Two-stage Reimplantation Research Articles

Is two-stage reimplantation effective for virulent pathogenic infection in a periprosthetic hip? A retrospective analysis.

To investigate the effectiveness of two-stage reimplantation using antibiotic-loaded bone cement (ALBC) and the risk factors associated with failure to control periprosthetic joint infection (PJI). We retrospectively reviewed 38 consecutive hips managed using two-stage reimplantation with ALBC. The mean follow-up period was 5.4 years (range: 2.5-9 years). The causative pathogens were isolated from 29 patients (76%), 26 of whom were infected with highly virulent organisms. Sixteen patients (42%) underwent at least two first-stage debridements. An increased debridement frequency correlated significantly with high comorbidity (P < 0.001), a lower preoperative Harris hip score (HHS; P < 0.001), antimicrobial resistance, and gram-negative and polymicrobial infection (P = 0.002). Of the 35 patients who underwent two-stage reimplantation, 34 showed no signs of recurrence of infection. The mean HHS improved from 46 ± 12.64 to 78 ± 10.55 points, with 7 (20%), 12 (34%), 11 (32%) and 5 (14%) patients receiving excellent, good, fair and poor ratings, respectively. The current study demonstrated that two-stage reimplantation could successfully treat PJI after hip arthroplasty. However, the ability of ALBC to eradicate infection was limited because frequent debridement was required in high-risk patients (i.e., patients who are either in poor general health due to associated comorbidities or harbor infections due to highly virulent, difficult-to-treat organisms). Level IV.

Use of a Modular Tapered Fluted Femoral Component in Revision Total Hip Arthroplasty Following Resection of a Previously Infected Total Hip: Minimum 5-year Follow-Up

Femoral reconstruction in the setting of two stage reimplantation can be difficult and substantial reoperation rates due to implant loosening have been reported. We retrospectively reviewed 28 male and 29 female patients who underwent a two-stage reimplantation using a modular, tapered femoral stem. The mean clinical follow-up was 62months. The mean Harris Hip score at 5-year follow-up was 76. Two stems were revised for aseptic loosening. Reinfection occurred in 16% of patients. Stem survivorship was 87% at 5-years. Use of a modular tapered stem provided a high rate of stable femoral fixation and acceptable rate of reinfection in two stage treatment of infected THA.

Mortality of Elderly Patients After Two-Stage Reimplantation for Total Joint Infection: A Case–Control Study

The mortality of two-stage reimplantation for periprosthetic joint infection in patients over the age of 80 has not previously been studied. We retrospectively reviewed 134 elderly patients undergoing two-stage reimplantation at 90days, 1year and 5years and compared them to a matched cohort who underwent single-stage aseptic total joint revision. There was no significant difference in preoperative comorbidities between groups. The mortality rates for the two-stage and aseptic groups were 39.9% and 34.1% respectively with an overall mortality rate of 36.7%. There was no significant difference in mortality at any time point (95% CI: 29.4, 43.1). Two-stage reimplantation does not significantly increase the mortality of patients over the age of 80 when compared to a matched cohort undergoing aseptic revision at our institution.

Sonication of Antibiotic Spacers Predicts Failure during Two-stage Revision for Prosthetic Knee and Hip Infections

Periprosthetic joint infection is a leading cause of failure after two-stage reimplantation. One cause of relapse may be persistent subclinical infection. Difficulty exists in detecting biofilm-forming infections. Sonication disrupts biofilm and has led to higher rates of positive intraoperative cultures. Our aims in this study were to determine (1) if sonication results were predictive of failure, including reinfection, at 2-year followup; and (2) whether sonication of antibiotic spacers at the time of reimplantation improves sensitivity of intraoperative cultures. We prospectively followed 36 consecutive patients undergoing two-stage reimplantation for periprosthetic hip or knee infection. Minimum followup was 19 months (mean, 29.9 months; range, 19–38 months). Results of intraoperative cultures and sonicated antibiotic spacers were analyzed. Positive sonication results were predictive of failure as defined by reinfection at 2-year followup. Among the 18 patients who had positive sonication results, reinfection developed in nine patients (50%) compared with two of 18 patients (11%) with negative sonication results (odds ratio, 8.0; 95% CI, 1.2–69.0). Sonication of antibiotic spacers improved the sensitivity of intraoperative cultures from 45% to 82%. [corrected]. Sonication of antibiotic spacers appears to be useful in predicting failure attributable to recurrent infection after two-stage reimplantation. For patients with positive sonication cultures during reimplantation, more aggressive antimicrobial treatment may be indicated after reimplantation. Level III, diagnostic study. See the Instructions for Authors for a complete description of levels of evidence.

Glenoid revision is best treated with glenoid implants: Affirms

Radiographic lucency adjacent to the glenoid component is a common finding after a total shoulder arthroplasty. In fact, the majority of patients with this entity are asymptomatic and require no management. However, when there is documented progression of lucent lines, leading to clinically symptomatic loosening, revision total shoulder arthroplasty is warranted. Treatment options for revision surgery are guided by the amount of glenoid bone loss and include either reimplanation or removal. When feasible, reimplantation of the glenoid yields superior clinical results. Reimplantation strategies include reimplantation without bone grafting, one-stage reimplantation with bone grafting, two-stage reimplantation with bone grafting, and reimplantation with the use of glenoid augments. If bone loss precludes, the clinician may consider implant removal with either biologic resurfacing or hemiarthroplasty.

Arthrodesis Should Be Strongly Considered After Failed Two-stage Reimplantation TKA

A two-stage reimplantation procedure is a well-accepted procedure for management of first-time infected total knee arthroplasty (TKA). However, there is a lack of consensus on the treatment of subsequent reinfections. The purpose of this study was to perform a decision analysis to determine the treatment method likely to yield the highest quality of life for a patient after a failed two-stage reimplantation. We performed a systematic review to estimate the expected success rates of a two-stage reimplantation procedure, chronic suppression, arthrodesis, and amputation for treatment of infected TKA. To determine utility values of the various possible health states that could arise after two-stage revision, we used previously published values and methods to determine the utility and disutility tolls for each treatment option and performed a decision tree analysis using the TreeAgePro 2012 software suite (Williamstown, MA, USA). These values were subsequently varied to perform sensitivity analyses, determining thresholds at which different treatment options prevailed. Overall, the composite success rate for two-stage reimplantation was 79.1% (range, 33.3%-100%). The utility (successful outcome) and disutility toll (cost for treatment) for two-stage reimplantation were determined to be 0.473 and 0.20, respectively; the toll for undergoing chronic suppression was set at 0.05; the utility for arthrodesis was 0.740 and for amputation 0.423. We set the utilities for subsequent two-stage revision and other surgical procedures by subtracting the disutility toll from the utility each time another procedure was performed. The two-way sensitivity analysis varied the utility status after an additional two-stage reimplantation (0.47-0.99) and chance of a successful two-stage reimplantation (45%-95%). The model was then extended to a three-way sensitivity analysis twice: once by setting the variable arthrodesis utility at a value of 0.47 and once more by setting utility of two-stage reimplantation at 0.05 over the same range of values on both axes. Knee arthrodesis emerged as the treatment most likely to yield the highest expected utility (quality of life) after initially failing a two-stage revision. For a repeat two-stage revision to be favored, the utility of that second two-stage revision had to substantially exceed the published utility of primary TKA of 0.84 and the probability of achieving infection control had to exceed 90%. Based on best available evidence, knee arthrodesis should be strongly considered as the treatment of choice for patients who have persistent infected TKA after a failed two-stage reimplantation procedure. We recognize that particular circumstances such as severe bone loss can preclude or limit the applicability of fusion as an option and that individual clinical circumstances must always dictate the best treatment, but where arthrodesis is practical, our model supports it as the best approach.

Two-stage treatment of infected total knee arthroplasty: two to thirteen year experience using an articulating preformed spacer

Infection following knee replacement is an important cause of failure despite rigorous prophylaxis antibiotic protocols. The two-stage reimplantation procedure is considered the gold standard for treatment of subacute and chronic deep periprosthetic infections. The purpose of this study was to determine whether or not a preformed articulated spacer would allow comparable eradication of infection equal to rates reported in published studies and to see whether there is a resulting improvement in postoperative function with an acceptable quality of life, reducing postoperative pain and limiting surgical complications, thus simplifying the second stage of the procedure. We retrospectively reviewed 50 patients with infected TKA who underwent a two-stage exchange arthroplasty using an articulating preformed spacer. The device, designed like an ultracongruent condylar knee prosthesis, is composed of acrylic cement impregnated with antibiotic, with tested and standardised mechanical properties and antibiotic content and release mechanism. The median follow-up period was seven (two to 13) years. Two-stage exchange arthroplasty was successful in controlling the infection in 92% of patients; 64% of patients where women, and median patient age was 68 (54-80) years. Median implantation time of the preformed spacer was 16 (four to 60) weeks; 4% of infections were delayed, and 96% were late. Forty-six percent were caused by coagulase-negative Staphylococcus (CoNS). Mean Knee Society Score (KSS) was 35.38 (clinical) and 37.96 (function) on presentation; it improved to a mean of 72.92 (clinical) and 76.04 (function) after the first stage and to a mean of 75.38 (clinical) and 80.58 (function) at the final review. Bone loss was unchanged between stages, and range of motion remained unchanged or improved after definitive reimplantation. The use of preformed articulated knee spacer during a two stage technique for infected TKA improves patient QOL between stages and increases patient compliance and cooperation, reducing social costs.

One‐stage Versus Two‐stage Exchange

Liaison: Paul Lichstein MD, MSLeaders: Thorsten Gehrke MD (International), Adolph Lombardi MD, FACS (US), Carlo RomanoMD (International), Ian Stockley MB, ChB, MD, FRCS (International)Delegates: George Babis MD, Jerzy Bialecki MD, La´szlo´ Bucsi MD, Xu Cai MD, Li Cao MD, Briande Beaubien MD, Johannes Erhardt MD, Stuart Goodman MD, PhD, FRCSC, FACS, FBSE,William Jiranek MD, Peter Keogh, David Lewallen MD, MS, Paul Manner MD, WojciechMarczynski MD, J. Bohannon Mason MD, Kevin Mulhall MB, MCh, FRCSI, Wayne PaproskyMD, Preetesh Patel MD, Francisco Piccaluga MD, Gregory Polkowski MD, Luis Pulido MD, IanStockley MBBS, ChB, FRCS, Juan Suarez MD, Fritz Thorey MD, Rashid Tikhilov MD, JobDiego Velazquez MD, Heinz Winkler MD

Irrigation and Debridement

Irrigation and Debridement

Use of Static or Articulating Spacers for Infection Following Total Knee Arthroplasty

The so-called gold standard for treatment of periprosthetic joint infection following total knee arthroplasty is two-stage reimplantation. However, it is unclear whether use of static or articulating antibiotic-impregnated spacers during the interim period between these two stages is superior. The purpose of this study was to compare the outcomes of static and articulating spacers in the treatment of infection following total knee arthroplasty. A systematic review of the peer-reviewed literature indexed by MEDLINE and Embase was performed to identify studies reporting the outcomes of antibiotic spacers in the treatment of infection following total knee arthroplasty. Seven Level-III comparative studies and thirty-two Level-IV case series remained following the screening process. The data in these studies were extracted and aggregated to compare the reinfection rate, range of knee motion, functional scores, and complication rates between static and articulating spacers. The two types of spacers demonstrated similar reinfection rates (7% for articulating and 12% for static, p = 0.2). However, the articulating spacers resulted in significantly greater range of knee motion after reimplantation (101° for articulating and 91° for static, p = 0.0002). Despite this difference in ultimate knee motion, functional scores in the treatment groups were similar. Rates of wound-related and spacer-related complications were similarly low with both types of spacers. Our review failed to identify a significant difference in the ability of static or articulating spacers to eradicate periprosthetic infection following total knee arthroplasty. Compared with static spacers, articulating spacers provided improved knee motion following reimplantation, although functional scores were similar in the two treatment groups. We encourage arthroplasty surgeons to consider both static and articulating spacers in the treatment of infection following total knee arthroplasty and to tailor treatment on the basis of patient-related factors.

High Rate of Infection After Aseptic Revision of Failed Metal-on-Metal Total Hip Arthroplasty

Evidence suggests some metal-on-metal (MOM) THAs have higher rates of failure and subsequent revision than other bearing surfaces. However, there are few studies demonstrating how these patients fare after revision. We asked: (1) What is the short-term survivorship of revision THA in patients whose index THAs employed MOM bearings? (2) What are the causes of failure of revision THA in these patients (ie, what are the indications for repeat revision)? (3) What are the most common complications after revisions of MOM THAs? We identified 37 patients (24 women, 13 men; mean age, 55 years; 37 hips) revised for aseptic failure of primary stemmed MOM THAs. Reasons for revision included pain with loose components (n = 19), adverse reaction to metal debris (n = 8), periprosthetic fracture (n = 4), impingement (n = 3), dislocation (n = 2), and pain of unknown origin (n = 1). Minimum followup was 24 months (mean, 33 months; range, 24-81 months) postrevision, but 11 were not seen in the last 2 years as our routine followup is at 2 and 5 years. Clinical histories were reviewed for reasons for failure of the MOM THAs and complications associated with revision surgery. Survivorship free from further revision for any cause was 95% at 24 months and 92% at latest followup (24-81 months). There were three repeat revisions, all for periprosthetic infection, and all were treated with two-stage reimplantation. No other complications were observed. We observed a higher-than-expected rate of infection after revision of MOM THAs. The infection rate was higher in this report than in an earlier series looking at revision THAs for other indications at our institution. As revision of MOM THA becomes more common, it will be important to continue monitoring postrevision outcomes and providing treatment strategies to mitigate complications for these patients.

Are Cementless Stems More Durable Than Cemented Stems in Two-stage Revisions of Infected Total Knee Arthroplasties?

The routine use of stems in revision TKA improves survival rates by enhancing the stability of the prosthesis. The ideal method of stem fixation (cemented or uncemented) in two-stage reimplantation remains controversial. The purpose of this study was to answer the following questions: (1) Are rerevision rates for aseptic loosening comparable between cemented stems and uncemented stems in two-stage reimplantation? (2) Is the reinfection rate comparable between antibiotic-impregnated cemented stems and uncemented stems for two-stage reimplantation? (3) Are there any differences in Knee Society radiographic scores between stem techniques? A retrospective analysis was performed in all patients who underwent two-stage reimplantation between 1990 and 2010 at Anderson Orthopaedic Research Institute (AORI) and OrthoCarolina (OC). One hundred fourteen patients with 228 stems met the inclusion criteria. Of these 228 stems, 102 stems were cemented and 126 stems were uncemented. The indication for stem fixation was largely institution specific; AORI used cementless stems 92% (118) of the time, whereas OC used a cemented stem 92% (92) of the time. A 2-year minimum radiographic and clinical followup was required for inclusion into the study. Radiographic evaluations were performed using a modification of the Knee Society radiographic score. Rerevision rates for aseptic loosening were comparable with three cemented and three cementless stem constructs. The reinfection rate was also comparable between cemented and cementless stems (p = 0.86). Using post hoc analysis, 32% of cemented stems were radiographically classified as loose or closely observe (33 of 102) compared with 17% of the cementless stem group (21 of 126; p = 0.006). Patients with good bone quality had a significantly lower rate of radiographic loosening compared with patients with poor bone quality (p = 0.01). There was no significant correlation with radiographic loosening and level of constraint (p = 0.90) or use of articulating versus static antibiotic spacer (p = 0.06). In this retrospective study, cementless diaphyseal-engaging stems had a lower rate of radiographic failure than did cemented stems in two-stage reimplantation. Reinfection rates remain similar despite the absence of antibiotic cement in the cementless constructs. At this time we believe the use of hybrid, cementless diaphyseal-engaging stems should be considered as a possible option at the time of reimplantation.

Periprosthetic shoulder infection.

Shoulder arthroplasty is considered the most effective surgical procedure for endstage shoulder pain from different causes including osteoarthritis, cuff-tear arthropathy, trauma, and tumors. Although uncommon and less frequent than knee or hip periprosthetic infection, periprosthetic shoulder infection represents a devastating complication and, despite treatment, is associated with unsatisfactory results. The most commonly identified microorganisms in periprosthetic shoulder infections are Staphylococcus aureus, coagulase-negative Staphylococci and Propionibacterium acnes. Diagnosis is not always easy and mainly derives from the integration of clinical symptoms, laboratory exams, radiological studies and microbiological swabs. Different options are available for treatment, including antibiotic therapy, lavage and debridement with retention of the prosthesis, one-stage reimplantation, two-stage reimplantation with antibiotic-impregnated cement spacer and resection arthroplasty. The aim of this review is to describe the current knowledge regarding risk factors, etiology, diagnosis and treatment of periprosthetic shoulder infection.

Revision in cemented and cementless infected hip arthroplasty.

Infection is a frequent cause of failure after joint replacement surgery. The infection rate after total hip arthroplasty (THA) has been reduced to 1-2% in the last years. However, it still represents a challenging problem for the orthopedic surgeon.Difficulty of therapeutic approach, and poor functional outcomes together with length of treatment and overall cost are the main burden of this issue. Even the diagnosis of an infected hip could be challenging although it is the first step of an accurate treatment. At the end, many cases require removing the implants. Afterwards, the treatment strategy varies according to authors with three different procedures: no re-implantation, immediate placement of new implants or a two-stage surgery re-implantation.Based on the most recently systematic review there is no suggestion that one- or two-stage revision methods have different re-infection outcomes.The two-stage implant-exchange protocol remains the gold standard. It is considered as the most efficacious clinical approach for the treatment of periprosthetic infection, especially in patients with sinus tracts, swelling, extended abscess formation in depth and infection of Methicillin Resistant Staphylococcus Aureus (MRSA), and other multidrug-resistant bacteria as reported in recent consensus documents.

Comment on: Two-stage revision of septic knee prosthesis with articulating knee spacers yields better infection eradication rate than one-stage or two-stage revision with static spacers

We have read the recent article by Dr. Romano et al. [6] with great interest. The number of periprosthetic infections associated with hip and knee arthroplasties is increasing worldwide. In addition to the clinical problems they present, the financial burden of each case is high and the socioeconomic costs are increasing each year. The current standard treatment options for eradicating such infections are oneand twostage exchanges. The literature overview seems to be biased. The wellperformed review by Jamsen et al. [4] failed to show a difference between the oneand two-stage approaches. Romano et al. conclude that better eradication rates may be achieved by a two-stage approach. We were wondering why the retrospective analysis by Mortazavi et al. [5] was not mentioned although it was online in the summer of 2011 and presented the previous year in a meeting. Mortazavi et al. concluded that there are currently no proper indicators that can guide orthopaedic surgeons in patient selection between a two-stage exchange and a reimplantation. Next, they observed that the failure rate after two-stage reimplantation for infected TKA is relatively high. There were no variables identified that would guide the surgeon to perform the second stage. It is therefore very surprising that 1 year later, another group is able to make a clear statement using a meta-analysis. Next, we would like to mention a recent published article by Singer et al. [7]. They stated that the rate of infection control for one-stage revision of infected knee arthroplasties is still unclear according to the literature. For their series, they observed an infection control rate of 95 % for one-stage protheses and higher knee scores were reported than for two-stage revisions. This contrasts greatly with Dr. Romano et al.’s study. The worst series in the article by Romano et al. comes from our own institution by von Foerster et al. [8]. These patients were treated around 1980. Algorithms regarding topical antibiotic choice have improved in the last three decades, and although they are still missing in the literature, we currently observe better outcomes. This study is the only outlier in their overview and seems to present misleading results and conclusions. The combination of germ-specific systemic and topical antibiotic therapy is the key to success. Recent publications identified much higher infection control rates for the one-stage approach to septic THA exchanges [1, 2]. Such actual data are missing for septic TKA exchanges. As one of the biggest centres for revision arthoplasties in the world, we prefer a one-stage approach in septic TKA surgery because it is well documented that one-stage surgery is associated with less stress for the patient, fewer complications, better surgical conditions and better functional results [3]. There is currently a strong trend favouring one-stage approaches. However, we have to state that valid literature data are still missing and that this review misleads the reader. This comment refers to the article available at doi:10.1007/s00167-012-1885-x.

Reduced re-infection rates with postoperative oral antibiotics after two-stage revision hip arthroplasty.

BackgroundSurgeons are often trying to decreased reinfection rates following two-stage reimplantation arthroplasty, which range from 3.2% to 13% because multiple staged revision procedures for infection can be costly and have high morbidity. We therefore asked: (1) Did the use of postoperative oral antibiotics reduce reinfection rates after 2-staged revision of THA? And (2) how did this compare with the infection rate after aseptic revision procedures?MethodsWe identified all patients who underwent two-stage revision THA for a periprosthetic deep hip infection and found 66 patients (67 hips) who had a minimum 24 months’ followup. Twenty-two of the 66 procedures (33%) were followed by a minimum of 14 days of postoperative oral antibiotics (mean, 36 days; range, 14 days to lifelong), while 44 were prescribed only immediate parenteral postoperative antibiotic therapy (mean, 1.3 days; range, 1–3 days). We then identified 407 patients (410 hips) who underwent aseptic revision hip arthroplasty and evaluated the infection rate in these patients for comparison; these patients were treated with 24 hours of postoperative parenteral antibiotics. The authors used previously described creteria to establish the presence of infection.ResultsThere were no reinfections in the group receiving oral postoperative antibiotics compared to six reinfections (13.6%) in the 44 patients not receiving oral antibiotics. We observed infection in 2 of the 410 hips (0.5%) revised for aseptic reasons.ConclusionsWe believe that our findings warrant further investigation for using postoperative oral antibiotics after reimplantation for periprosthetic infection in an effort to decrease the likelihood and risks associated with additional revision arthroplasty procedures.

Revision of Infected Total Knee Arthroplasty: Two-Stage Reimplantation Using an Antibiotic-Impregnated Static Spacer

BackgroundA two-stage revision remains as the "gold standard" treatment for chronically infected total knee arthroplasties.MethodsForty-five septic knee prostheses were revised with a minimum follow-up of 5 years. Static antibiotic-impregnated cement spacers were used in all cases. Intravenous antibiotics according to sensitivity test of the culture were applied during patients' hospital stay. Oral antibiotics were given for another 5 weeks. Second-stage surgery was undertaken after control of infection with normal erythrocyte sedimentation rate and C-reactive protein values. Extensile techniques were used if needed and metallic augments were employed for bone loss in 32 femoral and 29 tibial revisions.ResultsThe average interval between the first-stage resection and reimplantation was 4.4 months. Significant improvement was obtained with respect to visual analog scale pain and clinical and functional scores, and infection was eradicated in 95.6% of cases following a two-stage revision total knee arthroplasty. Radiographic evaluation showed suitable alignment without signs of mechanical loosening.ConclusionsThis technique is a reasonable procedure to eradicate chronic infection in knee arthroplasty and provides proper functional and clinical results. However, it sometimes requires extensile surgical approaches that could imply arduous surgeries. Metallic augments with cementless stems available in most of the knee revision systems are a suitable alternative to handle bone deficiencies, avoiding the use of bone allografts with its complications.

Salvage revision TKR for infection: a 10-year experience of a two-stage re-implantation technique

The management of an infected total knee replacement (TKR) is a major challenge to the orthopedic surgeon. We report the outcome of a two-stage re-implantation technique over a 10-year period. Thirty-eight primary TKRs were treated with from 1996 to 2008. Treatment consisted of thorough debridement and removal of the implants with the insertion of an antibiotic-impregnated static cement spacer in the interim period. Prolonged antibiotics were administered, and C-reactive protein values were monitored. At the second stage, all patients were clinically, biochemically, and histologically free of infection. The average length of follow-up was 8.3 years (13 to 112 months), and the Oxford knee scores improved from 47 ± 7.5 points preoperatively to 24 ± 4.8 points postoperatively. Average range of motion achieved was 78° (40 to 100°). No recurrence of infection was noted. Complications recorded in our series included six lateral patellae subluxations (none chronic), one fracture of the modular implant, one aseptic loosening, nine spacer subluxations during the interim period, and three extensor mechanism failures. Two-stage re-implantation with a non-articulating spacer between stages is a safe and acceptable salvage procedure while treating infected primary TKRs. Complication rates are high in short and intermediate terms, and realistic expectations must be held.

Two-stage Treatment of Hip Periprosthetic Joint Infection Is Associated With a High Rate of Infection Control but High Mortality

Periprosthetic infection after total hip arthroplasty (THA) is a devastating complication. Reported rates of infection control range from 80% to 95% but mortality rates associated with treatment of infected THA are also substantial and we suspect underreported. For patients selected for two-stage treatment of infected THA we therefore determined (1) mortality; (2) rate of reimplantation; and (3) rate of reinfection. We identified 202 patients (205 hips) with infected primary or revision THA treated with a two-stage protocol between 1996 and 2009 in our prospectively collected practice registry. Patients underwent two-stage treatment for infection, including removal of all implants and foreign material with implantation of an antibiotic-laden cement spacer in the first stage followed by intravenous culture-specific antibiotics for a minimum of 6 weeks. Second-stage reimplantation was performed if erythrocyte sedimentation rate and C-reactive protein were trending toward normal and the wound was well healed. Thirteen patients (13 hips) were lost to followup before 24 months. The minimum followup in surviving patients was 24 months or failure (average, 53 months; range, 24-180 months). Fourteen patients (7%; 14 hips) died before reimplantation and two were not candidates because of medical comorbidities. The 90-day mortality rate after the first-stage débridement was 4% (eight patients). Of the 186 patients (189 hips) who underwent reimplantation, 157 (83%) achieved control of the infection. Including all patients who underwent the first stage, survival and infection control after two-stage reimplantation was 76%. Two-stage treatment of deep infection in primary and revision THA is associated with substantial mortality and a substantial failure rate from both reinfection and inability to perform the second stage. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Aggressive Early Débridement for Treatment of Acutely Infected Cemented Total Hip Arthroplasty

Up to 2% of THAs are complicated by infection, leading to dissatisfied patients with poor function and major social and economic consequences. The challenges are control of infection, restoration of full function, and prevention of recurrence. Irrigation and débridement with or without exchange of modular components remains an attractive alternative to two-stage reimplantation in acutely infected THAs but with variable results from previous studies. We therefore determined the rate at which aggressive early débridement with exchange of modular components controlled acutely infected cemented THAs. We retrospectively studied all 26 patients presenting with acutely infected cemented THAs (16 primaries, 10 revisions) occurring within 6 weeks of the index operation or of hematogenous spread from a confirmed source of infection elsewhere between 1999 and 2006. Microbiology confirmed bacterial colonization in all patients, with 18 early postoperative infections and eight acute hematogenous infections. Patients underwent aggressive débridement with open complete synovectomy, exchange of all mobile parts, débridement of all aspects of the joint, irrigation with antiseptic solutions, and pulsatile lavage. Minimum followup was 5 years (mean, 6.6 years; range, 5-11 years). Eight patients had multiple washouts with control of infection in four at latest followup. Five patients underwent two-stage revisions and one patient was placed on long-term antibiotic suppression. Twenty patients returned to their expected functional level with no radiographic evidence of prosthetic failure. At minimum 5-year followup, we had a 77% infection control rate. Our data confirm current literature and suggest there may be a role for aggressive early débridement in controlling acute postoperative and hematogenous infections after cemented THA. Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.