Structural allografts for bone stock reconstruction in two-stage revision for infected total hip arthroplasty: good outcome in 16 of 18 patients followed for 5-14 years

Mortality During Total Hip Periprosthetic Joint Infection

BACKGROUND

We sought to understand the mortality rate of periprosthetic joint infection (PJI) of the hip undergoing 2-stage revision for infection.

METHODS

Database search, yielding 23 relevant studies, totaled 19,169 patients who underwent revision for total hip PJI.

RESULTS

One-year weighted mortality rate was 4.22% after total hip PJI. Five-year mortality was 21.12%. Average age was 65 years. When comparing the national age-adjusted risk of mortality and the reported 1-year mortality risk in this systematic review, the risk of death after total hip PJI is significantly increased (odds ratio 3.58, P < .001).

CONCLUSION

The mortality rate during total hip revision for infection is high. When counseling a patient regarding complications of this disease, death should be discussed.

Intravenous drug abuse is a risk factor in the failure of two-stage treatment for infected total hip arthroplasty

Reinfection after two-stage revision hip arthroplasty (RHA) is still a complex issue. Only few studies revealed the factors affecting the success rate in the treatment of periprosthetic hip infection (PHI), especially risk factors. A retrospective study was conducted using records of 30 patients underwent two-stage RHA for infected total hip arthroplasty (THA). Treatment was defined as successful if a patient did not need any reoperation or invasive procedure such as image-guided drainage during the two years after reimplantation. Treatment was defined as failure if any surgery or invasive procedure or long-term antibiotic suppression was considered necessary to control infection. Four patients had infection recurrence defined as failed and three of them had intravenous drug abuse. Twenty-six patients had no infection recurrence at the end of follow-up and one of them had intravenous drug abuse but quitting after surgery. We suggest that once adequate cleaning up achieved, risk of reinfection may be little even in immunocompromised patients with RHA because of relative less old age than those with revisional total knee arthroplasty. Patients of the reinfection group were younger and non-obese with adequate nutritional status. We may consider intravenous drug abuse could take a great toll on health and lead to reinfection. Finally, we suggest performing the gold-standard two-stage reimplantation technique to manage cases with infection, educating drug abusers regarding the risk of surgical failure, and implementing a quitting program at least 1 year before the index surgery.

Does cemented or cementless single-stage exchange arthroplasty of chronic periprosthetic hip infections provide similar infection rates to a two-stage? A systematic review

Background

The best surgical modality for treating chronic periprosthetic hip infections remains controversial, with a lack of randomised controlled studies. The aim of this systematic review is to compare the infection recurrence rate after a single-stage versus a two-stage exchange arthroplasty, and the rate of cemented versus cementless single-stage exchange arthroplasty for chronic periprosthetic hip infections.

Methods

We searched for eligible studies published up to December 2015. Full text or abstract in English were reviewed. We included studies reporting the infection recurrence rate as the outcome of interest following single- or two-stage exchange arthroplasty, or both, with a minimum follow-up of 12 months. Two reviewers independently abstracted data and appraised quality assessment.

Results

After study selection, 90 observational studies were included. The majority of studies were focused on a two-stage hip exchange arthroplasty (65 %), 18 % on a single-stage exchange, and only a 17 % were comparative studies. There was no statistically significant difference between a single-stage versus a two-stage exchange in terms of recurrence of infection in controlled studies (pooled odds ratio of 1.37 [95 % CI = 0.68-2.74, I² = 45.5 %]).

Similarly, the recurrence infection rate in cementless versus cemented single-stage hip exchanges failed to demonstrate a significant difference, due to the substantial heterogeneity among the studies.

Conclusion

Despite the methodological limitations and the heterogeneity between single cohorts studies, if we considered only the available controlled studies no superiority was demonstrated between a single- and two-stage exchange at a minimum of 12 months follow-up. The overalapping of confidence intervals related to single-stage cementless and cemented hip exchanges, showed no superiority of either technique.

The Fate of Spacers in the Treatment of Periprosthetic Joint Infection

BACKGROUND

Two-stage exchange arthroplasty remains the preferred method to treat periprosthetic joint infection. The aim of this study was to investigate the clinical course of periprosthetic joint infection following resection arthroplasty and insertion of a spacer.

METHODS

Our institutional database was used to identify 504 cases of periprosthetic joint infection (326 knees and 178 hips) treated with resection arthroplasty and spacer insertion as part of a two-stage exchange arthroplasty. A review of the patient charts was performed to extract information relevant to the objectives of this study that included the details of the clinical course following resection arthroplasty.

RESULTS

The mean follow-up duration after initial spacer implantation was 56.2 months. Reimplantation occurred in the joints of 417 (82.7%) of 504 cases. Of these 417 cases, 329 (78.9%) had a minimum one-year follow-up, and 81.4% of these had successful treatment. The mean duration from resection arthroplasty to reimplantation was 4.2 months (range, 0.7 to 131.7 months). Sixty (11.9%) of the 504 joints required interim spacer exchange(s). Of the eighty-seven cases that did not undergo reimplantation, six (6.9%) required amputation, five (5.7%) underwent a Girdlestone procedure, four (4.6%) underwent arthrodesis, and seventy-two (82.8%) underwent spacer retention. Thirty-six patients died in the interstage period.

CONCLUSIONS

The commonly held belief that two-stage exchange arthroplasty carries a high success rate for the eradication of periprosthetic joint infection may need to be reexamined. A considerable number of patients undergoing the first stage of a two-stage procedure do not undergo a subsequent reimplantation for a variety of reasons or require an additional spacer exchange in the interim. Reports on the success of two-stage exchange should account for the mortality of these patients and for patients who never undergo reimplantation.

Two-stage revision of an infected total hip arthroplasty: a follow-up of 136 patients

BACKGROUND AND PURPOSE

Periprosthetic infection of a total hip arthroplasty (THA) is commonly treated with a two-stage revision procedure. After resection of the infected THA and placement of a cement spacer loaded with antibiotics, a THA is inserted at a second procedure to restore hip function and mobility. Revision surgery carries a significant risk of complications. This study focuses on hip function, rate of complications and reinfection after two-stage revision surgery for an infected THA.

PATIENTS AND METHODS

From January 1996 to April 2010, 136 patients underwent revision surgery after removal of an infected THA. Follow-up ranged from 2 years to more than 15 years. Hip function was evaluated using the modified Harris Hip Score (mHHS) and the Hip disability and Osteoarthritis Outcome Score (HOOS). Visual Analogue Scale (VAS) measured pain. Annual follow-up included radiographs of the affected hip and blood sampling for inflammatory parameters.

RESULTS

After revision surgery, average mHHS was 63% and average HOOS was 54%. VAS pain averaged 26.8 on a 100-point scale and 40% of patients had no pain. Prosthesis-related complications unrelated to sepsis occurred in 32%. Most common were periprosthetic fractures, leg length discrepancy and dislocation. Reinfection occurred in 13% of these patients and Coagulase Negative Staphylococcus (CNS) was isolated in 67%.

CONCLUSION

Two-stage evision surgery is an accepted treatment for infected THAs. However, complications are common and hip function afterwards is modest. As previous studies have shown, CNS is an important microorganism in reinfection.

The use of Gamma-irradiated proximal femoral allografts for bone stock reconstruction in complex revision hip arthroplasty

We have followed a consecutive series of 49 revision hip arthroplasties, performed for severe femoral bone loss using Gamma-irradiated anatomic-specific proximal femoral allografts longer than five centimetres. The patients were followed for a median 10.2 years, with a five year minimum follow-up. The median preoperative Harris Hip Score (HHS) improved from 42 points to 77 points postoperatively. In four hips the femoral component was further revised for non-union of the allograft and aseptic failure. In one hip the allograft and the femoral component were removed because of infection. In one hip the allograft and the femoral component were re-revised for host step-cut fracture. Junctional-union was observed in 44/49 hips. By defining success as an increase of HHS by 20 points or more, a stable implant and no need for any subsequent re-operations related to the allograft and /or the implant, a success rate of 76% was observed. Kaplan-Meier survivorship analysis predicted 79% rate of survival at 10 years and 75% rate of survival at 17 years, with the need for further revision of the allograft and/or implant as the end point. Three hips underwent re-attachment of the greater trochanter for trochanteric escape. Asymptomatic non-union of the greater trochanter was noticed in another three hips. Moderate allograft resorption was observed in four hips. Two fractures of the host step-cut occurred. There were four dislocations. Good long-term results with the use of large anatomic-specific femoral allografts justify their continued use in cases of revision hip arthroplasty complicated with severe femoral bone loss.

Antibiotic mixing through impacted bone grafts does not seem indicated in two-stage cemented hip revisions for septic loosening

Impaction bone grafts (IBG) in two-stage revision for prosthetic hip infection (PHI) might be more susceptible for infection, therefore antibiotic mixing through these grafts has been suggested. However, outcomes have not been compared with IBG without antibiotics and no long-term results are available. Therefore, we evaluated long-term infection-free outcome after the use of IBG without antibiotic supplement in two-stage revision for PHI. Patients were divided into positive (group 1, n = 8) and negative (group 2, n = 28) cultures at re-implantation and followed up to 18 years after re-implantation. Five of 36 patients died from non-orthopaedic causes (median 37, range 24-149 months). Five patients had a re-operation not related to infection (median 39, range 7-140 months). These were censored in the Kaplan-Meier estimator at the last outpatient evaluation. We found an overall re-infection rate of 2.8% within two years, which matches comparative studies in which antibiotic impregnated bone grafts had been used. In group 1, there was one re-infection after 44 months. In group 2, all three infections occurred within 56 months with an estimated infection-free percentage at 10 years of 87% (95% CI 66-96). Follow-up should be extended beyond two years and randomised clinical trials are needed for further comparison with IBG impregnated with antibiotics.

[Reconstruction of metadiaphyseal bone defects of the femur with cortical strut allografts in periprosthetic bone loss]

OBJECTIVE

Biological augmentation and stabilization of high-grade bone defects with structural allografts from donor femur halfs.

INDICATIONS

Severe bone defects with aseptic loosening of hip prosthesis, periprosthetic femoral fracture or non-union, possibly even in cases of a healed infection.

CONTRAINDICATIONS

Local or systemic infection.

SURGICAL TECHNIQUE

The two modeled strut allografts are temporary fixed epiperiostal anterolateral and -medial with wire cerclages, while protecting the vascular supplying linea aspera of the femur. With the thus stabilized femur, the leg can be placed in the four-position in order to prepare the medullary canal of the revision prosthesis. Finally, the uncemented revision prosthesis is hammered in under successive tightening of the wire cerclages. With this "cracking technique", stem is stabilized and the grafts have repositioning, augmentative, and supportive function.

POSTOPERATIVE MANAGEMENT

Partial weight-bearing postoperatively for 12 weeks. X-ray control during surgery, 10 days postoperatively, after 6 and 12 weeks and every 1-2 years.

RESULTS

In four different studies, 123 patients were stabilized from December 1991 to June 2011 due to an extensive periprosthetic femoral bone defect and/or periprosthetic fracture, refracture, or non-union with strut allografts. After an average follow-up of 3.8 years (range 0.3-11 years), the average Harris Hip Score was 80.8 (range 44-100). During this time, there was 1 refracture, 103 stable stems, 20 fibrous stable stems, 9 patients with low graft resorption, and 122 patients with radiographic healing of the strut allografts based on classification according to Emerson et al. (Clin Orthop Relat Res 285:35-44, 1992).

Partial two-stage exchange for infected total hip arthroplasty: a preliminary report

BACKGROUND

One common approach to the infected total hip arthroplasty (THA) calls for a staged revision, including removal of all components. However, removal of well-fixed femoral components can result in bone loss and compromised fixation; it is not known whether it is effective to leave a well-fixed femoral component in situ, remove only the acetabular component, débride thoroughly, place a spacer, and delay reimplantation.

QUESTIONS/PURPOSES

The purposes of this study were to determine (1) the frequency of infection recurrence; (2) the frequency of death; and (3) the Harris hip scores of patients treated with a "two-stage partial exchange" approach.

METHODS

A retrospective analysis from 2000 through January 2011 revealed 19 patients with infected THA treated with partial two-stage exchange including complete acetabular component removal, aggressive soft tissue débridement, retention of the well-fixed femoral stem, placement of an antibiotic-laden cement femoral head on the trunnion of the retained stem, postoperative course of antibiotics, and delayed reimplantation. Indications for this treatment included those patients whose femoral component was determined to be well fixed and its removal would result in significant femoral bone loss and compromise of future fixation. During the study period, this represented 7% (19 of 262) of the patients whom we treated for a chronically infected THA. Minimum followup was 2 years (mean, 4 years; range, 2-11 years). None of the 19 patients in this series were lost to followup. We defined failure as recurrence of infection in the same hip or the use of long-term suppressive antibiotics.

RESULTS

Two patients (11%), both with prior failure of two-staged treatment of infection, failed secondary to recurrence of infection at an average of 3.3 years. There were no patient deaths within 90 days. The mean Harris hip score was 68 (range, 31-100; best score is 100).

CONCLUSIONS

Insofar as 89% of patients in this series were clinically free of infection at a minimum of 2 years, we believe partial two-stage exchange may represent an acceptable option for patients with infected THA when femoral component removal would result in significant bone loss and compromise of reconstruction. Further study is required on this approach.

Two-stage revision total hip arthroplasty for periprosthetic infections using antibiotic-impregnated cement spacers of various types and materials

Antibiotic-impregnated hip cement spacers of various types and materials have been used in the treatment of periprosthetic hip infections. We developed a handmade spacer by using polymethylmethacrylate (PMMA) and/or α-tricalcium phosphate (α-TCP). In this study, we retrospectively reviewed the surgical outcomes in 36 consecutive patients treated with 2-stage revision total hip arthroplasty by using our antibiotic-impregnated hip cement spacers. We aimed to analyze the infection control and reinfection rates after revision surgery. Moreover, we analyzed the possible predictors of postoperative reinfection. After exclusion of 1 patient who died immediately after the first-stage surgery, infection was controlled in 33 of the 36 hips (success rate, 91.7%). Two of these 33 hips underwent resection arthroplasty. Of the 36 hips that had been treated with the antibiotic-cement spacer, 31 hips (86.1%) were eligible for the second-stage prosthesis re-implantation. The 31 protocol hip joints of patients followed up for >6 months (mean, 48.6 months). Ten of these 31 hips (32.3%) became reinfected. No possible predictor examined differed significantly between the reinfection-positive and reinfection-negative groups. However, spacers consisting of PMMA cement alone were associated with the highest risk of reinfection. Therefore, α-TCP-containing antibiotic-impregnated hip cement spacers might decrease the reinfection rate in patients undergoing re-implantation.

Two-stage treatment of hip periprosthetic joint infection is associated with a high rate of infection control but high mortality

BACKGROUND

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.

QUESTIONS/PURPOSES

For patients selected for two-stage treatment of infected THA we therefore determined (1) mortality; (2) rate of reimplantation; and (3) rate of reinfection.

METHODS

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).

RESULTS

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%.

CONCLUSION

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 OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Chronic infections in hip arthroplasties: comparing risk of reinfection following one-stage and two-stage revision: a systematic review and meta-analysis

BACKGROUND

Two-stage revision is regarded by many as the best treatment of chronic infection in hip arthroplasties. Some international reports, however, have advocated one-stage revision. No systematic review or meta-analysis has ever compared the risk of reinfection following one-stage and two-stage revisions for chronic infection in hip arthroplasties.

METHODS

The review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Relevant studies were identified using PubMed and Embase. We assessed studies that included patients with a chronic infection of a hip arthroplasty treated with either one-stage or two-stage revision and with available data on occurrence of reinfections. We performed a meta-analysis estimating absolute risk of reinfection using a random-effects model.

RESULTS

We identified 36 studies eligible for inclusion. None were randomized controlled trials or comparative studies. The patients in these studies had received either one-stage revision (n = 375) or two-stage revision (n = 929). Reinfection occurred with an estimated absolute risk of 13.1% (95% confidence interval: 10.0%-17.1%) in the one-stage cohort and 10.4% (95% confidence interval: 8.5%-12.7%) in the two-stage cohort. The methodological quality of most included studies was considered low, with insufficient data to evaluate confounding factors.

CONCLUSIONS

Our results may indicate three additional reinfections per 100 reimplanted patients when performing a one-stage versus two-stage revision. However, the risk estimates were statistically imprecise and the quality of underlying data low, demonstrating the lack of clear evidence that two-stage revision is superior to one-stage revision among patients with chronically infected hip arthroplasties. This systematic review underscores the need for improvement in reporting and collection of high-quality data and for large comparative prospective studies on this issue.

Structural allograft as an option for treating infected hip arthroplasty with massive bone loss

BACKGROUND

Revision of the infected hip arthroplasty with major bone loss is difficult. Attempts to restore bone stock with structural allograft are controversial.

QUESTIONS/PURPOSES

We assessed the (1) reinfection rate; (2) rerevision rate; (3) radiographic graft union, resorption, and implant migration; (4) Harris hip scores at 1 year and at last followup compared with before surgery; and (5) other major complications associated with the use of bulk structural allograft to treat massive bone loss in infected hip arthroplasty.

METHODS

We retrospectively reviewed 27 patients who underwent two-stage revision arthroplasty using structural allograft to treat massive bone defects in infected hip arthroplasty. There were 17 proximal femoral grafts, three acetabular major column grafts, two acetabular minor column grafts, and 10 cortical strut grafts used. Five patients had combinations of two allografts. The minimum followup was 1.1 years (mean, 8.2 years; range, 1.1-16.8 years).

RESULTS

One of 27 patients had reinfection. The Kaplan-Meier survivorship was 93% at 10 years with rerevision for aseptic loosening as the end point. Radiographically, three patients had nonunion at the graft-host junction. All patients except two had graft resorption, of which all were mild except two, which were severe. Three patients had implant migration. The mean modified Harris hip scores were 39.2 points (range, 25-60) preoperatively, 67.3 points (range, 40-91) at 1-year followup, and 70.3 points (range, 46-81) at last followup. Other major complications included one patient with dislocation and one patient with transient sciatic nerve injury.

CONCLUSIONS

Based on our data, we believe the use of structural allografts is a reasonable option for treating massive bone loss in infected hip arthroplasties.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Cementless revision for infected total hip replacements

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

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

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

Cementless two-staged total hip arthroplasty with a short term interval period for chronic deep periprosthetic infection. Technique and long-term results

BACKGROUND

The two-staged exchange with delayed reimplantation is the most reliable method to treat a deep periprosthetic infection after a total hip arthroplasty (THR). Nether uniform recommendations for the technique of cementless reimplantation, nor long term clinical and radiological results are reported.

MATERIALS AND METHODS

Our protocol is performed under short term antibiosis with cementless primary porous hip implants to treat chronic deep periprosthetic infections following THR. A retrospective study was performed to evaluate the clinical and radiological long term outcome and the rate of persistent infection of 14 patients.

RESULTS

In a five year minimum follow up persistent infection was observed twice in a two-staged revision THR. A dislocation of the hip components was observed in three cases, and could be surgically treated in twice and by wearing a hip-brace in one case. We could not find a loosening of THR components. Three patients had a good or excellent, 11 patients a fair or bad functional outcome. There was a significant correlation between functional outcome and length of interval of prosthesis exand reimplantation.

CONCLUSION

Patients have an increased comfort resulting from a short, CRP depending time interval between ex- and reimplantation. Functional outcome is the better the shorter the interval is. The reinfection rate is comparable to those of cemented revision THR's with a long term interval. We could observe advantages in a reduced amount of bone loss and better osseous integration of the uncemented implants, compared to cemented implants reviewing literature. Alterations of acetabular bone stock and soft tissue are responsible for a high rate of instability of the THR. An inaccurate gait pattern is caused by gluteal weakness in the majority of patients. Repeated surgical intervention and duration of immobilization have to be minimalized.

Use of a cement-loaded Kuntscher nail in first-stage revision hip arthroplasty for massive femoral bone loss secondary to infection: a report of four cases

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

Role of capsular repair on dislocation in revision total hip arthroplasty

Dislocation remains one of the most common complications after revision total hip arthroplasty (THA). In contrast to primary THA the posterior capsule has been routinely excised to provide better visualization, but its role in preventing dislocation has been overlooked. We reviewed 69 patients (79 hips) patients who had revision THA with a posterolateral approach to determine if closing the posterior capsule resulted in a fewer dislocations. We followed the patients for a minimum of 24 months (mean 57 months, range, 24-120 months). Two (2.5%) hips dislocated. Both dislocated anteriorly in the immediate postoperative period. One dislocation was from implant malposition and the other occurred in a high risk patient. There were no posterior dislocations and no patients reported any hip subluxation. The historically high dislocation rates with the posterolateral approach can be reduced by carefully balancing soft tissues, ensuring correct implant alignment, meticulously closing the posterior capsule, and reattaching the external rotators.