reimplantation. Problems associated with antibiotic-impregnated cement in total joint arthroplasty include weakening of the cement and the generation of antibiotic-resistant bacteria in infected implant sites.

The treatment of the infected hip replacement. The complex case

The treatment of the infected total hip replacement remains expensive, leads to a long difficult course for the patient, and frequently results in a suboptimal functional outcome. Various treatment techniques are available, and may be suitable for the more straightforward case. These include one-stage exchange arthroplasty, two-stage exchange arthroplasty, resection arthroplasty, and debridement and irrigation. The complex infected total hip replacement encompasses numerous host and organism factors. These include unusual or multiple organisms, diagnostic difficulties, bone loss, immunocompromise, and reinfection. In the authors' experience, the problem of the complex infected hip replacement is best addressed using the prosthesis of antibiotic-loaded acrylic cement approach. This interval arthroplasty is a modular, custom-made, immediate fit, antibiotic selective, temporary spacer system that allows the surgeon to reconstruct even the most deficient bone stock safely and effectively using two-stage exchange arthroplasty. It affords the patient rapid pain relief, allows them to mobilize quickly while successfully eradicating infection in 96% of hips with severe bone loss, and sets an appropriate soft tissue environment for a relatively straightforward second stage procedure. The prosthesis of antibiotic-loaded acrylic cement system affords the benefits of two-stage exchange without the functional disadvantages of an excision arthroplasty particularly when the proximal femur is severely deficient. It allows flexibility for the interval period and the type of fixation used, and the potential for allograft reconstruction at the final stage.