Two-stage revision hip arthroplasty for infection: comparison between the interim use of antibiotic-loaded cement beads and a spacer prosthesis

BACKGROUND: A two-stage revision is a well-accepted method for the treatment of a deep infection of a hip with a joint implant. In the present study, the results associated with the interim use of antibiotic-loaded cement beads were compared with those associated with the interim use of an antibiotic-loaded cement prosthesis. METHODS: One hundred and twenty-eight consecutive patients who were managed with a two-stage revision hip arthroplasty for the treatment of an infection were followed clinically and radiographically for an average of 4.9 years. Cement beads were implanted following resection arthroplasty in the first seventy hips, and a custom cement prosthesis was implanted in the subsequent fifty-eight hips. RESULTS: There was no evidence of recurrent infection in 122 patients (95.3%); the infection-free rates in both groups were similar. The use of a spacer prosthesis was associated with a higher hip score, a shorter hospital stay, and better walking capacity in the interim period; a decreased operative time, less blood loss, and a lower transfusion requirement at the time of reimplantation; and fewer postoperative dislocations. CONCLUSIONS: The present study supports the safety and efficacy of the routine use of an antibiotic-loaded cement prosthesis in the interim between the stages of a two-stage revision procedure for the treatment of an infection at the site of a hip arthroplasty.     

Resection arthroplasty as a salvage procedure for a knee with infection after a total arthroplasty

Between 1970 and 1983, resection arthroplasty was done as a salvage procedure for twenty-eight knees (twenty-six patients) with infection after total arthroplasty. Eleven patients had multiarticular rheumatoid arthritis; fourteen, osteoarthritis; and one, multiarticular neuropathic arthropathy. Systemic signs of infection were eliminated in all patients and local signs, in 89 per cent of the patients. After resection arthroplasty alone, fifteen patients were able to walk independently. Six patients with monoarticular osteoarthritis who found the resection arthroplasty to be unacceptable had a successful secondary arthrodesis. In three patients a spontaneous bone fusion developed after the resection, with the knee in a good position. Two patients who were unable to walk before the resection arthroplasty were still unable to do so postoperatively. Neither the patient's disease nor the type of prosthesis that had been used was a reliable predictor of success of the resection arthroplasty. The patients who had had the most severe disability before the total knee arthroplasty were most likely to be satisfied. Patients who had had less disability were more likely to find the results of resection arthroplasty to be unsatisfactory.     

Total hip replacement in the previously septic hip

Total hip replacement was performed in either one or two stages in thirty-three hips with active sepsis. The sepsis had followed hemiarthroplasty in six hips, open reduction with internal fixation of a fracture in eight, cup arthroplasty in one, and total hip replacement in eight hips within six years prior to the second total hip replacement. Ten additional patients had total hip replacement following destruction of the hip joint by hematogenous sepsis in nine and by infection following a shrapnel wound in one. Of these thirty-three patients, twenty-three (70 per cent) reveal no signs of infection at three to nine years after prosthetic replacement. Of the remaining ten in whom an infection developed, six had definite recurrences of the original infection, three were infected with organisms different from the original one, and one was either a local recurrence or reseeding from a persistent pyelonephritis. The success rate when the original organism was gram-positive was 78 per cent, including two of three total hip replacements done in the presence of active infection with Staphylococcus epidermidis. The success with gram-negative organisms, however, was only 58 per cent. The prosthetic failure rate was highest in patients who had had a previous infection about a total hip replacement (37 per cent) and in patients who had had a previous infection but no prior prosthetic or internal fixation devices (37 per cent). The lowest prosthetic failure rates were in patients with an infected hemiarthroplasty (16 per cent), an infection around an internal fixation device (25 per cent), or an infected cup arthroplasty. A complete and differential blood-cell count, erythrocyte sedimentation rate, aspiration arthrogram, and radiographs did not effectively predict success or failure. For gram-positive infections, the success rates were similar following either a one or a two-stage procedure. We found that the success rates could be improved by a repeat course of parenteral antibiotics after the total hip replacement even if all preoperative and intraoperative studies failed to identify an infection. Patients with a successful total hip replacement achieved much better functional results than those who had to have a Girdlestone procedure. However, all patients must be carefully assessed prior to reimplantation of a prosthesis because of the high failure rate, especially with gram-negative organisms (Pseudomonas having the gravest prognosis), even when the procedure is done in two stages.(ABSTRACT TRUNCATED AT 400 WORDS)     

Prevention of venous thrombosis after total hip arthroplasty. Antithrombin III and low-dose heparin compared with dextran 40

The anticoagulant action of heparin is mediated through antithrombin III, and the postoperative decrease in the plasma concentration of antithrombin III may contribute to the relative ineffectiveness of prophylaxis with low-dose heparin in preventing venous thrombosis after total hip arthroplasty. We conducted a prospective, randomized trial to compare the effectiveness of a regimen of antithrombin III, given intravenously once daily, and low-dose heparin with a regimen of dextran 40, given intravenously, in preventing venographically documented venous thrombosis after total hip arthroplasty. The results demonstrated an incidence of venous thrombosis of 4.9 per cent in patients who received antithrombin III and heparin; this was significantly lower than the incidence (28.6 per cent) in patients who received dextran 40 (p less than 0.005). Venous thrombosis occurred only in patients who had total hip arthroplasty with a cemented prosthesis (fourteen of fifty-seven patients, or 24.6 per cent); none of the twenty-six patients in whom a non-cemented prosthesis was used had venous thrombosis (p less than 0.01). Of the patients in whom a cemented prosthesis had been inserted, the incidence of venous thrombosis was lower in those who were treated with antithrombin III and heparin (7.4 per cent) than in those who were treated with dextran 40 (40 per cent) (p less than 0.005). Postoperative levels of antithrombin III were maintained at more than 90 per cent of the baseline level in patients who received it; this was significantly higher than in patients who received dextran 40.(ABSTRACT TRUNCATED AT 250 WORDS)     

Infection after shoulder arthroplasty

Between 1972 and 1994, 2279 patients underwent primary shoulder arthroplasty (2512 shoulders) and 194 patients underwent revision shoulder arthroplasty (222 shoulders) at the authors' institution. Of these, 18 patients with primary shoulder arthroplasties (19 shoulders) and seven patients with revision shoulder arthroplasties (seven shoulders) were diagnosed with deep periprosthetic infection. Additionally, during this period, seven patients (seven shoulders) with primary shoulder arthroplasties and one patient (one shoulder) with a previously revised shoulder arthroplasty were referred to the authors' institution for treatment of deep periprosthetic infection. Two patients (two shoulders) were excluded because of incomplete medical records and with component removal performed elsewhere. The average time from arthroplasty to the diagnosis of infection was 3.5 years (range, 0-14.8 years). The patients were divided into four groups on the basis of treatment. Group I comprised 20 patients (21 shoulders) who underwent resection arthroplasty. Six of the 21 shoulders had additional episodes of infection. Group II comprised six patients (six shoulders) who underwent debridement and prosthetic retention. Three of the six shoulders failed this treatment with subsequent reinfection and underwent a resection arthroplasty. Group III comprised two patients (two shoulders) who had removal of the prosthesis, debridement, and immediate reimplantation. One patient underwent resection arthroplasty 9 months after direct exchange because of reinfection. Group IV comprised three patients (three shoulders) who had removal of the prosthesis, debridement, and delayed reimplantation. Reinfection has not occurred in any of these patients. At final followup, patients with a prosthesis in situ had better pain relief and shoulder function than patients treated with resection arthroplasty. Delayed reimplantation may offer the best hope for pain relief, eradication of infection, and maintenance of shoulder function.     

Revision total hip arthroplasty

Two hundred and ten hips in 206 patients who had an initial total hip arthroplasty performed at the Mayo Clinic between 1969 and 1978 required revision of the arthroplasty at the Mayo Clinic for reasons other than infection. One hundred and sixty-two of the patients (166 hips) were followed both clinically and roentgenographically for two years or more. One hundred and forty-five (90 per cent) reported that they had improvement after the surgical revision. Complications that occurred with revision included deep sepsis, superficial would infection, dislocation, intraoperative femoral fracture, and postoperative femoral fracture. Roentgenographic analysis showed probable loosening in thirty-three acetabular components (20.1 per cent) and seventy-two femoral components (44 per cent). Symptomatic loosening (moderate to severe pain and probable roentgenographic loosening) was seen in thirty-five patients. Eight patients required a second revision for this reason, and seven others required a second revision for other reasons. Modified Harris hip scores, calculated for 108 hips, showed a good or excellent result in sixty-seven hips (62 per cent), a fair result in twelve (11 per cent), and a poor result in twenty-nine (27 per cent). Using a new Mayo Clinic hip score that incorporates roentgenographic data (which will be described) in the evaluation of 165 revised hips, there was a good or excellent result in eighty-five (52 per cent), a fair result in thirty-two (19 per cent), and a poor result in forty-eight hips (29 per cent). Although 90 per cent of the patients thought that their condition had improved, the high incidence of roentgenographic signs of probable loosening of a component is of serious concern.     

Reimplantation of infected total hip arthroplasties in the absence of antibiotic cement

Twenty-two patients with deep infection of the hip were reimplanted and followed for a minimum of 3 years. All reimplantations were done without antibiotic-impregnated cement. Nine were done using cemented and 13 using cementless components. Two patients had recurrent infection. Both of these had primary Pseudomonas infections and had cemented revisions. At 3 or more years, 91% of patients are infection-free as determined by clinical evaluation, erythrocyte sedimentation rate, and, in a few, aspiration. Cemented hips had less pain than cementless hips, although both had equivalent functional scores. The significance of these findings is that reimplantation of infected hips can be successfully accomplished without antibiotic-impregnated cement. Cementless fixation can therefore be used. Clinical results with cementless hips for reimplantation will improve with current designs and techniques.     

Results of revision for mechanical failure after cemented total hip replacement, 1979 to 1982. A two to five-year follow-up

From January 1979 to February 1982, 143 patients (seventy-nine women and sixty-four men) with 146 uninfected cemented total hip arthroplasties had revision cemented hip arthroplasty at The Hospital for Special Surgery for what was considered to be mechanical failure. The average age of the patients at primary arthroplasty was 56.1 years and at revision, 62.1 years. Loosening of the femoral component before revision correlated with varus positioning in 50 per cent of the hips, inadequate cement in 34 per cent, and a relatively young age in 16 per cent. The average age of the patients (fifteen hips) with a loose femoral component that had been placed in a neutral or valgus position with good cementing technique was 48.2 years at the time of primary arthroplasty. Loosening of the acetabular component was attributed to high placement of the cup in 41 per cent, inadequate bone in 18 per cent, a vertical orientation of the opening of the cup in 7 per cent, and poor cementing technique in 3 per cent. Complications associated with revision included perforation of the femoral cortex in 13 per cent, postoperative deep infection in 3.4 per cent, postoperative dislocation in 8.2 per cent, trochanteric complications in 6.2 per cent, and sciatic palsy in 0.7 per cent. Of the 139 hips that were followed for an average of 3.6 years (range, two to five years) after revision, the results were excellent in 59 per cent, good in 7 per cent, fair in 16 per cent, and poor in 18 per cent. After revision of the 139 hips, 29 per cent showed progressive radiolucencies; 18 per cent, femoral subsidence; and 9 per cent, acetabular migration. Definite mechanical failure after revision was identified in 15.8 per cent of the hips. These failures were due to loosening in 12.2 per cent of the hips, femoral fracture in 2.2 per cent, and disabling dislocation in 1.4 per cent. At the time of follow-up, twelve hips (8.6 per cent) had been revised a second time: six (4.3 per cent) for loosening of one or both components, three (2.2 per cent) for femoral fracture, and three (2.2 per cent) for infection. Mechanical failure and progressive radiolucencies were associated with poor quality of bone (p less than 0.001) and inadequate anatomical reconstruction (p less than 0.03).     

Total hip arthroplasty in the ankylosed hip. A ten-year follow-up

Eighty total hip arthroplasties in seventy-four patients who had had either a spontaneous or a surgical ankylosis (arthrodesis) of the hip were evaluated at nine to fifteen years (average, 10.4 years) after the total hip replacement. There was only one failure in the twenty hips of the fifteen patients who had had a spontaneous ankylosis. In contrast, twenty (33 per cent) of the sixty hips of the sixty patients who had had a surgical ankylosis had complications that were associated with the arthroplasty. Of these twenty hips, mechanical loosening developed in eleven; infection, in eight; and recurring dislocation, in one. Failure of the total hip arthroplasty was more common (p less than 0.05) in the patients who had had a previous surgical attempt at arthrodesis and in the patients who were fifty years old or less at the time of the arthroplasty. The risk of failure was not related to the length of time that the hip had been ankylosed.     

Repeat 2-Stage Exchange for Infected Total Hip Arthroplasty : A Viable Option?

We investigated whether performing a repeat 2-stage exchange eradicates infection in patients who previously underwent 2-stage treatment for an infected total hip arthroplasty. We identified 15 patients who had failed a 2-stage total hip arthroplasty and underwent a planned repeat 2-stage between 2000 and 2009. Of the 15 patients, 8 were treated with a complete 2-stage procedure, whereas the remaining 7 patients were treated only with a first-stage resection of the infected implant. Of the 8 patients who underwent complete 2-stage exchange, 1 died because of in-hospital complications, and 1 had a recurrent infection. Repeat infection is highly associated with resistant organisms, obesity, and poor patient health. Of the 7 patients who underwent resection without reimplantation, 3 had a recurrent infection. Our data suggest that if infection can be adequately controlled after repeat resection of the joint prosthesis, reimplantation is a reasonable option.     

Repeat 2-stage exchange for infected total hip arthroplasty: a viable option?

We investigated whether performing a repeat 2-stage exchange eradicates infection in patients who previously underwent 2-stage treatment for an infected total hip arthroplasty. We identified 15 patients who had failed a 2-stage total hip arthroplasty and underwent a planned repeat 2-stage between 2000 and 2009. Of the 15 patients, 8 were treated with a complete 2-stage procedure, whereas the remaining 7 patients were treated only with a first-stage resection of the infected implant. Of the 8 patients who underwent complete 2-stage exchange, 1 died because of in-hospital complications, and 1 had a recurrent infection. Repeat infection is highly associated with resistant organisms, obesity, and poor patient health. Of the 7 patients who underwent resection without reimplantation, 3 had a recurrent infection. Our data suggest that if infection can be adequately controlled after repeat resection of the joint prosthesis, reimplantation is a reasonable option.     

Complications associated with reimplantation after girdlestone arthroplasty

Complications associated with reimplantation of a total hip arthroplasty after resection or Girdlestone arthroplasty for treatment of an infected hip are not well-documented. Forty-four hips in 44 patients with a minimum 2-year followup (range, 2-9 years) from the time of reimplantation total hip arthroplasty were evaluated retrospectively. The average Harris hip score changed from 40 preoperatively to 78 at the latest followup. One patient had persistent infection requiring rerevision surgery, and another patient had rerevision surgery for recurrent dislocation. Complications related to the prosthesis consisted of dislocations in five patients (11.4%), recurrent infection in one patient (2.3%), trochanteric nonunion in four patients (9.1%), hematoma in one patient, heterotopic ossification in one patient, and postoperative wound drainage in one patient. Resection arthroplasty of the hip is highly effective in eradicating infection. In the current series, 97.7% of patients were free of infection at the latest followup. However, with an 11.4% dislocation rate and 39% of patients having a persistent limp, alternative approaches need to be evaluated which might reduce these complications.     

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

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

Medial-displacement intertrochanteric osteotomy in the treatment of osteoarthritis of the hip. A long-term follow-up study

Of seventy-three adults who were treated for osteoarthritis of the hip by medial-displacement intertrochanteric osteotomy done by one of us, sixty-one (with sixty-seven treated hips) could be evaluated twelve to fifteen years after osteotomy or at the time when they had an arthroplasty for recurrent symptoms. Specific criteria based on preoperative data were used prospectively to categorize the hips as to their suitability for medial-displacement osteotomy. In addition, at the conclusion of the study, an osteotomy suitability score (maximum score, 12 points) was assessed retrospectively as a determinant of suitability for medial-displacement osteotomy. Ten years after the osteotomy, thirty-four (51 per cent) of the sixty-seven hips had been treated with a cup arthroplasty or total hip arthroplasty. At the conclusion of the study (between twelve and fifteen years after osteotomy), forty-four (66 per cent) of the sixty-seven hips had had an arthroplasty. Among the sixteen hips that had been considered excellent candidates according to the prospective criteria, 85 per cent had not yet required hip arthroplasty five years after osteotomy and two-thirds had not had an arthroplasty ten years after surgery. Of the thirty hips with a suitability score of 7 points or more, 85 per cent had not required arthroplasty at five years and 67 per cent had not done so at ten years. The numerical scoring therefore appeared to be a more reliable determinant of suitability.     

Infection after total elbow arthroplasty

Deep sepsis occurred after fourteen (9 per cent) of 156 elbow-replacement procedures in 140 patients. This high frequency of infection was attributed to several factors. First, the patients were drawn from a population that was at high risk of infection, because rheumatoid arthritis and post-traumatic arthritis were the indications for arthroplasty. Second, many of the patients had had prior surgery, which significantly (p less than 0.02) increased the risk of sepsis in those with rheumatoid arthritis. Third, some patients had surgery after the arthroplasty, which also seemed to predispose to deep infection (p less than 0.05). In one patient the elbow was salvaged by early débridement, and in two others reimplantation of a total joint replacement was successful after removal of the first prosthesis and control of the infection. Resection arthroplasty was required to arrest the infection in ten patients, eight of whom had a satisfactory result. The high incidence of this significant complication attests to the hazardous nature of the elbow-replacement procedure and should warn orthopaedic surgeons to be cautious when recommending this form of treatment.     

The outcome of resection shoulder arthroplasty for recalcitrant shoulder infections

Postarthroplasty infection is a devastating complication. In some patients, virulent pathogens or poor health complicate reconstruction. Resection arthroplasty is a viable option in such cases. Seven patients with resection arthroplasty following infection after shoulder arthroplasty were reviewed retrospectively at an average 20- month follow-up (range, 12-41). Average time between the initial procedure and the first debridement was 59.5 months (4-151 months). The average number of debridements was 2.2 per patient (range, 1-4 procedures). There were no complications, no recurrence of deep infection, no nerve damage, and no fractures. All patients were able to reach the opposite axilla, their backpocket and perineum, and their mouth. All but 1 patient were satisfied with their result. No patient had a satisfactory outcome via Neer's criteria. Resection arthroplasty is a reasonable salvage option for patients who are not good candidates for prosthetic reimplantation. This yields patients who can reliably perform basic activities of daily living.     

Revision total elbow arthroplasty

Over a ten-year period, thirty-three consecutive revision total elbow arthroplasties were performed at our institution. These were assessed at a minimum of three years after the revision, with an average length of follow-up of sixty-one months. Eighteen (55 per cent) of the elbows had a good result and fifteen (45 per cent) had a poor result. The poor results were due to infection in three elbows, loosening of the prosthesis in six, inadequate motion in two, continued pain in two, and prosthetic failure in two. Additional surgical revision with another implant was done in the fifteen elbows that initially had a poor result. Eventually the result was good in twenty-four elbows. The three elbows that became infected after surgical revision had a resection arthroplasty and all were rated as having a fair result. The data from this study indicated that reimplantation is a viable option for the revision of a failed total elbow arthroplasty, although more than one revision may be required. They also suggested that young patients who have post-traumatic arthritis should not undergo a total joint replacement, and that revision procedures should be performed in settings that can offer several surgical options and by surgeons who have had experience with these options. Alternatives to reimplantation as a revision procedure should be considered in selected patients.     

The infected hip after total hip arthroplasty

We studied the cases of fifty-two patients with an infection at the site of a prosthetic total hip replacement, and are reporting the significant clinical features, infecting organisms, methods of treatment, and results at long-term follow-up. Forty-eight per cent of the hips had had an operation prior to the index arthroplasty, and 42 per cent had a wound complication. All patients had pain in the infected hip, but only 54 per cent had an erythrocyte sedimentation rate of more than thirty millimeters per hour, 44 per cent had fever, and 15 per cent had leukocytosis. In 88 per cent of the patients a single organism was grown on culture, and Staphylococcus epidermidis, Staphylococcus aureus, and Escherichia coli were present in about 75 per cent. When antibiotic therapy alone was the initial treatment, the infection was eradicated in only one patient. Excisional arthroplasty was the definitive surgical procedure in thirty-three patients and the infection was eradicated in twenty-seven of them, but the clinical result was satisfactory in only twenty. Of ten patients who had a true Girdlestone arthroplasty, none had recurrence of the infection and all had a clinically satisfactory outcome.     

Reimplantation of a shoulder arthroplasty after a previous infected arthroplasty

Currently, there is little information on the results of reimplantation after previous resection for an infected shoulder arthroplasty. The purpose of this study was to determine the rate of recurrent infection and clinical results. Between 1975 and 2000, 4 patients with a resection arthroplasty from a previously infected shoulder arthroplasty underwent subsequent reimplantation of a prosthesis. The time interval from resection arthroplasty to reimplantation ranged from 7 months to 5.5 years. The mean clinical follow-up was 7.4 years (range, 2-15 years). There were no patients with recurrent infection. At the most recent follow-up, 2 patients had no pain, 1 had slight pain, and 1 had moderate pain. Mean elevation improved from 60 degrees to 80 degrees, and external rotation improved from 13 degrees to 50 degrees. With regard to patient satisfaction, 1 patient was much better, 2 were better, and 1 was the same. There were 2 satisfactory results and 2 unsatisfactory results. Reimplantation of a shoulder arthroplasty after a previous resection arthroplasty for infection can be performed with a low risk of reinfection. However, arthroplasty in this setting is especially challenging because of the potential for significant bone and soft-tissue deficits. These challenges can compromise the clinical results.     

Conventional versus resurfacing total hip arthroplasty. A long-term prospective study of concomitant bilateral implantation of prostheses

Fifty patients requiring bilateral total hip arthroplasty underwent a concomitant conventional hip arthroplasty on one side and an articular resurfacing procedure on the other, done by the senior one of us (M. A. R.). The average age of the patients was sixty-two years (range, twenty-one to eighty-seven years), and forty-seven of them were followed with serial radiographs and clinical evaluation for one year or more. The length of follow-up was five years for thirty-four patients with both prostheses intact. The average pain score for all hips at three years postoperatively was 5.5 points. Although the majority of patients at each follow-up interval did not prefer one procedure to the other, the conventional arthroplasty was significantly superior for those who had a preference, and radiographic evaluation revealed a statistically significant increased incidence of acetabular lucency at the bone-cement interface of the resurfacing arthroplasty at one, two, three, five, and seven years postoperatively (p less than 0.002). Two of the conventional prostheses were revised during this time-period (one because of infection and one, a broken stem) whereas thirteen (26 per cent) of the resurfacing prostheses were revised (eight hips had femoral loosening, five with concomitant acetabular loosening; three had acetabular loosening; and one had a femoral neck fracture) at an average of fifty-two months postoperatively (p less than 0.001).