Aspiration as a guide to sepsis in revision total hip arthroplasty

Accuracy of joint aspiration for the preoperative diagnosis of infection in total hip arthroplasty

The aim of this study was to assess the diagnostic accuracy of radiology department-based hip aspiration for the diagnosis of infection after total hip arthroplasty. Patient selection criteria were devised so that only patients with moderate to high risk of infection were selected for hip aspiration. Seventy-three patients are included in this study, all of whom underwent revision hip surgery after aspiration. Culture results of hip aspirates were compared with the intraoperative tissue cultures at the time of revision surgery, which was used as the gold standard for diagnosing infection. Seventeen patients (23%) had infected hip joints at operative culture. The sensitivity and specificity, positive and negative predictive values, and accuracy of the hip aspiration were 0.82 and 0.91, 0.74 and 0.94, and 0.89, respectively. We conclude that hip aspiration carried out in the radiology department is reliable, but appropriate patient selection is important to obtain accurate results.

[Improving microbiological diagnostics in septic orthopaedic surgery. Comparative study of patients receiving systemic antibiotic therapy]

MATERIAL AND METHODS

This prospective study included 63 patients with confirmed infections of soft tissue, joints, bones or implants. During 110 surgical interventions, 124 swab and deep tissue sample pairs were taken and analysed microbiologically using standard procedures.

RESULTS

In 40 patients who had not received prior antibiotic treatment, 57 sample pairs (swabs/tissue) were taken. In 70%, growth of microorganisms could be observed in both swabs and tissue samples. Growth in tissue sample only was observed in 14% and in 14% no growth could be detected. In 67 sample pairs taken from 23 patients who had received systemic antimicrobial treatment prior to surgery, microbial growth in both specimens was detected in 40%. Growth in tissue sample only was observed in 22% and 34% of the samples remained without detectable growth. The overall sensitivity of the tissue samples (70%) was significantly higher than in swab samples (44%) for the pretreated group.

CONCLUSION

The use of intraoperative tissue samples for microbiological diagnostics in septic orthopaedic surgery must be considered a "gold standard". The higher sensitivity of intraoperative tissue samples is particularly important in patients receiving systemic antibiotic therapy prior to surgical interventions.

Value of preoperative investigations in diagnosing prosthetic joint infection: retrospective cohort study and literature review

The diagnosis of a prosthetic joint infection is difficult, but crucial for appropriate treatment. Scintigraphy with specific markers for infection (labelled white cells or immunoglobulin-G) has been reported as a more reliable diagnostic tool than clinical assessment (fever, fistula), laboratory studies (polynuclear neutrophil count, erythrocyte rate sedimentation, and C-reactive protein), and preoperative aspiration. In the first part of this study, we retrospectively reviewed 230 patients admitted with a suspected prosthetic joint infection, and examined the validity of the different diagnostic tools for the group as a whole and for subgroups according to the Coventry classification. In the second part, we reviewed 35 articles about preoperative evaluation of infection in prosthetic joints and compared them to our findings. Our study indicates that C-reactive protein and joint aspiration are the most useful tools to diagnose prosthetic joint infection even in situations of chronic infection (Coventry type II).

The value of hip aspiration versus tissue biopsy in diagnosing infection before exchange hip arthroplasty surgery

The exclusion of infection is the most important factor in determining treatment options in a failed hip arthroplasty. Preoperative biopsy in the form of aspiration or tissue biopsy can be used to diagnose infection. Preoperative aspiration and tissue drill biopsy were performed in 273 consecutive patients under general anesthesia 3 months before exchange arthroplasty surgery. The results of the preoperative aspiration and tissue biopsy cultures were compared with the definitive intraoperative tissue cultures obtained at surgery. Seventy-one of 273 (26%) hips were infected. Overall accuracy of aspiration was 90.1% and tissue biopsy 87.9%. The sensitivity and specificity was 80% and 94% for aspiration and 83% and 90% for tissue biopsy. Positive predictive value and negative predictive values were 81.4% and 93.1% for aspiration and 73.8% and 93.8% for tissue biopsy. The more invasive tissue drill biopsy offers no advantage over aspiration in terms of bacterial accuracy and results in more false positives.

FDG PET for differentiation of infection and aseptic loosening in total hip replacements: comparison with conventional radiography and three-phase bone scintigraphy

PURPOSE

To compare the diagnostic efficacy of fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) with that of conventional radiography and three-phase bone scintigraphy in patients suspected of having infection in their total hip replacements.

MATERIALS AND METHODS

Thirty-five patients with painful total hip replacements and possible septic prosthetic loosening were examined with FDG PET, conventional radiography, and three-phase bone scintigraphy. PET, radiographic, and scintigraphic images were each evaluated by two independent observers in a blinded fashion. For 32 of 35 patients, serial conventional radiographs were available. Results of microbiologic examinations of surgical specimens represented the standard of reference in 26 patients, and results of joint aspiration plus clinical follow-up of at least 6 months represented the standard of reference in the remaining nine patients. Sensitivity, specificity, accuracy, and interobserver variability (kappa) values were calculated. The imaging modalities were compared in terms of diagnostic confidence by using the sign test.

RESULTS

Nine patients had septic and 21 patients had aseptic loosening. In five patients, neither loosening nor infection was confirmed. For diagnosing infection with FDG PET, conventional radiography, and bone scintigraphy, respectively, sensitivity values for reader 1 and reader 2 were 33% and 22%, 89% and 78%, and 56% and 44%, while specificity values were 81% and 85%, 50% and 65%, and 88% and 92% and accuracy values were 69% for both readers, 60% and 69%, and 80% for both readers. PET was significantly more specific (P =.035) but less sensitive (P =.016) than conventional radiography for the diagnosis of infection.

CONCLUSION

In a study population of patients suspected of having infected total hip replacements, FDG PET performed similarly to three-phase bone scintigraphy. FDG PET was more specific but less sensitive than conventional radiography for the diagnosis of infection.

Contribution of routine joint aspiration to the diagnosis of infection before hip revision surgery

OBJECTIVES

To define the sensitivity and specificity of routine preoperative hip aspiration for diagnosing hip prosthesis infection (HPI) and to separately analyze subgroups with and without a clinical suspicion of HPI before aspiration.

METHODS

From June 1994 to June 1997, all patients scheduled for hip revision surgery underwent aspiration of the hip under image intensifier guidance. Microbiological results were compared between these preoperative specimens and the intraoperative specimens. The reason for surgery was either a clinical suspicion of HPI or pain suggesting loosening.

RESULTS

The study patients had had multiple surgical procedures. HPI was suspected clinically in 39.4% of cases. Of the 109 patients who underwent aspiration, 54 had true-negative results, nine had false-negative results, and 44 had true-positive results (there were no false-positive results), yielding a sensitivity of 83% and a specificity of 100%. Diagnostic efficiency was 91.6%, positive predictive value was 100%, and negative predictive value was 85.7%. In the subset of 43 patients with a clinical suspicion of HPI, aspiration identified all the causative organisms in 60.5% of cases. Of the 66 patients with no clinical suspicion of HPI, 12 had HPI, and aspiration provided the diagnosis preoperatively in seven of these patients, radically changing their management plans. Restricting routine aspiration to patients whose prosthesis had been implanted within the last 5 years or whose erythrocyte sedimentation rate (ESR) was above 30 mm/h would not have modified our findings.

CONCLUSIONS

Hip aspiration before revision surgery for pain is effective in detecting HPI, which can simulate aseptic loosening. However, this investigation may be noncontributive in patients who have had their prosthesis for more than 5 years and whose ESR is less than 30 mm/h.

The value of white blood cell counts before revision total knee arthroplasty

A white blood cell count (WBC) of >50000 cell/mm(3) from a knee aspirate with >or=80% polymorphonuclear cells (PMNCs) is suggestive of infection. This study sought to determine if these same criteria were applicable when interpreting aspirates from a total knee. Of 440 revision total knee arthroplasties, 86 patients had preoperative aspirations of the knee before revision. Fifty-five aspirates were from aseptic failures; 31 aspirates were from patients determined to have septic failure. The mean white blood cell (WBC) count in aspirates from the aseptic group was 645 cells/mm(3) (SD = 878). The mean WBC count in the septic group was 25951 cells/mm(3) (SD = 34994; P=<.001). The mean percentage of PMNCs was statistically higher in the septic group compared with the aseptic group (72.8% vs 27.3%; P=<.001). The synovial fluid WBC count differential analysis is a statistically relevant indicator of the presence or absence of infection in revision knee arthroplasty. Aspirates with a WBC count of 2500 per milliliter and 60% PMNCs are highly suggestive of infection.

Molecular and antibiofilm approaches to prosthetic joint infection

The majority of patients with prosthetic joint replacement (arthroplasty) experience dramatic relief of pain and restoration of satisfactory joint function. In the United States, more than.5 million people have a primary arthroplasty each year. Less than 10% of prosthesis recipients have complications develop during their lifetime, commonly as a result of aseptic biomechanical failure, followed by prosthetic joint infection. The pathogenesis of prosthetic joint infection is related to bacteria in biofilms, in which they are protected from antimicrobial killing and host responses rendering these infections difficult to eradicate. Current microbiology laboratory methods for diagnosis of prosthetic joint infection depend on isolation of a pathogen by culture. However, these methods have neither ideal sensitivity nor ideal specificity. Therefore, culture-independent molecular methods have been used to improve the diagnosis of prosthetic joint infection. In the research setting, detection of 16S ribosomal deoxyribonucleic acid by polymerase chain reaction has been used in the molecular diagnosis of prosthetic joint infection. Various antibiofilm strategies directed at disruption of adherent bacteria are the focus of intense research to improve the detection of biofilm organisms and their eradication. In this article, molecular and antibiofilm approaches to prosthetic joint infection are reviewed.

The value of (18)FDG-PET for the detection of infected hip prosthesis

We compared the accuracy of fluorine-18 labelled 2-fluoro-2-deoxy- d-glucose positron emission tomography ((18)FDG PET) with that of technetium-99m hexamethylpropylene amine oxime leucocyte scintigraphy (LS) in the detection of infected hip prosthesis. Seventeen patients with a hip prosthesis suspected for infection were prospectively included and underwent (99m)Tc-methylene diphosphonate bone scintigraphy (BS), LS and an (18)FDG-PET scan within a 2-week period. Seven volunteers with ten asymptomatic hip prostheses were used as a control group and underwent BS and an (18)FDG-PET scan. Bacteriology of samples obtained by surgery or by needle aspiration and/or clinical follow-up for up to 6 months were used as the gold standard. Planar images of BS and LS (4 and 24 h p.i.) were acquired, followed by single-photon emission tomography (SPET) LS images (after 4 h). These images were scored as positive or negative by two experienced readers. The (18)FDG-PET scans of the patients were compared with the tracer distribution pattern in the asymptomatic control group and with BS. A phantom study was performed in order to identify artefacts. For this purpose, three different attenuation correction methods were tested. The combined analysis of the planar BS and LS resulted in a 75% sensitivity and a 78% specificity. The SPET LS images showed a better lesion contrast, resulting in an 88% sensitivity and a 100% specificity, while 24-h planar images were of no additional value. The analysis of PET images alone resulted in an 88% sensitivity and a 78% specificity. The combination of (18)FDG-PET and BS images resulted in an 88% sensitivity and a 67% specificity. Given the presence of small errors near the edge of the metal, which can induce significant artefacts in the corrected emission image, we decided to use the data without attenuation correction. In this preliminary study, (18)FDG-PET scans alone showed the same sensitivity as combined BS and LS, although the specificity was slightly lower.

Diagnosis of infection after total hip arthroplasty

Forty-eight total hip arthroplasties for which revision surgery was performed were reviewed to determine the accuracy of laboratory tests, plain radiographs, hip aspiration, and technetium-99m MDP and gallium-67 scans in demonstrating the presence or absence of infection of the prosthesis. Six of the 48 hips were diagnosed as having an infection at the revision surgery. The erythrocyte sedimentation rate and the C-reactive protein levels were significantly higher in the patients with infected prostheses. The difference in the white blood cell count was not significant. There was no significant relationship between the presence of infection and the severity of loosening and instability of the implants diagnosed by plain radiographs. The accuracy of hip aspiration in diagnosing the infection was 83%, with a sensitivity of 40% and a specificity of 92%. The accuracy of technetium-99m MDP bone scan was 79%, with a sensitivity of 83%, and a specificity of 79%. Gallium-67 scan had an accuracy of 96%, a sensitivity of 67%, and a specificity of 100%. The findings in the present study indicated that diagnostic tests consisting of laboratory tests and plain radiography, followed by hip aspiration and sequential use of technetium-99m MDP and gallium-67 scintigraphies, are suitable for differentiation between mechanical loosening and infection of total hip arthroplasty.

Ultrasound for diagnosis of infection in revision total hip arthroplasty

Eighty consecutive patients (85 hips; 43 women; median age, 74 years [range, 33-90 years]) underwent a revision total hip arthroplasty. Preoperatively and guided by ultrasound, biopsy specimens of the joint pseudocapsule were taken, and joint fluid was aspirated for culture. Capsule morphology was investigated with light microscopy. When septic loosening was defined as 2 intraoperative cultures yielding the same microorganism, the prevalence was 12%. Sensitivity of the capsule biopsy cultures was 67%; specificity, 68%; positive predictive value, 22%; and negative predictive value, 94%. Joint fluid was often sparse and always falsely sterile. One specimen from a hip with septic loosening showed histologic changes (> or =3 foci, each with > or =3 plasma cells/high-power field) consistent with chronic infection. The remaining 8 septic loosenings eluded histologic detection, yielding 11% sensitivity. All aseptic loosenings were classified correctly (specificity 100%). Positive and negative predictive values were 100% and 89%. Ultrasound-guided aspiration and capsule biopsy with cultures and histology does not seem to be sufficiently accurate in the preoperative diagnosis of infected total hip arthroplasty.

Two-stage exchange hip arthroplasty for deep infection

Although the risk of infection after total hip arthroplasty has decreased over the last three decades with the use of prophylactic antibiotics, laminar airflow operating rooms and whole-body exhaust suites, deep infection after total hip arthroplasty remains a serious complication. Significant morbidity to the patient and the cost to the health care system remain. During this period of time, diagnostic techniques also have improved including the use of polymerase chain reaction amplification. Treatment options now include: suppressive antibiotics, irrigation and debridement with retention of components, one-stage reimplantation, two-stage reimplantation, and salvage procedures. Based on the medical literature, the successful eradication of a total joint replacement infection with a two-stage reimplantation protocol is over 90% while the success rate with a one-stage protocol is approximately 80%. These success rates may decline however as the prevalence of antibiotic resistant organisms increases. Current controversies regarding two-stage reimplantation protocols include: duration of intravenous antibiotic therapy, timing of the reimplantation, the use of allograft bone in the reconstruction, the choice of fixation (cement versus cementless), and the use of antibiotic-loaded cement spacers.

Impregnation of vancomycin, gentamicin, and cefotaxime in a cement spacer for two-stage cementless reconstruction in infected total hip arthroplasty

Twenty-two patients with infected total hip arthroplasty were treated with 2-stage arthroplasty, using a cement spacer impregnated with a combination of 3 thermostable antibiotics (vancomycin, gentamicin, and cefotaxime). Initially, implants were removed, and a spacer was inserted. Six to 12 weeks later, the spacer was removed, and the patients underwent reconstruction using cementless components. The patients were followed for an average of 41 months. One patient had a recurrence of infection and was treated with resection arthroplasty. The remaining 21 patients (95%) had no evidence of infection at the final follow-up. We recommend using the combination of these 3 antibiotics in the cement spacer for 2-stage reconstruction in infected hip arthroplasty when the causative organism is not identified in the culture of preoperative aspiration.

Efficacy of combined technetium-99m sulfur colloid/indium-111 leukocyte scans to detect infected total hip and knee arthroplasties

The reliability of combined indium-111 leukocyte/technetium-99m sulfur colloid scans, with and without the addition of blood pooling and blood flow studies, in the diagnosis of infected total joint arthroplasty was investigated. Both scans were performed on 58 patients before reoperation of total hip or knee arthroplasty in the period 1996-1999. Results for imaging alone included 100% specificity, 46% sensitivity, 100% positive predictive value, 84% negative predictive value, and 88% accuracy. Inclusion of blood pooling and flow phase data improved results to 66% sensitivity, 89% negative predictive value, and 90% accuracy, with reductions in specificity (98%) and positive predictive value (91%). Routine use of these radionuclide scans is not supported by these data.

New developments in diagnosis and treatment of infection in orthopedic implants

Orthopedic implants have revolutionized treatment of bone fractures and noninfectious joint arthritis. Today, the risk for orthopedic device-related infection (ODRI) is <1%-2%. However, the absolute number of patients with infection continuously increases as the number of patients requiring such implants grows. Treatment of ODRIs most frequently includes long-term antimicrobial treatment and removal of the implant. Recent evidence from observational trials and 1 randomized clinical trial indicate that a subset of patients can be successfully treated with retention of the implant. Patients eligible for such a treatment must meet the following criteria: acute infection defined as signs and symptoms lasting <14-28 days, an unambiguous diagnosis based on histopathology and microbiology, a stable implant, and susceptibility of the microorganism to an effective orally available antimicrobial agent.

Use of blood culture vial specimens in intraoperative detection of infection

A retrospective study was performed evaluating the results of three different intraoperative culture techniques and their diagnostic value in determining clinical infection in patients after a total joint replacement. Twenty-four patients (34 cases) met the selection criteria and were evaluated using intraoperatively collected tissue samples, swab samples, and fluid samples injected into standard blood culture vials. Results of the cultures of these specimens were compared with the clinical diagnoses to determine specificity, sensitivity, and accuracy of each technique. The current study suggests the use of fluid aspirate from intraoperative wounds immediately injected into blood culture vials is a highly specific, sensitive, and accurate diagnostic culture technique (100%, 92%, and 94%, respectively). The superiority of vial cultures is enhanced when organisms grown from the liquid media only are discounted as contaminants. This led to significant decreases in the sensitivity and accuracy of swab culture and tissue biopsy results when compared with vial culture results. Thus, vial cultures are a more cost-effective means for intraoperative detection of infection.

The predictive value of indium-111 leukocyte scans in the diagnosis of infected total hip, knee, or resection arthroplasties

To evaluate the usefulness of the indium-111 scan in detecting actually or potentially infected total hip, knee, and resection arthroplasties, 153 scans were performed on 143 patients who underwent reoperation for a loose or painful total joint arthroplasty or a resection arthroplasty between 1990 and 1996. Scans were interpreted as infected, not infected, or equivocal by an experienced nuclear medicine radiologist. Patients were considered to be infected if they met any 2 of the following criteria: i) positive intraoperative cultures, ii) final permanent histologic section indicating acute inflammation, and iii) intraoperative findings of gross purulence within the joint. Twenty-six patients (17%) met the infection criteria at the time of reoperation. Indium scans were found to have a 77% sensitivity, 86% specificity, 54% and 95% positive and negative predictive values, and 84% accuracy for the prediction of infection. Of 6 equivocal scans, none were infected. The results of this study suggest limited indications for the use of the indium-111 scan in the evaluation of painful hip, knee, or resection arthroplasties. A negative indium scan may be helpful in suggesting the absence of infection in cases in which the diagnosis is not otherwise evident.

Prospective analysis of preoperative and intraoperative investigations for the diagnosis of infection at the sites of two hundred and two revision total hip arthroplasties

BACKGROUND

Total hip arthroplasty is a commonly performed procedure in the United States and Canada that is associated with a definite risk of postoperative infection. Moreover, diagnosing an infection after total hip arthroplasty can present a challenge as there are no preoperative tests that are consistently sensitive and specific for infection in patients who need a revision arthroplasty. The present prospective study was performed to evaluate a variety of investigations for the diagnosis of infection at the site of a previous arthroplasty in order to determine if any combination of diagnostic studies could be used to determine which patients are at risk for a postoperative wound infection.

METHODS

We prospectively analyzed the preoperative and intraoperative investigations used for the diagnosis of infection in 178 patients who had a total of 202 revision hip replacements. Clinical data were collected preoperatively. Investigations to determine the presence or absence of infection included a white blood-cell count, measurement of the erythrocyte sedimentation rate, measurement of the level of C-reactive protein, preoperative aspiration of the joint, intraoperative gram-staining and culture of periprosthetic tissue, a white blood-cell count in synovial fluid, and examination of intraoperative frozen sections. Frozen sections were analyzed in a blinded fashion without knowledge of clinical or laboratory data. Patients receiving antibiotics at the time of aspiration or collection of specimens for intraoperative culture were excluded from the analysis of those investigations, regardless of the results of the cultures. A positive result (suggestive of infection) was clearly defined for each of the investigations.

RESULTS

Thirty-five hips (17 percent) were determined to be infected on the basis of clinical findings and positive results, according to the defined criteria, of investigations. With inflammatory conditions excluded, the sensitivity, specificity, positive predictive value, and negative predictive value were 0.82, 0.85, 0.58, and 0.95, respectively, for the erythrocyte sedimentation rate and 0.96, 0.92, 0.74, and 0.99, respectively, for the level of C-reactive protein. All patients who had a periprosthetic infection had an elevated erythrocyte sedimentation rate or level of C-reactive protein, but not always both. When patients who were receiving antibiotics were excluded, the results of aspiration of the joint were 0.86 for sensitivity, 0.94 for specificity, 0.67 for the positive predictive value, and 0.98 for the negative predictive value. Intraoperative studies revealed sensitivities, specificities, positive predictive values, and negative predictive values of 0.19, 0.98, 0.63, and 0.89, respectively, for gram-staining of specimens of the most inflamed-appearing tissue; 0.36, 0.99, 0.91, and 0.90, respectively, for the white bloodcell count in synovial fluid; and 0.89, 0.85, 0.52, and 0.98, respectively, for a neutrophil count in synovial fluid of more than 80 percent. The sensitivity, specificity, positive predictive value, and negative predictive value were 0.80, 0.94, 0.74, and 0.96, respectively, for the frozen sections and 0.94, 0.97, 0.77, and 0.99, respectively, for the intraoperative cultures.

CONCLUSIONS

The combination of a normal erythrocyte sedimentation rate and C-reactive protein level is reliable for predicting the absence of infection. Aspiration should be used when the erythrocyte sedimentation rate or the C-reactive protein level is elevated or when a clinical suspicion of infection remains. We found the gram stain to be unreliable. Examination of intraoperative frozen sections is useful in equivocal cases or when hematological markers may be falsely elevated because of an inflammatory or other condition.

Analysis of frozen sections of intraoperative specimens obtained at the time of reoperation after hip or knee resection arthroplasty for the treatment of infection

BACKGROUND

Despite the effectiveness of a two-stage exchange protocol for the treatment of deep periprosthetic infection, infection can persist after resection arthroplasty and treatment with antibiotics, leading to a failed second-stage reconstruction. Intraoperative analysis of frozen sections has been shown to have a high sensitivity and specificity for the identification of infection at the time of revision arthroplasty; however, the usefulness of this test at the time of reoperation after resection arthroplasty and treatment with antibiotics is, to our knowledge, unknown.

METHODS

The medical records of sixty-four consecutive patients who had had a resection arthroplasty of either the knee (thirty-three patients) or the hip (thirty-one patients) and had had intraoperative analysis of frozen sections of periprosthetic tissue obtained at the time of a second-stage operation were reviewed. The mean interval between the resection arthroplasty and the attempted reimplantation was nineteen weeks. The results of the intraoperative analysis of the frozen sections were compared with those of analysis of permanent histological sections of the same tissues and with those of intraoperative cultures of specimens obtained from within the joint. The findings of the analyses of the frozen sections and the permanent histological sections were considered to be consistent with acute inflammation and infection if a mean of ten polymorphonuclear leukocytes or more per high-power field (forty times magnification) were seen in the five most cellular areas.

RESULTS

The intraoperative frozen sections of the specimens from two patients (one of whom was considered to have a persistent infection) met the criteria for acute inflammation. Four patients were considered to have a persistent infection on the basis of positive intraoperative cultures or permanent histological sections. Overall, intraoperative analysis of frozen sections at the time of reimplantation after resection arthroplasty had a sensitivity of 25 percent (detection of one of four persistent infections), a specificity of 98 percent, a positive predictive value of 50 percent (one of two), a negative predictive value of 95 percent, and an accuracy of 94 percent.

CONCLUSIONS

A negative finding on intraoperative analysis of frozen sections has a high predictive value with regard to ruling out the presence of infection; however, the sensitivity of the test for the detection of persistent infection is poor.

Cementless fixation in 2-stage reimplantation for periprosthetic sepsis

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.