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Peddada KV, Welcome BM, Parker MC, Delman CM, Holland CT, Giordani M, Meehan JP, Lum ZC. Survivorship and Etiologies of Failure in Single-stage Revision Arthroplasty for Periprosthetic Joint Infection: A Meta-analysis. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202305000-00015. [PMID: 37167581 PMCID: PMC10181575 DOI: 10.5435/jaaosglobal-d-22-00218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 02/27/2023] [Indexed: 05/13/2023]
Abstract
INTRODUCTION Single-stage revision arthroplasty for periprosthetic joint infection (PJI) may yield comparable infection-free survivorship with two-stage revision arthroplasty. It is unclear if the most common mode of failure of single-stage revision arthroplasty is infection or aseptic loosening. In this meta-analysis, we sought to (1) determine survivorship and (2) compare rates of different etiologies of failure of single-stage revision total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS Preferred Reporting Items for Systematic Review and Meta-analyses guidelines search was done using search terms for "single stage revision," "exchange arthroplasty," "periprosthetic infection," "PJI," and "single stage." Patient demographics such as age, body mass index, and mean follow-up time were recorded. Overall survivorship and rates of revision surgery were aggregated using a random-effects model. Comparison of septic and aseptic loosening rates was done by risk difference and associated 95% confidence interval (CI) calculation. RESULTS Twenty-four studies were identified with 2,062 and 147 single-stage revision THA and TKA procedures performed between 1984 and 2019, respectively. The weighted mean follow-up and age were 69.8 months and 66.3 years, respectively, with 55% men overall. The all-cause revision surgery rate was 11.1% and 11.8% for THA and TKA, respectively. The revision surgery rate secondary to infection and aseptic loosening and associated 95% CI for the risk difference for THA and TKA was 5.5% and 3.3% (-1.7% to 5.0%), and 3% and 8.8% (-11.4% to 2.3%), respectively. Revision surgeries due to instability and fracture combined and mortality rate were both less than 3%. DISCUSSION Single-stage revision THA and TKA for PJI demonstrated overall high rates of survivorship, low mortality, and revision surgeries secondary to infection and aseptic loosening to be equivalent. Aseptic loosening after single-stage revision TKA might be higher than in primary TKA. As implant survivorship from infection improves in PJI, surgeons should be aware of aseptic loosening as an equally common mode of failure.
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Affiliation(s)
- Kranti V Peddada
- From the Department of Orthopaedic Surgery, Davis Medical Center, University of California (Dr. Peddada, Dr. Delman, Dr. Holland, Dr. Giordani, Dr. Meehan, and Dr. Lum), and the Reno School of Medicine, University of Nevada (Mr. Welcome, and Mr. Parker)
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Lum ZC, Holland CT, Meehan JP. Systematic review of single stage revision for prosthetic joint infection. World J Orthop 2020; 11:559-572. [PMID: 33362992 PMCID: PMC7745489 DOI: 10.5312/wjo.v11.i12.559] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/20/2020] [Accepted: 11/29/2020] [Indexed: 02/06/2023] Open
Abstract
While advanced technology, increased medical knowledge and improved surgical technique has improved patient outcomes in total joint arthroplasty, prosthetic joint infection still remains one of the leading causes of increased healthcare costs, medical resources and societal burdens in orthopaedic care. Two stage arthroplasty revision remains the gold standard for treatment of prosthetic joint infection. Proponents of single stage revision arthroplasty for infection argue that it results in lower healthcare costs while improving patient reported functional outcomes and with equivalent success rates. Here we review the history of single stage revision arthroplasty, discuss the key principles, highlight the indications and contraindications, and review the reported outcomes with a focus on future developments of single stage revision arthroplasty for hip and knee periprosthetic joint infections.
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Affiliation(s)
- Zachary C Lum
- Department of Orthopaedic Surgery, Davis Medical Center, University of California, Sacramento, CA 95817, United States
| | - Christopher Thomas Holland
- Department of Orthopaedics, University of California, Davis Medical Center, Sacramento, CA 95817, United States
| | - John P Meehan
- Department of Orthopaedics, University of California, Davis Medical Center, Sacramento, CA 95817, United States
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Contemporary 2-Stage Treatment of Periprosthetic Hip Infection with Evidence-Based Standardized Protocols Yields Excellent Results: Caveats and Recommendations. J Arthroplasty 2020; 35:2983-2995. [PMID: 32540305 DOI: 10.1016/j.arth.2020.05.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 05/05/2020] [Accepted: 05/14/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND This study quantified the effectiveness of contemporary and evidence-based standardized 2-stage treatment for periprosthetic hip infection. Findings illustrate potential limitations of criticisms of 2-stage protocols and potential consequences of adopting single-stage protocols before definitive data are available. METHODS Fifty-four consecutive hips treated with 2-stage resection and reimplantation were retrospectively reviewed. Standardized protocols were adhered to including implant resection, meticulous surgical debridement, antibiotic spacer, 6-week intravenous antibiotics, a 2-week drug holiday, and laboratory assessment of infection eradication before reimplantation. After reimplantation, patients were placed on prophylactic intravenous antibiotics until discharge and discharged on oral antibiotics for a minimum of 7 days until intraoperative cultures were final. Successful treatment was defined per Delphi-based International Multidisciplinary Consensus. RESULTS The overall treatment success rate was 95.7% (44 of 46 cases) with mean infection-free survivorship of 67.2 (range, 23.8-106.4) months. Success rates were 100% for early and acute hematogenous infections regardless of host type and 100% for chronic infections in uncompromised hosts. 95% (19/20) of chronic infections in compromised hosts and 83.3% (5/6) of chronic infections in significantly compromised hosts were successfully treated. About 4% of primary hips and 20% of revision hips required repeat debridement and spacer exchange after initial resection. No patients died because of treatment. CONCLUSION Details from this consecutive series of patients undergoing 2-stage treatment for hip infection suggest that some criticisms of 2-stage treatment as well as some arguments in support of single-stage treatment may be overstated. Promotion and uncritical adoption of single-stage treatment protocols are discouraged until further and more definitive data exist.
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McAlister IP, Perry KI, Mara KC, Hanssen AD, Berry DJ, Abdel MP. Two-Stage Revision of Total Hip Arthroplasty for Infection Is Associated with a High Rate of Dislocation. J Bone Joint Surg Am 2019; 101:322-329. [PMID: 30801371 DOI: 10.2106/jbjs.18.00124] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Two-stage exchange is the most common form of treatment of chronic infection following total hip arthroplasty (THA). We examined the prevalence of, and risk factors associated with, hip instability following 2-stage exchange as well as the fate of reimplanted hip prostheses that dislocated. METHODS Data on 515 2-stage exchange THAs performed between 2000 and 2014 at a single institution were retrospectively reviewed. Risk factors for instability as well as postoperative reoperations and revisions were analyzed. The impact of dislocation on these outcomes was evaluated as well. The mean age at the time of reimplantation was 65 years, and the mean duration of follow-up was 5 years (range, 2 to 15 years). RESULTS Dislocation occurred in 52 hips following reimplantation (cumulative probability = 8.9% at 1 year). There was a higher risk of instability in women (hazard ratio [HR] = 1.8, p = 0.038) and in those who had a history of dislocation prior to the 2-stage revision (HR = 5.1, p < 0.001). Younger age, body mass index, number of previous operations, spacer type, surgical approach, use of a constrained liner, femoral head diameter, and persistent or recurrent infection were not found to be significant risk factors. Patients with an absent or ununited greater trochanter or abductor deficiency also had a higher rate of dislocation (HR = 30, p < 0.001), as did patients who underwent reimplantation with a megaprosthesis (HR = 6.0, p < 0.001). The risk of additional reoperations (HR = 121, p < 0.001) and revision surgery (HR = 13, p < 0.001) was significantly higher in patients who experienced a dislocation after the 2-stage exchange. CONCLUSIONS Dislocation after 2-stage exchange THA continues to be a major concern, with the 1-year cumulative probability found to be 9% in the present study. Female sex, a history of dislocation, an absent or ununited greater trochanter or abductor deficiency, and reimplantation with a megaprosthesis were identified as risk factors for dislocation. There is a remarkable 121-fold increase in the rate of reoperations and a 13-fold increase in the rate of revisions in hips that dislocated after 2-stage exchange THA. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Does cemented or cementless single-stage exchange arthroplasty of chronic periprosthetic hip infections provide similar infection rates to a two-stage? A systematic review. BMC Infect Dis 2016; 16:553. [PMID: 27724919 PMCID: PMC5057405 DOI: 10.1186/s12879-016-1869-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 09/27/2016] [Indexed: 12/13/2022] Open
Abstract
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.
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Li P, Hou M, Zhu ZQ, Shi ZJ. Cementless revision for infected hip arthroplasty: an 8.6 years follow-up. Orthop Surg 2015; 7:37-42. [PMID: 25708034 DOI: 10.1111/os.12159] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 11/09/2014] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Peng Li
- Department of Orthopaedic Surgery, Longgang District People's Hospital of Shenzhen, Shenzhen, China
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Hoberg M, Konrads C, Engelien J, Oschmann D, Holder M, Walcher M, Steinert A, Rudert M. Similar outcomes between two-stage revisions for infection and aseptic hip revisions. INTERNATIONAL ORTHOPAEDICS 2015; 40:459-64. [PMID: 26130288 DOI: 10.1007/s00264-015-2850-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 04/12/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE Two-stage revision hip arthroplasty using an antibiotic-loaded spacer is the most widely performed procedure for infected hip arthroplasties. The clinical outcome of this type of surgery compared with aseptic joint revision with exchange of femoral and acetabular components is still controversial due to the relative lack of medium- to long-term follow-up. Therefore, we analysed clinical and radiological outcomes of septic two-stage revisions compared with aseptic hip revision surgeries. METHODS In this retrospective study we assessed 82 consecutive patients who underwent two-stage revision for septic total hip (45 patients) or one-stage aseptic revision arthroplasty (37 patients). The average follow-up was 53 months for the aseptic group and 55 months for the septic group. For clinical evaluation, we used the Harris Hip Score (HHS) and the Merle d'Aubigné and Postel score. The postoperative pain level was determined with the visual analogue pain scale. RESULTS The surgeries were performed 124 months (aseptic group) and 119 months (septic group) after primary total hip arthroplasty on average. The main indications for aseptic revision surgeries were aseptic loosening (96%), dislocation (2.2%), and periprosthetic fracture (2.2%). In the clinical outcome patients achieved 75.5 points in the aseptic group and 73.4 points in the septic group in the Harris Hip Score. The Merle d'Aubigné and Postel Score revealed 12.5 points for the aseptic group and 13.1 points for the septic group. Mean level of persisting pain was 0.8 (aseptic group) and 0.4 (septic group) on the visual analogue scale (VAS). Overall survival in the aseptic group was 85.6% at 9.8 years 82.7% at 10.1 years for the septic group, with a repeat revision rate of 8.1% and 6.7%, respectively. CONCLUSIONS Performing aseptic acetabular and femoral revision hip arthroplasty showed equal clinical outcomes in relation to septic two-stage revision hip surgeries. Our results showed a tendency for better outcome in comparison with the information given in the literature for septic and nonseptic exchange arthroplasties, including a lower rate of re-revisions.
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Affiliation(s)
- Maik Hoberg
- Orthopaedic Department Koenig-Ludwig-Haus, Center for Musculoskeletal Research, Julius-Maximilians-University Wuerzburg, Brettreichstr. 11, 97074, Wuerzburg, Germany.
| | - Christian Konrads
- Orthopaedic Department Koenig-Ludwig-Haus, Center for Musculoskeletal Research, Julius-Maximilians-University Wuerzburg, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Jana Engelien
- Orthopaedic Department Koenig-Ludwig-Haus, Center for Musculoskeletal Research, Julius-Maximilians-University Wuerzburg, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Dorothee Oschmann
- Orthopaedic Department Koenig-Ludwig-Haus, Center for Musculoskeletal Research, Julius-Maximilians-University Wuerzburg, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Michael Holder
- Orthopaedic Department Koenig-Ludwig-Haus, Center for Musculoskeletal Research, Julius-Maximilians-University Wuerzburg, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Matthias Walcher
- Orthopaedic Department Koenig-Ludwig-Haus, Center for Musculoskeletal Research, Julius-Maximilians-University Wuerzburg, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - André Steinert
- Orthopaedic Department Koenig-Ludwig-Haus, Center for Musculoskeletal Research, Julius-Maximilians-University Wuerzburg, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Maximilian Rudert
- Orthopaedic Department Koenig-Ludwig-Haus, Center for Musculoskeletal Research, Julius-Maximilians-University Wuerzburg, Brettreichstr. 11, 97074, Wuerzburg, Germany
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Two-Stage Revision Arthroplasty for Periprosthetic Hip Infection: Mean Follow-Up of Ten Years. BIOMED RESEARCH INTERNATIONAL 2015; 2015:345475. [PMID: 26064901 PMCID: PMC4429212 DOI: 10.1155/2015/345475] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 10/14/2014] [Indexed: 01/27/2023]
Abstract
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.
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Dieckmann R, Schulz D, Gosheger G, Becker K, Daniilidis K, Streitbürger A, Hardes J, Hoell S. Two-stage hip revision arthroplasty with a hexagonal modular cementless stem in cases of periprosthetic infection. BMC Musculoskelet Disord 2014; 15:398. [PMID: 25428415 PMCID: PMC4289174 DOI: 10.1186/1471-2474-15-398] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 11/18/2014] [Indexed: 12/15/2022] Open
Abstract
Background Two-stage revision arthroplasty is today regarded as the gold standard treatment method for deep prosthetic joint infection. The aim of the present study was to evaluate clinical and functional outcomes with the Modular Universal Tumor And Revision System (MUTARS) RS stem in patients undergoing two-stage revisions. Methods The functional and clinical outcomes for 43 patients who had undergone two-stage revision procedures for PJI were analyzed in a retrospective study. The minimum follow-up period was 24 months. Shorter follow-up periods were only observed when there were complications such as loosening or recurrent infection. The mean follow-up period was 3.86 years (range 7 months to 11.6 years). Results The success rate with infection control for PJI was 93%. Reinfection occurred in four cases (7%). The risk of reinfection after MRSA infection was 20.5 times greater (P >0.01) than with sensitive or unknown bacteria. Two aseptic loosening occurred after 7 and 20 months. The average Harris Hip Score was 80 (range 62–93). Conclusion This retrospective study showed a 93% rate of eradication using specific antibiotic therapy. With the modular MUTARS RS stem, there was a low rate of aseptic loosening of 4.6%. MRSA infection was identified as a risk factor for reinfection. The two-stage procedure with modular cementless implants used is therefore appropriate for treating periprosthetic infections associated with hip endoprostheses. Electronic supplementary material The online version of this article (doi:10.1186/1471-2474-15-398) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ralf Dieckmann
- Department of Orthopedics and Tumor Orthopedics, Münster University Hospital, Albert-Schweitzer-Campus 1, A1, 48149 Münster, Germany.
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Ibrahim MS, Raja S, Khan MA, Haddad FS. A multidisciplinary team approach to two-stage revision for the infected hip replacement. Bone Joint J 2014; 96-B:1312-8. [DOI: 10.1302/0301-620x.96b10.32875] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We report the five year outcomes of a two-stage approach for infected total hip replacement. This is a single-surgeon experience at a tertiary centre where the more straightforward cases are treated using single-stage exchange. This study highlights the vital role of the multidisciplinary team in managing these cases. A total of 125 patients (51 male, 74 female) with a mean age of 68 years (42 to 78) were reviewed prospectively. Functional status was assessed using the Harris hip score (HHS). The mean HHS improved from 38 (6 to 78.5) pre-operatively to 81.2 (33 to 98) post-operatively. Staphylococcus species were isolated in 85 patients (68%). The rate of control of infection was 96% at five years. In all, 19 patients died during the period of the study. This represented a one year mortality of 0.8% and an overall mortality of 15.2% at five years. No patients were lost to follow-up. We report excellent control of infection in a series of complex patients and infections using a two-stage revision protocol supported by a multidisciplinary approach. The reason for the high rate of mortality in these patients is not known. Cite this article: Bone Joint J 2014;96-B:1312–18
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Affiliation(s)
- M. S. Ibrahim
- University College London Hospitals, 235
Euston Rd, London NW1 2BU, UK
| | - S. Raja
- London Hospital, Barts
Health NHS Trust, Royal Whitechapel, London
E1 1BB, UK
| | - M. A. Khan
- The Royal Sussex County Hospital, Brighton & Sussex University Hospitals NHS Trust, Eastern Road, Brighton BN2 5BE, UK
| | - F. S. Haddad
- University College London Hospitals, 235
Euston Rd, London NW1 2BU, UK
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Fink B, Urbansky K, Schuster P. Mid term results with the curved modular tapered, fluted titanium Revitan stem in revision hip replacement. Bone Joint J 2014; 96-B:889-95. [PMID: 24986941 DOI: 10.1302/0301-620x.96b7.33280] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
We report our experience of revision total hip replacement (THR) using the Revitan curved modular titanium fluted revision stem in patients with a full spectrum of proximal femoral defects. A total of 112 patients (116 revisions) with a mean age of 73.4 years (39 to 90) were included in the study. The mean follow-up was 7.5 years (5.3 to 9.1). A total of 12 patients (12 hips) died but their data were included in the survival analysis, and four patients (4 hips) were lost to follow-up. The clinical outcome, proximal bone regeneration and subsidence were assessed for 101 hips. The mean Harris Hip Score was 88.2 (45.8 to 100) after five years and there was an increase of the mean Barnett and Nordin-Score, a measure of the proximal bone regeneration, of 20.8 (-3.1 to 52.7). Five stems had to be revised (4.3%), three (2.9%) showed subsidence, five (4.3%) a dislocation and two of 85 aseptic revisions (2.3%) a periprosthetic infection. At the latest follow-up, the survival with revision of the stem as the endpoint was 95.7% (95% confidence interval 91.9% to 99.4%) and with aseptic loosening as the endpoint, was 100%. Peri-prosthetic fractures were not observed. We report excellent results with respect to subsidence, the risk of fracture, and loosening after femoral revision using a modular curved revision stem with distal cone-in-cone fixation. A successful outcome depends on careful pre-operative planning and the use of a transfemoral approach when the anatomy is distorted or a fracture is imminent, or residual cement or a partially-secured existing stem cannot be removed. The shortest appropriate stem should, in our opinion, be used and secured with > 3 cm fixation at the femoral isthmus, and distal interlocking screws should be used for additional stability when this goal cannot be realised.
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Affiliation(s)
- B Fink
- Orthopaedic Clinic Markgröningen, Kurt-Lindemann-Weg 10, D-71706 Markgröningen, Germany
| | - K Urbansky
- Orthopaedic Clinic Markgröningen, Kurt-Lindemann-Weg 10, D-71706 Markgröningen, Germany
| | - P Schuster
- Orthopaedic Clinic Markgröningen, Kurt-Lindemann-Weg 10, D-71706 Markgröningen, Germany
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Gil Gonzalez S, Marqués López F, Rigol Ramon P, Mestre Cortadellas C, Cáceres Palou E, León García A. Two-stage revision of hip prosthesis infection using a hip spacer with stabilising proximal cementation. Hip Int 2014; 20 Suppl 7:S128-34. [PMID: 20512784 DOI: 10.1177/11207000100200s721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2010] [Indexed: 02/04/2023]
Abstract
Two-stage revision hip arthroplasty for infection using an antibiotic-loaded cement spacer has been used frequently with good results. However, spacer instability is also frequent. Proximal cementation of the spacer could avoid spacer dislocation. We retrospectively assessed 35 patients in whom a 2-stage revision hip arthroplasty for infection was carried out using an antibiotic-loaded cement spacer with gentamicin (Spacer-G) in which the spacer was proximally cemented in 16 patients. The mean follow-up was 32 months. We assessed spacer stability and infection elimination. There were 8 spacer dislocations (22.9%), 5 in hips without proximal cementation and 2 in hips with proximal cementation (p>0.05). There was no fracture in any hip. Reinfection occurred in 5 hips (14.3%), in 3 with the same microorganism, while 2 had a different microorganism. Our results indicate that the proximal cementation of the spacer prevents its dislocation. Infection was eliminated in 86% of the hips.
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Affiliation(s)
- Sergi Gil Gonzalez
- Orthopaedic Surgery Department, Hospitales del Imas, Mar y Esperanza, Universitat Autónoma de Barcelona, Barcelona, Spain
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Leonard HAC, Liddle AD, Burke Ó, Murray DW, Pandit H. Single- or two-stage revision for infected total hip arthroplasty? A systematic review of the literature. Clin Orthop Relat Res 2014; 472:1036-42. [PMID: 24057192 PMCID: PMC3916596 DOI: 10.1007/s11999-013-3294-y] [Citation(s) in RCA: 147] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 09/12/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND The best approach for surgical treatment of an infected THA remains controversial. Two-stage revision is believed to result in lower reinfection rates but may result in significant functional impairment. Some authors now suggest that single-stage revision may provide comparable results in terms of infection eradication while providing superior functional outcomes. QUESTIONS/PURPOSES We performed a systematic review to determine whether single- or two-stage revision for an infected THA provides lower reinfection rates and higher functional outcome scores. METHODS We conducted a comprehensive search of PubMed and Embase, using the search string [Infection AND ("total hip replacement" OR "total hip arthroplasty") AND revision]. All studies comparing reinfection rates or functional scores for single- and two-stage revision were retrieved and reviewed. A systematic review was performed according to the PRISMA checklist. RESULTS The initial search retrieved 1128 studies. Following strict exclusion criteria, we identified nine comparative studies comparing reinfection rates (all nine studies) or functional scores (four studies) between single- and two-stage revisions. The overall quality of studies was poor with no randomized studies being identified. Groups often varied in their baseline characteristics. There was no consensus among the studies regarding the relative incidence of reinfection between the two procedures. There was a trend toward better functional outcomes in single-stage surgery, but this reached significance in only one study. CONCLUSIONS In appropriate patients, single-stage revision appears to be associated with similar reinfection rates when compared with two-stage revision with superior functional outcomes. This concurs with earlier studies, but given the methodologic quality of the included studies, these findings should be treated with caution. High-quality randomized studies are needed to compare the two approaches to confirm these findings, and, if appropriate, to determine which patients are appropriate for single-stage revision.
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Affiliation(s)
- Hugh A. C. Leonard
- />Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD UK
| | - Alexander D. Liddle
- />Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD UK
| | - Órlaith Burke
- />Department of Statistics, University of Oxford, South Parks Road, Oxford, OX1 3TG UK
| | - David W. Murray
- />Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD UK
| | - Hemant Pandit
- />Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD UK
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High diagnostic value of synovial biopsy in periprosthetic joint infection of the hip. Clin Orthop Relat Res 2013; 471:956-64. [PMID: 22806261 PMCID: PMC3563795 DOI: 10.1007/s11999-012-2474-5] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Accepted: 06/25/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND The role of the synovial biopsy in the preoperative diagnosis of a periprosthetic joint infection (PJI) of the hip has not been clearly defined. QUESTIONS/PURPOSES We asked whether the value of a biopsy for a PJI is greater than that of aspiration and C-reactive protein (CRP). METHODS Before revision in 100 hip endoprostheses, we obtained CRP values, aspirated the joint, and obtained five synovial biopsy samples for bacteriologic analysis and five for histologic analysis. Microbiologic and histologic analyses of the periprosthetic tissue during revision surgery were used to verify the results of the preoperative diagnostic methods. The minimum followup was 24 months (median 32; range, 24-47 months). RESULTS Forty-five of the 100 prostheses were identified as infected. The biopsy, with a combination of the bacteriologic and histologic examinations, showed the greatest diagnostic value of all the diagnostic procedures and led to a sensitivity of 82% (95% CI, ± 11%), specificity of 98% (95% CI, ± 4%), positive predictive value of 97% (95% CI, ± 5%), negative predictive value of 87% (95% CI, ± 8.3%), and accuracy of 91%. CONCLUSIONS The biopsy technique has a greater value than aspiration and CRP in the diagnosis of PJI of the hip (Masri et al. J Arthroplasty 22:72-78, 2007). In patients with a negative aspirate, but increased CRP or clinical signs of infection, we regard biopsy to be preferable to just repeating the aspiration. LEVEL OF EVIDENCE Level II prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
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15
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Neumann DRP, Hofstaedter T, List C, Dorn U. Two-stage cementless revision of late total hip arthroplasty infection using a premanufactured spacer. J Arthroplasty 2012; 27:1397-401. [PMID: 22177795 DOI: 10.1016/j.arth.2011.10.022] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2011] [Accepted: 10/21/2011] [Indexed: 02/01/2023] Open
Abstract
We observed 44 patients with 2-stage revisions for septic hip prostheses. We used a uniform protocol consisting of the implantation of a preformed spacer (interval 12-26 weeks), specific systemic antibiotic therapies, and cementless total hip arthroplasty at time of reimplantation. The minimum follow-up was 36 months (mean, 67 months; range, 36-120 months). During the spacer period, we observed 4 dislocations and 2 fractures leading to a resection arthroplasty interval before reimplantation in 5 cases. In one patient, reinfection was diagnosed 12 months after reimplantation. The Harris hip score increased from a preoperative mean of 39 to 90 at a mean follow-up of 67 months after reimplantation.
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16
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Fink B. Revision of late periprosthetic infections of total hip endoprostheses: pros and cons of different concepts. Int J Med Sci 2009; 6:287-95. [PMID: 19834595 PMCID: PMC2755126 DOI: 10.7150/ijms.6.287] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2009] [Accepted: 09/02/2009] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Bernd Fink
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany.
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17
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Fink B, Grossmann A, Fuerst M, Schäfer P, Frommelt L. Two-stage cementless revision of infected hip endoprostheses. Clin Orthop Relat Res 2009; 467:1848-58. [PMID: 19002539 PMCID: PMC2690736 DOI: 10.1007/s11999-008-0611-y] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2008] [Accepted: 10/22/2008] [Indexed: 01/31/2023]
Abstract
UNLABELLED 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.
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Affiliation(s)
- Bernd Fink
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany.
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18
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Rudelli S, Uip D, Honda E, Lima ALLM. One-stage revision of infected total hip arthroplasty with bone graft. J Arthroplasty 2008; 23:1165-77. [PMID: 18534510 DOI: 10.1016/j.arth.2007.08.010] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2006] [Accepted: 08/08/2007] [Indexed: 02/01/2023] Open
Abstract
There are many different opinions in the literature regarding the best procedure for revision of infected hip arthroplasty and hence in achieving long-term stabilization of a new implant. Thirty-two patients with 32 loose and infected total hip arthroplasties underwent revision with a bone graft in a 1-stage procedure. The bone graft was used in the acetabulum and femur in 25 patients, in the acetabulum alone in 4 patients and in the femur alone in 3 patients. A metal mesh was necessary in 15 patients to contain the morselized bone graft. At the time of surgical revision, 9 patients had a draining sinus, 6 had a closed sinus, and 17 had never had sinuses in the surgical wound. Antibiotic therapy was administered intravenously and orally for 6 months. Mean follow-up was 103 months (range, 63-183 months), and infection recurred in 2 (6.2%) cases. Further studies are necessary, and continuation of this method is justified.
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Affiliation(s)
- Sergio Rudelli
- Department of Orthopaedic Surgery, Santa Casa Medical School, São Paulo, Brazil
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19
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Masri BA, Panagiotopoulos KP, Greidanus NV, Garbuz DS, Duncan CP. Cementless two-stage exchange arthroplasty for infection after total hip arthroplasty. J Arthroplasty 2007; 22:72-8. [PMID: 17197311 DOI: 10.1016/j.arth.2006.02.156] [Citation(s) in RCA: 138] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2005] [Accepted: 02/20/2006] [Indexed: 02/01/2023] Open
Abstract
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.
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Affiliation(s)
- Bassam A Masri
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
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20
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Abstract
Dislocation is a well documented complication after a two-stage revision arthroplasty for a deep periprosthetic hip infection. We are aware of no reports specifically evaluating the risk factors for dislocation after reimplantation for infection. We hypothesized greater age, increase in the number of operations on the hip, increase in the length of time from resection to reimplantation, greater limb length discrepancy, smaller femoral offset, and using smaller femoral heads would increase the risk of dislocation. We retrospectively reviewed 34 patients who had a two-stage hip revision for periprosthetic infection with a minimum followup of 2 years. Risk factors for dislocation were evaluated. We compared the rate of dislocation in this group to those patients having revision for aseptic failure. Sixteen dislocations occurred in five (14.7%) of 34 patients. Dislocation occurred in three (1.7%) of 171 patients having revision for aseptic failure. In this small series, age at reimplantation, number of previous operations on the hip, length of time from resection to reimplantation, limb length discrepancy, femoral offset, and femoral head size did not seem to be risk factors for dislocation.
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Affiliation(s)
- Curtis W Hartman
- University of Nebraska Medical Center, Department of Orthopaedic Surgery and Rehabilitation, Omaha, NE 68198-1080, USA.
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21
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Abstract
Success in the treatment of infected orthopedic prosthesis requires the best surgical approach in combination with prolonged optimum targeted antimicrobial therapy. In choosing the surgical option, one must consider the type of infection, condition of the bone stock and soft tissue, the virulence and antimicrobial susceptibility of the pathogen, the general health and projected longevity of the patient, and the experience of the surgeon. If surgery is not possible, an alternative is long-term oral antimicrobial suppression to maintain a functioning prosthesis. Treatment must be individualized for a specific infection in a specific patient.
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Affiliation(s)
- Irene G Sia
- Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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22
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Kraay MJ, Goldberg VM, Fitzgerald SJ, Salata MJ. Cementless two-staged total hip arthroplasty for deep periprosthetic infection. Clin Orthop Relat Res 2005; 441:243-9. [PMID: 16331010 DOI: 10.1097/01.blo.0000194312.97098.0a] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
UNLABELLED 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.
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Affiliation(s)
- Matthew J Kraay
- Department of Orthopaedic Surgery, University Hospitals of Cleveland and the Case Western Reserve University, Cleveland, OH 44106, USA.
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23
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Hsieh PH, Chen LH, Chen CH, Lee MS, Yang WE, Shih CH. Two-stage revision hip arthroplasty for infection with a custom-made, antibiotic-loaded, cement prosthesis as an interim spacer. ACTA ACUST UNITED AC 2004; 56:1247-52. [PMID: 15211133 DOI: 10.1097/01.ta.0000130757.53559.bf] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Pang-Hsin Hsieh
- Department of Orthopedics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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24
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Abstract
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.
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Affiliation(s)
- Arlen D Hanssen
- Department of Orthopedics, Mayo Clinic and Mayo Foundation, 200 First Street Southwest, Rochester, MN 55906, USA.
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25
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Charlton WPH, Hozack WJ, Teloken MA, Rao R, Bissett GA. Complications associated with reimplantation after girdlestone arthroplasty. Clin Orthop Relat Res 2003:119-26. [PMID: 12567138 DOI: 10.1097/00003086-200302000-00019] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Complications associated with reimplantation of a total hip arthroplasty after resection or Girdlestone arthroplasty for treatment of an infected hip are not well-documented. Forty-four hips in 44 patients with a minimum 2-year followup (range, 2-9 years) from the time of reimplantation total hip arthroplasty were evaluated retrospectively. The average Harris hip score changed from 40 preoperatively to 78 at the latest followup. One patient had persistent infection requiring rerevision surgery, and another patient had rerevision surgery for recurrent dislocation. Complications related to the prosthesis consisted of dislocations in five patients (11.4%), recurrent infection in one patient (2.3%), trochanteric nonunion in four patients (9.1%), hematoma in one patient, heterotopic ossification in one patient, and postoperative wound drainage in one patient. Resection arthroplasty of the hip is highly effective in eradicating infection. In the current series, 97.7% of patients were free of infection at the latest followup. However, with an 11.4% dislocation rate and 39% of patients having a persistent limp, alternative approaches need to be evaluated which might reduce these complications.
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Affiliation(s)
- William P H Charlton
- Department of Orthopaedic Surgery, Rothman Institute Orthopaedics, Thomas Jefferson University, Philadelphia, PA 19107, USA
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26
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Wentworth SJ, Masri BA, Duncan CP, Southworth CB. Hip prosthesis of antibiotic-loaded acrylic cement for the treatment of infections following total hip arthroplasty. J Bone Joint Surg Am 2003; 84-A Suppl 2:123-8. [PMID: 12479350 DOI: 10.2106/00004623-200200002-00017] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Abstract
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.
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Affiliation(s)
- F S Haddad
- Division of Reconstructive Orthopaedics, University of British Columbia, Vancouver, Canada
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28
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Abstract
Twenty-five patients with documented infection of the hip were reviewed. All patients underwent reconstruction in a 2-stage fashion with cementless implants. The average follow-up in this group was 41 months. The average time to reimplantation was 4.8 months. Of the 25 living patients, 22 retained their implants. There were 2 recurrences of infection, for an infection recurrence rate of 8% (2 of 25). The average postoperative Harris Hip Score was 81. Bone ingrowth was confirmed radiographically via the Engh fixation score in all but 1 of the surviving implants. Cementless fixation in 2-stage reimplantation can result in acceptable eradication rates, while supplying predictable fixation, provided that appropriate cementless revision implants are used.
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Affiliation(s)
- T K Fehring
- Charlotte Orthopedic Specialists and the Charlotte Orthopedic Research Institute, USA
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29
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HANSSEN ARLEND, RAND JAMESA. Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Evaluation and Treatment of Infection at the Site of a Total Hip or Knee Arthroplasty*†. J Bone Joint Surg Am 1998. [DOI: 10.2106/00004623-199806000-00016] [Citation(s) in RCA: 94] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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Abstract
Between 1976 and 1992, reinfection developed in 34 patients treated for an infected total hip arthroplasty with removal of the prosthesis and implantation of another prosthesis. These patients included 15 men and 19 women with a mean age of 62 years. Infection recurred an average of 2.2 years after reimplantation of the new prosthesis. Followup after the diagnosis of reinfection averaged 5.1 years. Reinfection after an attempt at reimplantation total hip arthroplasty was seldom compatible with a good functional outcome. Resection arthroplasty was reliable in eradicating reinfection but led to poor function and was associated with persistent pain. Although reimplantation of a third prosthesis allowed 3 patients to achieve an excellent result, the 8 hips that failed a third reimplantation attempt had the worst functional results in this study. The results from the present series suggest that reinfection after an attempt at reimplantation is a contraindication to further attempts at a 1-stage reimplantation of another prosthesis. Those patients in whom the same single microorganism has been identified from the failed primary total hip and from the failed first reimplantation, however, may be reasonable candidates for an attempt at a 2-stage reimplantation of a third prosthesis, particularly when a deficiency in prior antibiotic therapy or surgical technique can be identified.
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Affiliation(s)
- M W Pagnano
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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31
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Kendall RW, Duncan CP, Beauchamp CP. Bacterial growth on antibiotic-loaded acrylic cement. A prospective in vivo retrieval study. J Arthroplasty 1995; 10:817-22. [PMID: 8749767 DOI: 10.1016/s0883-5403(05)80081-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Twenty-three patients with intraoperative culture-proven periprosthetic infection of the hip or knee were enrolled in a prospective cement retrieval study. All were treated with a two-stage technique using antibiotic-loaded acrylic cement as an antibiotic depot. Staphylococcus epidermidis was the most commonly isolated organism (19 of 23 cases). Cement and tissue were examined at second-stage revision for the presence of viable organisms. In this series, no organisms were isolated from the surface of the cement, a 100% concordance with the tissue cultures. A subsequent failure rate of 4.4% (1 case) was seen in this series. Investigation suggests this may represent reinfection from a new strain of organism rather than failure of eradication of the original infection.
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Affiliation(s)
- R W Kendall
- Department of Orthopaedics, University of British Columbia, Vancouver, Canada
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32
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Affiliation(s)
- K L Garvin
- Department of Orthopaedic Surgery, University of Nebraska Medical Center, Omaha 68198-1080, USA
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33
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Nestor BJ, Hanssen AD, Ferrer-Gonzalez R, Fitzgerald RH. The use of porous prostheses in delayed reconstruction of total hip replacements that have failed because of infection. J Bone Joint Surg Am 1994; 76:349-59. [PMID: 8126040 DOI: 10.2106/00004623-199403000-00005] [Citation(s) in RCA: 83] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Between March 1984 and March 1989, thirty-four patients who had an infection at the site of a cemented total hip prosthesis were managed with resection arthroplasty and delayed implantation of a porous total hip prosthesis without cement. The interval from the time of the resection arthroplasty to the implantation of another prosthesis averaged eight months (range, three to nineteen months). At an average of forty-seven months (range, twenty-four to seventy-two months) after the reimplantation, six patients (18 per cent) had recurrence of the infection. Patients who had rheumatoid arthritis were at significantly higher risk for the development of a recurrent infection (p < 0.01). Of the twenty-eight patients who did not have a recurrent infection, six had definite radiographic evidence of loosening of the femoral component at the latest follow-up evaluation. For twenty-five of the twenty-eight patients, sufficient data were available for calculation of the Mayo Clinic hip score; only fourteen (56 per cent) of these patients had a satisfactory functional outcome. The high (68 per cent) rate of complications and the long-term durability of the prosthesis in these patients remain a concern. The fact that 18 per cent of the patients had a recurrent infection suggests that avoidance of the use of bone cement does not improve the rate of resolution of infection after a delayed revision operation in patients who have an infection following a total hip arthroplasty.
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Affiliation(s)
- B J Nestor
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota 55905
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34
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Abstract
The role of aspiration of the hip joint before revision of a total hip arthroplasty remains controversial. To address this issue, we reviewed the results of 270 consecutive hips in which aspiration had been attempted before revision procedures that were performed between 1980 and 1988. All hips had intraoperative findings and clinical follow-up of at least two years to confirm the presence or absence of infection. Only six (2 per cent) of the 270 hips were determined to be infected. Aspiration had been attempted in all six hips, but fluid could be obtained from only four. All six hips also had clinical or radiographic signs, or both, of infection, including increasing pain within three years after the arthroplasty (four hips), inability of the patient to attain pain-free status after the original procedure (four hips), radiographic findings compatible with infection (six hips), and a positive finding on culture of a specimen obtained from a previous aspiration (two hips). Because of these factors, aspiration was attempted a second time in four of the six hips and a third time in three of the four. The four hips from which fluid could be obtained had a total of ten successful aspirations; the cultures of specimens obtained from six of these procedures were positive and those from four were negative. The appearance of the capsular tissue at the time of the operation suggested infection in five of the six infected hips. Histological sections were positive for inflammation in all six: there was acute inflammation only in one, chronic inflammation only in two, and acute and chronic inflammation in three. No organisms were seen on gram stains of specimens from any of the six infected hips. Of the 254 hips that did not have an infection and had been aspirated successfully, thirty-two (13 per cent) had a false-positive result on culture of a specimen of the aspiration fluid. Only two (6 per cent) of the thirty-four hips that had a positive result on culture of fluid from the initial aspiration had a true-positive result. No hip had a true-positive result on culture of fluid that had been aspirated preoperatively without also having clinical and radiographic evidence of infection. On the basis of these findings, we recommend that aspiration be performed in selected patients rather than routinely. It also should be performed only if a detailed clinical history suggests infection or if radiographs demonstrate focal lysis, aggressive non-focal lysis, or periostitis.
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Affiliation(s)
- R L Barrack
- Orthopaedic Biomechanics Laboratory, Massachusetts General Hospital, Boston 02114
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