Two-Stage Revision for Periprosthetic Joint Infection of the Hip: Indications, Contraindications, and Preparation

DR.MOHAMMAD HUTAIF, EMIAL

This article discusses the indications, contraindications, and preparation for two-stage revision for periprosthetic joint infection of the hip. It also covers the different types of spacers that can be used during the interval period.

INTRODUCTION

Total hip arthroplasty has developed into one of the most successful interventions for the treatment of disabling degenerative disease of the hip (1). However, while uncommon, periprosthetic joint infection (PJI) of the hip remains a devastating complication for the patient (2) and continues to challenge surgeons involved with their treatment. PJIs of the hip place a significant economic and logistic burden on the institutions involved with their care (3,4), and with the demand for total hip

 

 

arthroplasty expected to increase in the next two decades (5), it is likely that this burden will also increase.

 

The treatment of PJI of the hip remains an area of controversy. It is widely accepted among the North American orthopedic community that the two-stage approach, in which the removal of infected material and components and reinsertion of revision components are separated by an interval period with either no components or antibiotic-loaded components in situ, is the gold standard treatment for PJI of the hip (6,7). However, this strategy may be associated with increased morbidity and mortality and certainly carries a cost implication above that of a one-stage approach unless the latter fails (8,9,10,11). Proponents of the single-stage approach argue that the successful outcome following revision for PJI, as measured by eradication of infection, is determined by the quality of the initial debridement, and as long as strict protocols are adopted, reinfection rates are at worst comparable to those seen with a two-stage approach (12,13). In spite of these findings, a number of systematic reviews and meta-analyses have failed to identify a superior approach to the management of PJI of the hip (14,15,16,17,18), which may, in part, reflect the multifactorial nature of periprosthetic infection as well as the heterogeneous populations included in the included studies.

When considering the two-stage approach to the management of PJI of the hip, consideration must be given to whether a spacer is used between stages and, if so, to the nature of the spacer utilized. Spacers are formed from antibiotic-loaded cement, the purpose of which is to deliver high local concentrations of antibiotic through elution from the cement. These spacers can be articulating or nonarticulating and custom-made or preformed.

Nonarticulating spacers are not designed for weight bearing or for keeping the limb out to length and so inevitably result in some contraction of the soft tissues of the hip during the interval period. However, they do offer a reduced risk of complications including spacer dislocation and fracture. In contrast, articulating spacers are designed to keep the limb out to length, and some may allow some weight bearing and thus offer improved function of the hip and preservation of the soft tissue envelope, but do carry an increased risk of complications (19).

The purpose of this chapter, therefore, is to report the techniques available for interval spacers in the two-stage treatment of PJI of the hip, addressing both the static and articulating varieties.

 

INDICATIONS

The successful treatment of PJI of the hip by two-stage revision is reliant on the eradication of infection during the interval period before reimplantation. This is dependent on a thorough debridement at the time of the first stage, designed to remove all foreign, infected, and devitalized material. In conjunction, an identification of the infecting pathogen, including its antibiotic sensitivities, is vital to direct antimicrobial therapy between stages and thus improved outcomes.

Antibiotic spacers are indicated for the treatment of chronic infections, infections due to resistant or fungal organisms, and in patients in whom host factors are likely to result in failure with a one-stage approach (20,21,22). While the time between onset of symptoms and surgical intervention often guides the choice between component retention and two-stage revision, the exact duration of symptoms permitting component retention remains controversial. Certainly, the longer symptoms have been present, the more likely biofilm formation, osteomyelitis, and sinus formation are to be established, associated with a higher risk of failure with more conservative revision options (23,24). As the first stage of a two-stage approach involves removal of the prosthesis, this offers the surgeon the opportunity to access bone and soft tissues adjacent to the components as well as reduces the bacterial burden in association with the prosthesis. The choice between an articulating or static spacer at this stage is largely at the discretion of the operating surgeon though a static spacer may be more appropriate in cases of severe bone loss and for surgeons with limited experience with the subtleties of articulated spacers and their limitations.

The accurate diagnosis of PJI of the hip remains a controversial and evolving subject. It is reliant on not only an accurate history and examination but also investigation of radiographs, blood, and synovial fluid. All hip arthroplasties presenting with ongoing pain should be considered infected until proven otherwise, especially when the onset of symptoms correlates with concurrent illness or surgical intervention.

Cutaneous manifestations of PJI of the hip are often absent though the presence of a sinus is invariably indicative of deep infection (25) (Fig. 30-1). Systemic inflammatory

markers including white cell count (WCC), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) are sensitive though nonspecific markers of infection and serve as first-line screening investigations

(26). The diagnosis of PJI has been defined by the Musculoskeletal Infection Society (MSIS) on the basis of one of two major criteria (a sinus tract communicating with the prosthesis or a pathogen isolated by culture from tissue or fluid samples) or four of six minor criteria (elevated CRP and ESR; elevated synovial leukocyte count; elevated synovial neutrophil percentage; presence of purulence in the affected joint; pathogen isolated from one sample of tissue or fluid from the affected joint; greater than 5 neutrophils per high-power field at ×400 magnification on frozen section analysis of periprosthetic soft tissue) (27). While these guidelines have a role in the accurate diagnosis of PJI, there will always be cases that defy these criteria in which clinical assessment remains the gold standard for diagnosis.

Techniques to Manage Infection around Total Hip Arthroplasty and Antibiotic-Loaded Spacers for Infection

 

 

FIGURE 30-1 A: Late presentation of a chronically infected hip arthroplasty, in this case a cemented hemiarthroplasty inserted a number of years previously for the treatment of a displaced subcapital fracture of the femoral neck. B: The radiograph confirms debonding at the cement-bone interface and varus malalignment of the femoral component in keeping with septic failure of the implant.

The rational for a two-stage approach is the assumption that even an aggressive debridement cannot reliably produce a sterile field. Much like the use of chemotherapy following tumor resection, antibiotics eluted from the cement spacer and administered systemically will eradicate any organisms remaining at the site of infection, and systemic antibiotics will further kill any residual organisms. Therefore, for this to be successful, a pathogen and its antibiotic sensitivities should be identified. When suspected, a preoperative aspiration from the hip should be performed under radiologic guidance (28). Fluid obtained under aseptic techniques must be analyzed for cell count and differential and also cultured to confirm the species and sensitivities of the infecting organism. Prolonged culture up to 14 days is often required and should be stipulated at the time of retrieval, as many pathogens implicated in PJI are slow growing in routine culture environments. The identified pathogen can be used to guide the choice of antibiotic added to the cement at the time of first-stage revision and the systemic antibiotic used during the interval period (29).

CONTRAINDICATIONS

A patient-centered approach should be applied to the treatment of PJI of the hip. Two-stage revision presents a significant physiologic insult to the patient who is often compromised on the basis of comorbidities including diabetes, immunosuppression, cardiac, respiratory, or renal impairment. While the two-stage approach remains the appropriate intervention for the treatment of PJI of the hip in the majority of cases, it carries a high cost in terms of mortality and morbidity (8). In such patients in whom aggressive, staged surgical intervention is associated with an unacceptable predicted risk of mortality, an alternative

 

intervention, including chronic antibiotic suppression, may be a more appropriate treatment strategy (30,31).

 

 

PREPARATION

Having completed preoperative investigations and following discussion with the patient of the protracted nature of the two-stage treatment approach, preparation for the first stage begins with preoperative assessment of upto-date radiographs. Radiographs should be assessed for the degree of bone loss on both the femoral and acetabular sides as well as evidence of established osteomyelitis. The presence of cement and the volume of proximal femur filled by prosthesis, cement, and plug should be established as all this material will need to be removed at the first stage (32). Knowledge of the infected prosthesis, including component sizes, should be established preoperatively and often necessitates communication with the index hospital to trace the original implant labels, which are located in the medical record. Ideally, the operative report from the index procedure should be obtained as this will aid in planning the approach for the first stage of the revision. Specialized implant extraction instruments are often required in readiness for the first-stage procedure. In the case of well-fixed fully coated uncemented prostheses, or cemented prostheses without evidence of lucency at the cementbone interface, an extended trochanteric osteotomy may be required and should be anticipated prior to the surgery date. On the acetabular side, significant bone loss, particularly of the anterior and posterior column or migration of the acetabular component medial to Kohler's line, should be noted. In such circumstances, a nonarticulating spacer may be more appropriate in an attempt to preserve as much residual pelvic bone stock ahead of the second-stage reimplantation.

As often as possible, antibiotics should be withheld in the period leading up to the first-stage procedure, especially where the diagnosis is in doubt and intraoperative frozen section is anticipated. An integrated management strategy encompassing surgeon, pathologist, and infectious diseases specialist, preferably with an interest in PJIs, is mandatory to the successful treatment of PJI of the hip, and involvement early in the treatment is recommended.

TECHNIQUE

The principle aim of the first stage is the removal of all infected and nonviable material, including prostheses, cement, soft tissue, and bone. This is reliant on adequate exposure. The previous incision should be extended to allow adequate exposure, excising any sinuses within the incision and excising the tract down to the prosthesis. Regardless of surgical approach, adequate exposure of the prosthesis and periarticular region must be achieved to allow a complete debridement. On entering the hip joint, samples of fluid and tissue from both the acetabular and femoral region, as well as any suspicious material, should be sent for microbiologic assessment (33). It is at the surgeons' discretion whether to expose the acetabulum first, following removal of the femoral head if possible, or to address the femoral component first. In the case of a cemented femoral stem, it is our preference to remove the stem first, remove the acetabular component next, and finally remove the femoral cement last. This maintains strength in the femur to allow safe retraction while working on the acetabular side and it reduces blood loss. Exposure often requires removal of much of the thickened capsular tissue to allow dislocation. Retraction of the femur then allows exposure of the remainder of the capsule and synovium, which can then be debrided.

Debridement of the synovium is vital to the identification of the implant-bone interface, which will aid in their removal. Extraction of the femoral component will often require clearance of the shoulder of the prosthesis, which often necessitates removal of a portion of an overhanging greater trochanter using a high-powered burr to prevent fracture on extraction. Shorter, proximally coated stems can often be removed from within the femoral canal using a combination of flexible osteotomes, saws, and burrs, without a femoral osteotomy (Video 30-1). On the other hand, well-fixed fully coated stems, fluted tapered titanium stems, and well-fixed cement mantles necessitate an extended trochanteric osteotomy. Whichever is used, preservation of the femoral bone stock, so

long as it does not jeopardize the quality of the debridement, is paramount for reimplantation at the second stage. Removal of a well-fixed cement mantle can present a challenge. As for the removal of an uncemented prosthesis, this can be achieved

from within the femoral canal using a combination of osteotomes, high-speed burrs, and ultrasonic cement removal tools, depending on the surgeon's preference. In the case of a long cement mantle or a low placed cement plug, an extended trochanteric osteotomy should be considered.

While it is beyond the scope of this chapter to describe the surgical technique of extended trochanteric osteotomy, we wish to emphasize the importance of retaining the blood supply of the osteotomy fragment,

particularly when the saw blade cannot traverse the medullary canal, which contains a canal-filling cementless stem (Fig. 30-2).

Removal of the acetabular component relies on adequate exposure and should only be attempted following a thorough debridement of the periarticular capsule and synovium with adequate retraction of the femur. In the case of an uncemented component, the liner and any acetabular screws should be removed. Using a combination of size-specific curved thin blades with a diameter matched to the existing acetabular component (34), most shells can be removed with minimal violation of the host bone stock. In the case of a cemented acetabular component, a combination of reamers and osteotomes is usually sufficient. In principle, the polyethylene socket should be removed first from the cement mantle, which can then be removed from the underlying bone using osteotomes. Removal of a loose cemented socket is typically fairly simple; however, removal of a well-fixed cemented acetabular component can incur damage to the underlying bone unless great care is taken. In such cases, reaming of the polyethylene socket may be considered if it cannot be easily removed from the cement mantle using osteotomes.

Following removal of the components and any cement, a thorough debridement of the exposed bony anatomy is undertaken. The thick fibrous membrane often present at the bone-implant interface must be removed from the femoral canal and the acetabulum, which often necessitates a combination of burrs, reamers, and reverse cutting hooks. Debridement of the acetabulum is often achieved with an appropriate-sized reamer, taking into consideration any areas of bony deficiency.

At this stage, the debrided bed is irrigated with a large volume of solution. While the exact volume and nature of this irrigate remains open for debate (35,36), it is our practice to irrigate the bed with a minimum of 9 L of normal saline with additional antibiotic (Bacitracin 50,000 per liter normal saline) via low-pressure pulsed lavage.

The purpose of the cement spacer is to allow continued elution of antibiotic establishing local concentrations well above the minimum inhibitory concentration of the infecting organism. Secondary

 

goals are the preservation of limb length and function, preservation of the soft tissue envelope, and facilitation of re-exposure at the second stage (37).

 

 

FIGURE 30-2 A: Proximally coated, canal filling uncemented stem presenting with chronic infection. B: Component removal at the first stage required an extended trochanteric osteotomy with care taken to preserve the blood supply of the osteotomy fragment.

 

Historically, antibiotic cement beads were often used, though these have largely been abandoned in favor of solid spacers, which offer improved soft tissue preservation and aid removal at the time of the second-stage procedure (38).

Static Cement Spacers

When considering a static spacer, the choice depends on the type of cement to be used and the additive antibiotic required, which depends largely on the infecting organism and its sensitivity. Palacos polymethylmethacrylate (PMMA) bone cement (Zimmer, Warsaw, IN) demonstrates excellent antibiotic elution (39,40,41), though elution is dependent on cement porosity and surface area as well as the chosen additive antibiotics. Addition of antibiotics to the bone cement is mandatory to achieve local concentrations sufficient to induce a bactericidal effect. The concentrations of antibiotic in commercially available bone cements are for prophylaxis only and do not achieve sufficient local levels to act as treatment in PJI.

A number of antibiotics can be added to bone cement including gentamicin, tobramycin, vancomycin, daptomycin, erythromycin, clindamycin, and ciprofloxacin, though most utilize a combination of vancomycin and tobramycin when susceptible. Addition of 3.6 g of tobramycin powder and 1.5 g of vancomycin per 40-g pack of cement is a commonly used combination as tobramycin has been shown to have excellent elution properties from PMMA (42,43,44). The cement and antibiotic can be mixed in a bowl by hand, or using a vacuum technique depending on the cement used, with a concomitant effect on the porosity of the final construct, which may be advantageous in the setting of antibiotic elution (45). Vacuum mixing reduces porosity and thus may reduce antibiotic elution.

The static spacer can be molded around existing material available in the operating room such as cement nozzles, suction bulbs, or specimen bowls. Many prefer to mold the spacer by hand fashioning a separate femoral and acetabular spacer. Cement is loosely inserted to both the femoral and acetabular defects. Care

should be taken to not interdigitate the cement with the bone surface. Such an effect, while increasing the macrolock of the spacer, increases the risk of subsequent bone loss at the time of removal.

Articulating Cement Spacers

A number of preformed molds, hemiarthroplasty devices, and articulating spacer devices are commercially available. The preferred technique in our institution is to utilize the PROSTALAC (Prosthesis of antibiotic-loaded acrylic cement) (DePuy Orthopaedics, Warsaw, IN), which is a facsimile of a femoral stem where antibioticloaded cement is molded around a metal endoskeleton with a femoral neck and morse taper in a size-specific mold (46). The femoral component is available in four lengths (100 mm, 150 mm, 200 mm, and 240 mm) and two offsets for the 100-mm length. The appropriate length and offset are selected on the basis of femoral bone loss and soft tissue tension. In cases where the femur has been weakened by osteotomy or osteolysis, or in the case of segmental bone loss, a longer stem can be used, which incorporates an anterior bow. The 100-mm stems are available in 5 sizes and two offsets to allow for an excellent press fit and immediate weight bearing when appropriate. Following judicious broaching of the femur for the 100 mm length, or reaming for the longer stems, the spacer is prepared using PMMA augmented with antibiotic as detailed above. This is molded around the femoral component and allowed to harden (Fig. 30-3; Video 30-2). The spacer can then be inserted and a press fit achieved to allow rotational stability and ease of removal at the time of second-stage revision (Video 30-3). In instances where there is deficiency of the proximal femur, a cuff or collar of cement can be applied to the proximal spacer to maintain torsional and vertical stability.

The acetabular component is a 42-mm × 32-mm ultra high molecular weight polyethylene cup with a simple

snap-fit constrained configuration and is cemented into the acetabular defect. PMMA augmented with antibiotic is inserted into the acetabulum and the cup inserted into this cement bed (Video 30-4). The acetabular component has a snap fit to retain the femoral head in an attempt to obviate the risk of dislocation in the poorly tensioned soft tissue envelope. Variations on this design have been described, such as the CUMARS (custom-made articulating spacer) using the Exeter design of femoral and acetabular components (47). Partial exchange of the acetabular component only in the presence of a well-fixed femoral component has also been described (48). In this setting, there must be no suspicion of infection involving the uncemented femoral component-bone interface with infection localized to the acetabulum only. Following removal of the femoral head and acetabular component and a thorough debridement, an antibiotic-laden acrylic cement articulating femoral head is fashioned using either a pediatric ear syringe or a bulb irrigation syringe or using a disposable cement spacer mold. This cement femoral head is then applied to the existing trunnion and the hip reduced.

 

 

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FIGURE 30-3 A: Preparation of the PROSTALAC articulating cement spacer. B: The cement is prepared with the addition of antibiotics. The prepared cement is poured into the preselected mould around a central endoskeleton. C,D: Following the cement curing, the stem is inserted to the desired length into the prepared femoral canal.

 

In all cases, the wound should be closed in layers where possible and drains should not be used to maximize the local concentration of antibiotic eluted from the cement (32).

PEARLS AND PITFALLS

Whether a static or articulating spacer is employed, a successful outcome is dependent on a thorough debridement and removal of all infected and nonviable material. Extensive exposure recreating fascial planes as well as osteotomies of the proximal femur should be used to allow visualization of all potential loci of infection.

Careful preoperative and intraoperative assessment of bone loss, particularly on the acetabular side, should be made, as this will predict the requirements for augmentation and grafting at the second-stage procedure. Great effort should be made in the search for the infecting organism prior to the first stage, as this will guide the additional antibiotics used for the spacer.

At the time of insertion of the spacer, care should be taken to not interdigitate cement with native bone as this will result in unnecessary bone loss at the second-stage procedure. In our experience, unless keyholes are made, because of the sclerotic nature of the acetabular host bone, it is unlikely to get rigid fixation of the spacer cup to the host bone and extraction is always easy. When using the PROSTALAC spacer, some advocate removing the

excess cement from the distal tip of the spacer prior to insertion as on occasion; this can snap off at the time of removal resulting in a distal cement plug within the femur.

 

 

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At the time of the second-stage procedure, extra time and care should be taken in the removal of the spacer from the femur. A combination of high-speed burrs and osteotomes should be used to clear soft tissue and excess cement from the shoulder of the prosthesis to prevent unnecessary damage to the often weakened greater trochanter.

POSTOPERATIVE MANAGEMENT

Postoperatively, we use thromboprophylaxis in all patients. The type of spacer employed, taking into consideration patient and surgical factors, will determine mobilization. For static cement spacers, weight bearing is often restricted as patients find this too uncomfortable to tolerate due to the lack of muscular control of the hip. Significant shortening is to be expected, and the majority of patients manage only touch weight bearing with a walker. In the case of an articulating spacer, we favor protected weight bearing to half normal so as to reduce the risk of stem subsidence or rotation.

In all cases, an integrated, multidisciplinary team approach to the perioperative period is utilized. Antibiotics should be commenced once specimens have been harvested. Antibiotics should be based on the organism identified from the preoperative workup or on the basis of the probable infecting organism. Intraoperative cultures will determine the final antibiotic choice. Specialists in infectious diseases as well as home intravenous antibiotic teams should be involved as soon as possible. Patients will invariably require intravenous antibiotics for a prolonged period, and long-term peripheral venous access should be obtained as soon as possible to prevent repetitive venipuncture.

Despite much research on the subject, the decision to reimplant remains a difficult one. It is accepted that patients should have completed a prolonged period of antibiotic therapy and been off antibiotics for a period with inflammatory markers including CRP and ESR trending downward toward normal (49). The use of aspiration from the hip while off antibiotics with assessment of cell count and differential, CRP and ESR, histology of synovial biopsies, and biomarkers have all been assessed as predictors of the point at which reimplantation can safely proceed (50,51,52,53,54,55,56,57,58). However, to date, no definitive green light marker to proceed to the second stage exists, and an assessment on the basis of the evolving clinical picture should be made. In the presence of unresolved infection manifest as a failure of the CRP or ESR to trend downward, persisting wound drainage, or sinus formation, a repeat first-stage procedure may be required.

At the time of the second-stage procedure, care should be taken during dissection as tissue planes can become markedly distorted during the interval period, particularly with static spacers (59). Removal of the spacer should be undertaken with great care to minimize unnecessary bone loss. A further debridement should be performed prior to implantation with revision components (Figs. 30-4 and 30-5). The revision surgery often requires management of bone loss in the acetabulum and femur.

 

 

 

FIGURE 30-4 A: Periprosthetic fracture below a short stem PROSTALAC femoral component inserted as part of a two-stage approach for the treatment of a late hematogenous infection of an uncemented THA. B: The fracture was treated by exchange of the femoral component to a longer stem with augmentation of fixation with cerclage cabling.

 

 

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FIGURE 30-5 A: The case of a 56-year-old male presenting with failure of fixation following an undisplaced subcapital fracture treated with internal fixation. B: The patient underwent primary THA, which, 2 years postarthroplasty, became infected. C,D: Treatment was by means of a two-stage revision with interval antibioticloaded articulating spacer and subsequent reconstruction with a tapered fluted monoblock stem.

 

COMPLICATIONS

In the absence of recurrent infection, the complications in relation to cement spacers comprise spacer fracture, femoral fracture (Fig. 30-6), and spacer dislocation. Handmade spacers fashioned around a central rod or pin are more susceptible to fracture than custom-made or molded designs. The stability of the spacer is largely dictated by its geometry, type of cement, additional antibiotics, the presence of an endoskeleton, and its process of preparation (60). The mechanical stability of the cement is not affected by additional antibiotics up to a proportional ratio of approximately 5% (61) with larger proportions resulting in a more difficult mix and heterogenicity in the final cement. However, more recent reports suggest that proportional ratios of antibiotic up to 20% do not affect the ease of manufacture of the cement (62). In order to make

 

cement mixing easier when a large

 

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volume of antibiotic powder is added, we remove a small amount of powder prior to adding the full amount of monomer, or add more monomer.

 

 

 

FIGURE 30-6 A: The case of a 65-year-old male presenting with a late hematogenous PJI involving a fully porous coated femoral stem with a large-diameter metal on metal bearing. B: Stage one of the two-stage approach required an extended trochanteric osteotomy and a long stem PROSTALAC articulating cement spacer. C: Subsequent reimplantation following eradication of infection was by means of tapered fluted monoblock stem.

The lack of intentional rigid interdigitation at the cement-bone interface can result in motion of the components, which can result in rotation of the femoral component or dislocation. The constrained nature of the acetabular component of the PROSTALAC system reduces, but does not eliminate, the risk of dislocation. The risk of spacer dislocation has been reported as high as 15% (63), but our experience with the constrained acetabular cup has been better than this. Using a large head diameter hemiarthroplasty as the endoskeleton of the spacer and paying attention to restoration of offset in the design of spacer chosen

can reduce this risk. Particular attention should be paid to the anteversion and abduction angles of the

implanted acetabular components to reduce the risk of dislocation. Subluxation or dislocation of a large-diameter hemiarthroplasty can also lead to acetabular bone loss.

RESULTS

Studies comparing static and articulating spacers do not exist. However, patients with articulating spacers have demonstrated better pain relief between stages and high levels of satisfaction (59,64). In their initial description of the PROSTALAC system, Younger et al. (64) reported an eradication

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rate of 94% at a mean of 43 months. At a mean of 12 years, the designer center reported a longterm

success rate of 89% (65). This has subsequently been supported by others when used to treat sensitive organisms (25,37). While a multitude of series describing the outcomes of two-stage revision exist, the reinfection rates in studies comprising more than 50 patients range from 8.3% to 12.3% (66,67,68,69,70,71,72) using either antibiotic-loaded cement beads (66,68,71) or cement spacers (69,70,72). Follow-up periods for these studies ranged between 12 and 36 months.

Much debate exists with regard to one-stage exchange versus two-stage revision for the treatment of PJI of the hip. In an attempt to answer the question of which has superior efficacy in the treatment of chronic infection, a number of systematic reviews, meta-analyses, and statistical models have appeared (14,15,16,17,18). None have demonstrated a superior approach. However, with the available evidence that exists at present, it appears that staged reimplantation with antibiotic cement in the interval period is associated with improved eradication and lower rates of reinfection, making it the gold standard for treatment of PJI of the hip in North America (20,25,38,73,74,75,76).

The treatment of infections secondary to resistant organisms remains a difficult area with such infections associated with higher failure rates despite two-stage revision. Leung et al. (22) reported an eradication rate of only 79% using an articulating spacer in the presence of resistant staphylococci, a figure mirrored by others (49,77). This is likely to become an ever-increasing problem in the future with the increasing incidence of resistant PJI and the increasing prevalence of community-associated methicillin-resistant staphylococci.

While much attention is focused on the ability of two-stage exchange with either a static or articulating spacer, the consequence for the patient should not be overlooked. Fehring et al. (63) demonstrated a 42% mortality within the first 5 years following the second stage. Leung et al. (22) demonstrated a mortality of 24% within the 4 years of follow-up of their study. Toulson et al. (72) demonstrated a 25.8% mortality associated with a two-stage approach, a figure mirrored by Berend et al. (8) who demonstrated a 76% survival and infection control with the two-stage approach. This may reflect not only the aggressive nature of the treatment but also the fragility of the patients affected by prosthetic joint infections.

 

CONCLUSIONS

Two-stage exchange for the treatment of prosthetic joint infection of the hip with the use of an interval antibiotic-loaded spacer remains the gold standard of treatment. With the advent of articulating spacers, designed to maintain limb length and function while preserving soft tissues, the use of static spacers has diminished. Static cement spacers still have a role in the treatment of PJI of the hip, particularly when associated with significant bone loss. The use of cement allows elution of antibiotics to the local tissues in

 

high concentrations for prolonged periods and has resulted in high rates of eradication of infection. Critical

to success regardless of the type of spacer used is the surgical debridement. It is important to attempt to remove all foreign body as well as any devitalized tissue and granulomatous material. Imperative to the treatment of PJI of the hip are identification of the infecting organism and its sensitivities, with augmentation of the cement by appropriate antibiotics. The timing of reimplantation is often guided by the response to treatment and can usually be undertaken with 3 to 6 months of the first-stage procedure. Select centers are evaluating a shorter interval between stages. The use of the two-stage approach, while efficacious in the treatment of PJI of the hip, is associated with a high incidence of morbidity and mortality, and careful assessment of patient suitability for the prolonged treatment regimen is mandatory.

 

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1.  

 

periprosthetic joint infection

hip arthroplasty

two-stage revision

spacers

antibiotic therapy