Two-stage reconstruction with total implant removal and re-implantation after infection control is considered the gold standard treatment forinfection after hip arthroplasty. However, removal of the well-fixed stem or cup may cause substantial bone loss and other complications, thereby making reconstruction difficult. We evaluated whether an infection posttotal hip arthroplasty can be treated without removal of the radiographically and clinically well-fixed femoral stem or acetabular cup. Patients with a chronic infection aftertotal hip arthroplasty, with a radiographically well-fixed, cementless stem or cup, were selected. During the first surgical stage, we retained the stem or cup if we were unable to removethese with a stem or cup extractor. An antibiotic-impregnated cement spacer was then implanted. After control of infection (C-reactive proteinlevel within normal value), we performed the secondstage of re-implantation surgery. Treatment failure was defined as uncontrolled infection requiringremoval of the retained implant. From January 2004 to December 2013, 16 patients underwent partial component-retained 2-stage reconstruction. Thirteen patients (81.3%) were free of infection, with a mean follow-up time of 5 years. The remaining 3 patients, who had high-risk comorbidities and, of whom, 2 were infected by high-virulence organism, had uncontrolled infection and required furthersurgery to remove the retained implant. We conclude that partial component-retained 2-stage reconstruction could be an alternative treatment option for chronic infection afteran uncemented total hip arthroplasty with a radiographically and clinically well-fixed component in selected patients, who are notimmunocompromised and are infected by a low-virulence organism

When using a staged approach to eradicate chronic infection after total hip replacement, systemic delivery of antibiotics after the first stage is often employed for an extended period of typically six weeks together with the use of an in situ antibiotic-eluting polymethylmethacrylate interval spacer. We report our multi-surgeon experience of 43 consecutive patients (44 hips) who received systemic vancomycin for two weeks in combination with a vancomycin- and gentamicin-eluting spacer system in the course of a two-stage revision procedure for deep infection with a median follow-up of 49 months (25 to 83). The antibiotic-eluting articulating spacers fractured in six hips (13.9%) and dislocated in five patients (11.6%). Successful elimination of the infecting organisms occurred in 38 (92.7%) of 41 hips with three patients developing superinfection with a new organism. We conclude that prolonged systemic antibiotic therapy may not be essential in the two-stage treatment of a total hip replacement for Gram-positive infection, provided that a high concentration of antibiotics is delivered locally using an antibiotic-eluting system

Aims. The aim of this study was to compare the mid-term patient-reported outcome, bone remodelling, and migration of a short stem (Collum Femoris Preserving; CFP) with a conventional uncemented stem (Corail). Methods. Of 81 patients who were initially enrolled, 71 were available at five years’ follow-up. The outcomes at two years have previously been reported. The primary outcome measure was the clinical result assessed using the Oxford Hip Score (OHS). Secondary outcomes were the migration of the stem, measured using radiostereometric analysis (RSA), change of bone mineral density (BMD) around the stem, the development of radiolucent lines, and additional patient-reported outcome measures (PROMs). Results. There were no statistically significant differences between the groups regarding PROMs (median OHS (CFP 45 (interquartile range (IQR) 35 to 48); Corail 45 (IQR 40 to 48); p = 0.568). RSA showed stable stems in both groups, with little or no further subsidence between two and five years. Resorption of the femoral neck was evident in nine patients in the CFP group and in none of the 15 Corail stems with a collar that could be studied. Dual X-ray absorbiometry showed a significantly higher loss of BMD in the proximal Gruen zones in the CFP group (mean changes in BMD: Gruen zone 1, CFP -9.5 (95% confidence interval (CI) -14.8 to -4.2), Corail 1.0 (95% CI 3.4 to 5.4); Gruen zone 7, CFP -23.0 (95% CI -29.4 to -16.6), Corail -7.2 (95% CI -15.9 to 1.4). Two CFP stems were revised before two years’ follow-up due to loosening, and one Corail stem was revised after two years due to chronic infection. Conclusion. The CFP stem has a similar clinical outcome and subsidence pattern when compared with the Corail stem. More pronounced proximal stress-shielding was seen with the CFP stem, suggesting diaphyseal fixation, and questioning its femoral neck-sparing properties in the long term. Cite this article: Bone Joint J 2022;104-B(5):581–588

Aims. Two-stage exchange revision total hip arthroplasty (THA) performed in case of periprosthetic joint infection (PJI) has been considered for many years as being the gold standard for the treatment of chronic infection. However, over the past decade, there have been concerns about its safety and its effectiveness. The purposes of our study were to investigate our practice, collecting the overall spacer complications, and then to analyze their risk factors. Methods. We retrospectively included 125 patients with chronic hip PJI who underwent a staged THA revision performed between January 2013 and December 2019. All spacer complications were systematically collected, and risk factors were analyzed. Statistical evaluations were performed using the Student's t-test, Mann-Whitney U test, and Fisher's exact test. Results. Our staged exchange practice shows poor results, which means a 42% mechanical spacer failure rate, and a 20% recurrent infection rate over the two years average follow-up period. Moreover, we found a high rate of spacer dislocation (23%) and a low rate of spacer fracture (8%) compared to the previous literature. Our findings stress that the majority of spacer complications and failures is reflecting a population with high comorbid burden, highlighted by the American Society of Anesthesiology grade, Charlson Comorbidity Index, and Lee score associations, as well as the cardiac, pulmonary, kidney, or hepatic chronic conditions. Conclusion. Our experience of a two-stage hip exchange revision noted important complication rates associated with high failure rates of polymethylmethacrylate spacers. These findings must be interpreted in the light of the patient’s comorbidity profiles, as the elective population for staged exchange has an increasing comorbid burden leading to poor results. In order to provide better results for this specific population, our conclusion suggests that comparative strategy studies are required to improve our therapeutic indication. Cite this article: Bone Jt Open 2022;3(6):485–494

Two-stage exchange revision total hip arthroplasty performed in case of infection has been considered during many years the gold standard for treatment of chronic infection. Nevertheless, during the last decade, concerns have risen regarding its safety and its efficiency. The purpose of our study was to, first investigate the spacer complications, then to analyze their risks factors. We retrospectively included 125 patients with chronic hip periprosthetic joint infection who underwent a two stage exchange revision arthroplasty performed between January 2013 and December 2019. All spacer complications were systematically collected and risk factors were analyzed. Statistical evaluation were performed using the Student and Mann-Whitney tests. Our study confirms the hypothesis of a high-risk strategy with 42% of patients who had a mechanical spacer failure and a 20% recurrence of infection during the average two years period of follow-up. We found a high rate of spacer migration (23%) and a low rate of spacer fracture (8%) compared to literature. The most important finding was that the majority of spacer complications and failures were found in a population with high medical comorbidities as highlighted by the ASA, Charlson and Lee score associations, as well as with the cardiac, pulmonary, kidney or hepatic chronic conditions. This study showed that a two-stage hip exchange revision is a high-risk procedure regarding complications and mechanical failures of PMMA spacers. In patients with high medical comorbidities, other strategies may be considered and interdisciplinary cooperation with other facilities are needed to identify and control each risk factor

Cement-in-cement femoral revision is a proven technique in revision total hip arthroplasty, with excellent results when using standard sized Exeter stems. The Exeter 44/00 125 mm short revision stem was introduced in 2004 to facilitate cement-in-cement revision. The stem is 25mm shorter and has a slimmer body to allow greater flexibility to adjust depth of insertion and version of the stem. However, it is not known if this change in stem length and size effects its longer term performance. We therefore reviewed the clinical outcome and survival of the Exeter 44/00 short stem used for cement-in-cement revision in our unit, with a minimum of 5 years follow up. 166 cases were performed between 2004 and 2010. 103 hips were available for 5 year clinical and radiological follow up, with 91 hips surviving to final review in 2017. At 5 years, 43 hips had died, 13 were revised and 7 were too frail to attend clinical review. The fate of all 166 hips were known and included in the survival analysis. Median clinical scores improved significantly. Sixteen hips required re-revision (infection 6, loose cup 3, periprosthetic fracture 3, instability 2, stem fracture with chronic infection 1 and pain 1). Kaplan-meier survival analysis revealed 100% survival for aseptic loosening, 96.8% survival for stem failure and 88.9% survival for all causes. This is the largest series with the longest follow up of the Exeter 44/00 short revision stem. The stem performs equally well as standard Exeter stems with regards to aseptic loosening. The single stem fracture occurred secondary to bone loss in chronic infection, highlighting the importance of providing adequate proximal support for the stem. Periprosthetic fracture occurred in 2.4% of this series of revision cases. Larger registry-based studies may provide additional information on the performance of this stem

Aims

Periprosthetic joint infection (PJI) in total hip arthroplasty in the elderly may occur but has been subject to limited investigation. This study analyzed infection characteristics, surgical outcomes, and perioperative complications of octogenarians undergoing treatment for PJI in a single university-based institution.

Aims

Total hip arthroplasty (THA) is considered the preferred treatment for displaced proximal femoral neck fractures. However, in many countries this option is economically unviable. To improve outcomes in financially disadvantaged populations, we studied the technique of concomitant valgus hip osteotomy and operative fixation (VOOF). This prospective serial study compares two treatment groups: VOOF versus operative fixation alone with cannulated compression screws (CCSs).

Aims

The number of revision arthroplasties being performed in the elderly is expected to rise, including revision for infection. The primary aim of this study was to measure the treatment success rate for octogenarians undergoing revision total hip arthroplasty (THA) for periprosthetic joint infection (PJI) compared to a younger cohort. Secondary outcomes were complications and mortality.

Aims

Although the Fitmore Hip Stem has been on the market for almost 15 years, it is still not well documented in randomized controlled trials. This study compares the Fitmore stem with the CementLeSs (CLS) in several different clinical and radiological aspects. The hypothesis is that there will be no difference in outcome between stems.

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

The management of periprosthetic joint infection is challenging and the duration of systemic antibiotic therapy whether it be during the interval phase or after reimplantation of a new prosthesis is controversial. We report our experience of managing chronic periprosthetic infection of the hip by the two stage exchange procedure. Patients who were scheduled to undergo a two stage revision for chronic periprosthetic infection of the hip were identified from our prospective database. Of 425 patients with microbiologically proven periprosthetic infection, 369 (87%) underwent a two stage procedure, leaving 56 patients who did not proceed to reimplantation. 41 of these were clinically infection free but for personal or medical reasons did not proceed. The remaining 15 had persistent infection. The mean age at the time of the first stage was 68 years (26 – 92 yrs). 256 (61%) patients were alive for review. The mean time between stages was 6.3 months with a mean follow up after the second stage was 65 months (range 5 to 276 months). The success rate of a single 1. st. stage debridement, confirmed by negative cultures at the time of second stage reimplantation was 94%. 19 patients underwent a repeat 1. st. stage debridement and were classed as failures of the 1. st. stage. At the time of final review, 340 (92%) patients were deemed infection free out of those who had completed a 2 stage exchange. The duration of systemic antibiotic treatment after both the 1. st. and 2. nd. stages was divided into <48 hrs and >48 hours. There was no significant difference in the success of the 1. st. stage procedure in patients who received < 48 hours (48% of the patients) as opposed to > 48 hours (p = 0.98, Chi Squared Test, Relative Risk 1.009). Similarly there was no difference in the overall success of the two stage procedure irrespective of the duration of antibiotic therapy with 76% of patients receiving <48hrs of antibiotics after the second stage. Aggressive surgical debridement together with targeted local and short term systemic antibiotic therapy should be the mainstay of treatment in two stage revision surgery

Aims

Femoral cement-in-cement revision is a well described technique to reduce morbidity and complications in hip revision surgery. Traditional techniques for septic revision of hip arthroplasty necessitate removal of all bone cement from the femur. In our two centres, we have been using a cement-in-cement technique, leaving the distal femoral bone cement in selected patients for septic hip revision surgery, both for single and the first of two-stage revision procedures. A prerequisite for adoption of this technique is that the surgeon considers the cement mantle to be intimately fixed to bone without an intervening membrane between cement and host bone. We aim to report our experience for this technique.

Aims

One-stage exchange for periprosthetic joint infection (PJI) in total hip arthroplasty (THA) is gaining popularity. The outcome for a repeat one-stage revision THA after a failed one-stage exchange for infection remains unknown. The aim of this study was to report the infection-free and all-cause revision-free survival of repeat one-stage exchange, and to investigate the association between the Musculoskeletal Infection Society (MSIS) staging system and further infection-related failure.

Aims

One-stage revision hip arthroplasty for periprosthetic joint infection (PJI) has several advantages; however, resection of the proximal femur might be necessary to achieve higher success rates. We investigated the risk factors for resection and re-revisions, and assessed complications and subsequent re-revisions.

Aims

The purpose of this study was to evaluate unexpected positive cultures in total hip arthroplasty (THA) revisions for presumed aseptic loosening, to assess the prevalence of low-grade infection using two definition criteria, and to analyze its impact on implant survival after revision.

The aim of this study was to assess the role of synovial C-reactive protein (CRP) in the diagnosis of chronic periprosthetic hip infection. We prospectively collected synovial fluid from 89 patients undergoing revision hip arthroplasty and measured synovial CRP, serum CRP, erythrocyte sedimentation rate (ESR), synovial white blood cell (WBC) count and synovial percentages of polymorphonuclear neutrophils (PMN). Patients were classified as septic or aseptic by means of clinical, microbiological, serum and synovial fluid findings. The high viscosity of the synovial fluid precluded the analyses in nine patients permitting the results in 80 patients to be studied. There was a significant difference in synovial CRP levels between the septic (n = 21) and the aseptic (n = 59) cohort. According to the receiver operating characteristic curve, a synovial CRP threshold of 2.5 mg/l had a sensitivity of 95.5% and specificity of 93.3%. The area under the curve was 0.96. Compared with serum CRP and ESR, synovial CRP showed a high diagnostic value. According to these preliminary results, synovial CRP may be a useful parameter in diagnosing chronic periprosthetic hip infection. Cite this article: Bone Joint J 2015; 97-B:173–6

Introduction. Two-stage revision surgery remains the gold standard as treatment for periprosthetic hip infections. The purpose of this study was to determine the rate of infection eradication after two-stage revision hip arthroplasty in patients treated with intraoperatively surgeon-molded articulating spacers as well as to foreshadow the future economical impact of these articulating antibiotic spacers to those commercially available. Methods. Thirty-five patients who underwent two-stage revision hip arthroplasty due to chronic periprosthetic infection between 2003–2014 were followed clinically and radiographically an average of 4.9 years postoperatively [2.2–9.2]. 17 male and 18 female patients with a mean age of 62 [34–82] had articulating spacers, made in the operating room, inserted at the first stage. [The overall expense of the custom-made antibiotic spacers and the commercially available spacers was calculated and compared using a student t test.]. Results. Thirty-one patients (91%) had no clinical or radiographic signs of infection at the time of most recent follow-up. There were no periprosthetic femur fractures and two (6.0%) had a dislocation of hip spacer prior to the second stage surgery. After reimplantation, three patients (9.0%) suffered dislocations of the prosthetic hip, with one of those patients undergoing a second dislocation of the previously reduced hip. [The antibiotic articulating hip spacer manufactured intraoperatively cost $2,712 as compared to commercially available injectable molds $4,619 (p<0.05) and prefabricated spacers $3,820 (p<0.05).]. Conclusions. Patients treated using intraoperatively molded articulating spacers had similar infection eradication rates and outcomes compared to previously reported commercially available articulating spacers1. In the era of cost containment and surgical bundles, surgeon-made articulating spacers should be considered in the first stage of periprosthetic infections. The adjustment in treatment could equate to a national savings of over $12 million annually

We evaluated the potential of a vastus lateralis muscle flap in controlling infection after resection arthroplasty of the hip. We retrospectively reviewed 119 patients with 120 chronic infections after resection arthroplasty treated with this procedure. The flap was fixed with Mitek anchors in the acetabular cavity. The mean duration of infection after resection before the muscle flap procedure was 6.5 months (2 to 13). The patients had previously undergone a mean of 4.9 operations (2 to 25). In all patients the infected cavity was the origin of the persistent infection. The mean follow-up was for 2.6 years (1.0 to 4.7). No patient had recurrent infection post-operatively and all had an improvement in the pain and better quality of life

Aims

The aim of this study was to investigate whether the use of antibiotic-loaded bone cement influenced the risk of revision surgery after primary total hip arthroplasty (THA) for osteoarthritis.