Abstract
Infected total hip arthroplasty (THA) is catastrophic, but it is treatable with a high degree of success. Two-stage revision with an antibiotic-loaded cement spacer is the most widely accepted method of treatment, and considered by some to be the best method; however, single-stage treatment currently is used widely, and is gaining acceptance. Although antibiotic-loaded cement is considered to be important for antibiotic delivery after surgery, cementless revision is equally successful with one- or two-stage procedures.
Delivery of antibiotics with depot methods, such as cement or bone graft impregnated with antibiotics, is considered to be effective, but the antibiotic levels rapidly deteriorate after the first three days, leaving the cement itself vulnerable to colonization by resistant organisms. Nephrotoxicity is not common, but it does occur, and necessitates removal of the cement. This can be catastrophic if the implants are fixed with antibiotic-impregnated cement.
Success rates of THA revision for infection can be as high as 98%, but this rate is dependent on the organism. Failure rates of 20% are the norm for resistant organisms such as methicillin-resistant Staphylococcus aureus, The cost of this failure rate is huge. Failure probably is due to the low concentration of antibiotics in the operative site. Antibiotic infusion into the operative site achieves concentrations that are hundreds of times higher than can be achieved with any other technique and has the additional advantage of being able to be discontinued in the case of renal or auditory damage. Limited personal experience suggests that the failure rate of revision total hip with resistant organisms is significantly lower with intra-articular delivery than with other currently available methods.
Between January 2002 and July 2013, 9 patients (9 hips) presented with late-onset acute infections in cementless THA with bone-ingrown implants. These patients were all more than 2 years from their original surgery and had acute symptoms of infection for 4 to 9 days. Two were the author's patients and 7 were referred from another institution. None had symptoms until the onset of their infection, and none had postoperative wound complications, fever, or prolonged pain suggestive of a chronic process. All were treated with debridement and head/liner exchange, followed by catheter infusion of intraarticular antibiotics. All remained free of signs of infection at a mean follow-up of 74 months (range, 62–121 months). This sequential series of successful treatment of late-onset infection of osteointegrated total hip replacement suggests that this is a highly effective method. It has the advantages of being a single-stage procedure, and of avoiding the catastrophic surgical procedure of removing fully osteointegrated total hip replacements.
