Treatment for an infected Total Hip replacement (THR) remains controversial with two stage revision surgery traditionally recommended. We describe a series of one stage revisions performed in a District General Hospital to help inform other surgeons and help treatment decisions. 8 patients with a bacteriologically proven infection in their hip underwent single stage revision THR. Cemented Exeter prostheses were used with additional antibiotics added to the cement mixture prior to implantation. Follow-up ranged from 6 to 36 months (average 16.6 months) and there were no re-infections. No radiological changes consistent with re-infection were noted throughout patient follow-up. One patient suffered a periprosthetic fracture (thought to be secondary to myeloma) 3 months post-surgery and underwent further revision surgery. Post-operative antibiotics were given for a minimum of 6 weeks with 2 patients having a 3 month supply after Microbiology advice. Single stage revision THR surgery is a viable and useful option for treatment of infected THR's. Re-infection rates are low. Avoiding the traditional second stage surgery is beneficial to both patients and the NHS trust in terms of health and cost outcomes. We will continue to undertake single stage revisions in this trust and advocate its use by other surgeons.
Removal of well-fixed cement at the time of revision THA for sepsis is time consuming and risks bone stock loss, femoral perforation or fracture. We report our experience of two-stage revision for infection in a series of cases in which we have retained well-fixed femoral cement. All patients underwent two-stage revision for infection. At the first stage the prostheses and acetabular cement were removed but when the femoral cement mantle demonstrated good osseo-integration it was left in-situ. Following Girdlestone excision arthroplasty (GEA), patients received local antibiotics delivered by cement spacers, as well as systemic antibiotics. At the second stage the existing cement mantle was reamed, washed and dried and then a femoral component was cemented into the old mantle. Sixteen patients (M:F 5:11) had at least three years follow-up (mean 80 months – range 43 to 91). One patient died of an unrelated cause at 53 months. Recurrence of infection was not suspected in this case. The mean time to first stage revision was 57 months (3 to 155). The mean time between first and second stages was nine months (1 to 35). Organisms were identified in 14 (87.5%) cases (5 Staphylococcus Aureas, 4 Group B Streptococcus, 2 Coagulase negative Staphylococcus, 2 Enterococcus Faecalis, 1 Escheria Coli). At second stage, five (31.2%) acetabulae were uncemented and 11 (68.8%) were cemented. There were two complications; one patient dislocated 41 days post-operatively and a second patient required an acetabular revision at 44 days for failure of fixation. No evidence of infection was found at re-revision. One patient (1/16, 7%) has been re-revised for recurrent infection. Currently no other patients are suspected of having a recurrence of infection (93%). Retention of a well-fixed femoral cement mantle during two-stage revision for infection and subsequent cement-in-cement reconstruction appears safe with a success rate of 93%. Advantages include a shorter operating time, reduced loss of bone stock, improved component fixation and a technically easier second stage procedure.
It costs the NHS £2billion/year to treat 70000 hip fractures. Following hemiarthroplasty a departmental x-ray is standard practice. During 2009 217 hemiarthroplasties were performed in our unit. 210 had postoperative radiographs (148 departmental, 62 in theatre). All patient demographics were considered and hospital costs accounted for. Mean patient age was 83 (55-100) years. Mean theatre times were 120 (51-213) minutes in the departmental x-ray group and 128 (74-187) minutes in the theatre imaging group. Hospital stay was decreased from 12.8 (3-41) days in the departmental x-ray group to 11.8 (3-32) days in the theatre imaging group. Orthopaedic beds cost £136/day. Departmental x-rays give a radiation dose of ∼12mGy and costs £48.30, theatre imaging gives ∼0.26mGy with no additional cost given the radiographers previous allocation to the list. Changing our practice to intra-theatre imaging has improved patient safety, reduced the average inpatient stay and saves our trust approximately £40,000 annually.
