Infected Total Hip Replacement Research Articles

Cementless revision for infected total hip replacements

Cementless revision for infected total hip replacements

Cementless revision for infected total hip replacements

Our aim was to determine the success rate of repeated debridement and two-stage cementless revision arthroplasty according to the type of infected total hip replacement (THR). We enrolled 294 patients (294 hips) with an infected THR in the study. There were 222 men and 72 women with a mean age of 55.1 years (24.0 to 78.0). The rate of control of infection after the initial treatment and after repeated debridement and two-stage revisions was determined. The clinical (Harris hip score) and radiological results were evaluated. The mean follow-up was 10.4 years (5.0 to 14.0). The eventual rate of control of infection was 100.0% for early superficial post-operative infection, 98.4% for early deep post-operative infection, 98.5% for late chronic infection and 91.0% for acute haematogenous infection. Overall, 288 patients (98%) maintained a functioning THR at the latest follow-up. All the allografts appeared to be united and there were no failures. These techniques effectively controlled infection and maintained a functional THR with firm fixation in most patients. Repeated debridement and two-stage or repeated two-stage revisions further improved the rate of control of infection after the initial treatment and increased the likelihood of maintaining a functional THR.

The Use of PROSTALAC in Two-stage Reimplantation of Septic Total Knee and Hip Arthroplasty

The PROSTALAC (PROSThesis Antibiotic Loaded Acrylic Cement) functional spacer is made with antibiotic-loaded acrylic cement. We use it as an interim spacer in two-stage exchange arthroplasty in cases of infected total knee or total hip replacement. PROSTALAC allows continuous rehabilitation between stages as it maintains good alignment and stability of the joint with a reasonable range of movement. It also helps to maintain the soft-tissue planes, thereby facilitating the second-stage procedure. We report here early outcomes of the use of PROSTALAC in 5 patients - 3 in total knee replacements, 1 in a total hip replacement and 1 in a bipolar hemiarthroplasty.

Infected Total Hip Replacement in Our Clinic

Infected Total Hip Replacement in Our Clinic

Outcomes of revision total hip replacement for infection after grading according to a standard protocol

Periprosthetic infection following total hip replacement can be a catastrophic complication for the patient. The treatments available include single-stage exchange, and two-stage exchange. We present a series of 50 consecutive patients with a diagnosis of infected total hip replacement who were assessed according to a standardised protocol. Of these, 11 underwent single-stage revision arthroplasty with no recurrence of infection at a mean of 6.8 years follow-up (5.5 to 8.8). The remaining 39 underwent two-stage revision, with two recurrences of infection successfully treated by a second two-stage procedure. At five years, significant differences were found in the mean Harris Hip Scores (single-stage 87.8; two-stage 75.5; p = 0.0003) and in a visual analogue score for satisfaction (8.6; 6.9; p = 0.001) between the single- and two-stage groups. Single-stage exchange is successful in eradicating periprosthetic infection and results in excellent functional and satisfaction scores. Identification of patients suitable for the single-stage procedure allows individualisation of care and provides as many as possible with the correct strategy in successfully tackling their periprosthetic infection.

Use of a Cement-Loaded Kuntscher Nail in First-Stage Revision Hip Arthroplasty for Massive Femoral Bone Loss Secondary to Infection: A Report of Four Cases

A 2-stage revision total hip replacement (THR) is the standard treatment for a chronically infected THR with severe metadiaphyseal bone loss. A long-stem cemented prosthesis as part of a temporary articular spacer is commonly used during the first-stage procedure. Nonetheless, this option is expensive and can pose difficulties for patients with a small medullary canal. A construct using an antibiotic cement-loaded Kuntscher nail cemented with a highly polished Exeter stem has been devised and used in 4 patients.

One-stage revision of septic hip prosthesis with antibiotic-loaded bone grafts and cementless implants

Infection of total hip replacement (THR) is a serious complication, necessitating its complete removal and thorough debridement of the site. Usually long-term antibiotic treatment and a multitude of surgical interventions within a period of several months are required until a definitive supply can be achieved. One-stage exchange using antibiotic containing cement did not gain widespread use because of several risks, although the possible clinical and economic advantages are evident. Allograft bone may be impregnated with high loads of antibiotics using a special technique and acts as a carrier, avoiding the disadvantages of cement. Based on this technology 37 exchange procedures of infected THR were performed in a single stage, all of them without the use of bone cement. Three hips required re-revision because of re-infection, the remaining 34 hips (92%) stayed infection-free and stable for a period between 2 and 8 years after surgery. No adverse side effects could be found. Incorporation appeared as after grafting with unimpregnated grafts. Antibiotic impregnated allograft bone may enable reconstruction of bone stock, insertion of an uncemented implant and control of infection in a single operation.

A preformed temporary antibiotic-loaded cement spacer for the treatment of destructive septic hip arthritis: a case report

Preformed spacers have proved to be effective in the two-stage revision of infected total hip replacements. In the treatment of septic arthritis of the hip, the use of a temporary device has occasionally been described, but the implantation of a preformed antibiotic-loaded spacer has not yet been reported. A 71-year-old man with a destructive Staphylococcus aureus septic arthritis of the hip joint was admitted to hospital. Given the persistence of local infection regardless of all antibiotics and the worsening of joint damage, an aggressive surgical treatment including early placement of a preformed temporary spacer loaded with antibiotics was performed. Two months later an uncemented total hip replacement was successfully implanted. Two years after surgery the patient had a complete functional recovery with no signs of recurrence. The advantages of a preformed device include an effective and predictable local release of antibiotics and a mechanically tested resistance that allows early partial weight bearing and immediate joint mobilization.

Two Stage one Component Revision in Infected Total hip Replacements - two Case reports and Literature Review

We present two cases of infected primary total hip replacements (THR) where only one of the two components exhibited loosening. Both were revised using a two stage, one component revision technique, replacing the loose component only. In the first case the acetabular component was revised leaving the original femoral stem in situ. In the second case, the femoral component was revised, leaving the original acetabular cup undisturbed. Both patients remained infection free at three and half and three years follow up respectively.

Management of Infected Total Hip Replacement in A Patient of Bilateral Severe Osteoarthritis

A 53-year-old housewife with a 12-month history of progressively worsening pain in both hips and inability to walk, underwent THR Right hip in 2004, which got infected and was subsequently removed after 4 months. Acetabular cup was not removed. She came to Apollo Hyderabad in December 2005. Clinical examination revealed persistent discharging sinus in right hip with grossly painful right hip movements. Right hip debridement, removal of acetabular cup & cement with instillation of Gentamycin beads was done. Considering severe Osteoarthritic changes in the left hip, confirmed by clinical and radiological examination, Left THR was done 3 weeks later. Subsequently, revision Right THR was done 3 weeks later after confirmation of infection free status by clinical, radiological & haematological parameters. She is doing well and is walking without support at 3 years folllow up. This interesting case report illustrates the management of painful bilateral Osteoarthritis of the hip with an infected total hip prosthesis in situ on one side.

Management of Infected Total Hip Replacement in a Patient of Bilateral Severe Osteoarthritis

Management of Infected Total Hip Replacement in a Patient of Bilateral Severe Osteoarthritis

One stage uncemented revision of infected total hip replacement using cancellous allograft bone impregnated with antibiotics

Infection of a total hip replacement (THR) requires component removal and thorough local debridement. Usually, long-term antibiotic treatment in conjunction with a two-stage revision is required. This may take several months. One-stage revision using antibiotic-loaded cement has not gained widespread use, although the clinical and economic advantages are obvious. Allograft bone may be impregnated with high levels of antibiotics, and in revision of infected THR, act as a carrier providing a sustained high local concentration. We performed 37 one-stage revision of infected THRs, without the use of cement. There were three hips which required further revision because of recurrent infection, the remaining 34 hips (92%) stayed free from infection and stable at a mean follow-up of 4.4 years (2 to 8). No adverse effects were identified. Incorporation of bone graft was comparable with unimpregnated grafts. Antibiotic-impregnated allograft bone may enable reconstruction of bone stock, insertion of an uncemented implant and control of infection in a single operation in revision THR for infection.

The use of two-stage exchange arthroplasty with depot antibiotics in the absence of long-term antibiotic therapy in infected total hip replacement

We present a series of 114 patients with microbiologically-proven chronically-infected total hip replacement, treated between 1991 and 2004 by a two-stage exchange procedure with antibiotic-loaded cement, but without the use of a prolonged course of antibiotic therapy. The mean follow-up for all patients was 74 months (2 to 175) with all surviving patients having a minimum follow-up of two years. Infection was successfully eradicated in 100 patients (87.7%), a rate which is similar to that reported by others, but where prolonged adjuvant antibiotic therapy has been used. Using the technique described, a prolonged course of systemic antibiotics does not appear to be essential and the high cost of the administration of antibiotics can be avoided.

Impaction grafting of the femur in two-stage revision for infected total hip replacement.

We report the mid-term results of femoral impaction grafting which was used in 53 patients during the second stage of a two-stage revision for an infected total hip replacement. We reviewed all cases performed between 1989 and 1998. All patients underwent a Girdlestone excision arthroplasty, received local and systemic antibiotics and subsequently underwent reconstruction, using femoral impaction grafting. Four patients had further infection (7.5%), and four died within 24 months of surgery. One patient underwent revision of the stem for a fracture below its tip at ten months. This left 44 patients with a mean follow-up of 53 months (24 to 122). All had improved clinical scores and a satisfactory radiological outcome.

Impaction grafting of the femur in two-stage revision for infected total hip replacement

We report the mid-term results of femoral impaction grafting which was used in 53 patients during the second stage of a two-stage revision for an infected total hip replacement. We reviewed all cases performed between 1989 and 1998. All patients underwent a Girdlestone excision arthroplasty, received local and systemic antibiotics and subsequently underwent reconstruction, using femoral impaction grafting. Four patients had further infection (7.5%), and four died within 24 months of surgery. One patient underwent revision of the stem for a fracture below its tip at ten months. This left 44 patients with a mean follow-up of 53 months (24 to 122). All had improved clinical scores and a satisfactory radiological outcome.

Infection in Revision Total Hip Arthroplasty

Summary Though one of the most common and dangerous complications in the early years of total hip replacement, the incidence of infection has dramatically decreased. In revision total hip replacement, it is essential to differentiate aseptic loosening and infected total hip replacements. The c-reactive protein level and aspiration culture and white blood cell count are crucial parameters to differentiate an aseptic and septic revision. The intraoperative frozen section offers additional information during the procedure. Bone scans, leukocyte scans, and immunoglobulin G scintigraphy are reserved for inconclusive cases. Although Girdlestone resection arthroplasty has been used in the past, two-stage reimplantation is the gold standard for the treatment of infected total hip replacements today. One-stage revision, or debridement without implant removal, might be indicated in selected patients. In life threatening or intractable hip infection, when patient or limb viability is at risk, hip disarticulation should be considered.

Limited role of direct exchange arthroplasty in the treatment of infected total hip replacements.

A literature review was performed to determine when direct exchange was most likely to be successful. Twelve reports provided outcome data on infected hip replacements treated with direct exchange. The average duration of followup was 4.8 years, but the range was broad (0.1-17.1 years). Of the 1,299 infected hip replacements treated with direct exchange, 1,077 (83%) were thought to be free of infection at the last followup. Antibiotic-impregnated bone cement was used in 1,282 of the cases (99%). There was wide variability in the duration of parenteral antibiotic therapy, ranging from just 24 hours to as many as 8 weeks. In some cases, no oral antibiotics ever were given, whereas in others, oral antibiotics were given for as many as 8 months after parenteral therapy. Factors associated with a successful direct exchange included: (1) absence of wound complications after the initial total hip replacement; (2) good general health of the patient; (3) methicillin-sensitive Staphylococcus epidermidis, Staphylococcus aureus, and Streptococcus species; and (4) an organism that was sensitive to the antibiotic mixed into the bone cement. Factors associated with failure included: (1) polymicrobial infection; (2) gram-negative organisms, especially Pseudomonas species; and (3) certain gram-positive organisms such as methicillin-resistant Staphylococcus epidermidis and Group D Streptococcus. Methicillin-resistant organisms have become more common. Many current revision surgical techniques use cementless implants. Fixation without any cement (no depot antibiotics) may be a contraindication to direct exchange. Additionally, there essentially are no data on the use of bone graft in association with direct exchange. For these reasons, the indications for direct exchange are limited.

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.

Does Staphylococcus aureus infection worsen the prognosis for treatment of infected total hip replacements ?

During the period from 1984 to 1996, 38 infected total hip replacements were treated at Liestal. Staphylococcus aureus was identified in 14 single-agent infections and 8 mixed infections. The resulting procedures comprised 6 revisions without a change of implant, 17 two-stage and 7 one-stage replacements of the prosthesis, 4 revisions of infected Girdlestone hips, 2 reimplantations of prostheses in longstanding Girdlestone hips; one Girdlestone hip was created and one disarticulation was carried out for infection persisting despite a previous mid-thigh amputation.71% of the patients were treated during a single admission, while in 21% of the cases two admissions were required. Two patients died during the postoperative period. Apart from one female patient with persistent infection, all the remaining patients are now free from infection or died without infection. Comparing patients with and without Staph. aureus infection, the numbers of admissions required were 1.3: 1.4, the numbers of operations in each case were 2.8: 2.3, the admission duration 62: 47 days and the success rate after the first treatment cycle 77%: 68%. Using our therapeutic schedule, there was no demonstrable difference between the outcomes in this respect. We therefore continue to decide between a single- or two-stage treatment on the basis of the clinical picture of the infection. The simultaneous presence of Staph. Aureus does not influence our choice.

Inguinal abscess: An unusual presentation of infection around total hip replacement

We describe 2 patients who presented with inguinal abscesses arising from infected total hip replacement. Recognition of the source of the infection was delayed. Both infections were eventually controlled after incision and drainage with removal of the infected prosthesis.