Joint replacement is a highly effective intervention to treat osteoarthritis of the hip, relieving pain and improving mobility and quality of life.(1) Periprosthetic joint infection (PJI) is a devastating complication after arthroplasty. Debridement, antibiotics and implant retention are treatment of first choice in case of early infection after total hip arthroplasty (THA).(2) In case of persisting infection, one- or two-stage revision needs to be performed.(3) The use of different kinds of spacers has been widely debated in the past years.(4)

The aim of this study was to determine which type of spacer should be used during the interval of two-stage revision of an infected THA.

A search term with Boolean operators was constructed. We extracted all information regarding study and patient characteristics and baseline clinical and laboratory findings. Data regarding type of spacer and antibiotics used, timing of second stage surgery, tissue culture results, postoperative regimen, functional outcome and patient satisfaction were extracted.

A total of twenty-six studies met our inclusion criteria and were included for data analysis. Ten studies described various preformed spacers, six studies described functional spacers and eleven studies described custom made spacers. See Table 1 for results.

Research should focus on finding the preferred type of treatment and type of spacer to combine a high success rate of infection treatment with a good functional and patient reported outcome. There is a need for a prospective study evaluating patient satisfaction and functional outcome after two-stage revision THA comparing various spacers. Secondly, research should focus on the optimal timing of the second stage procedure.

Functional spacers achieve a comparable rate of infection eradication in the treatment of periprosthetic hip joint infections as compared to preformed spacers. There is insufficient evidence concerning rehabilitation and functional outcome after two-stage revisionTHA to advocate or discourage the use of either kind of interval spacer.

Aim. Identification of the causal pathogen is crucial in the management of periprosthetic joint infection (PJI) of the hip. Unfortunately, it was often difficult and negative culture could be a common findings. This situation made the treatment of PJI of the hip became more challenging. The negative culture finding resulted in a doubtful diagnosis of infection, and poses difficulty in choosing the appropriate antibiotics. Here we compared the treatment outcome of two-stage revision arthroplasty for culture-negative versus culture-positive PJI of the hip. Method. We retrospectively reviewed patients who received two-stage revision for PJI of the hip between January 2010 to June 2015. All patients was planned to received articulated antibiotic cement-spacer as the first stage and revision total hip arthroplasty (THA) as the second stage of the procedure. Out of total 94 patients, 10 patients was loss to follow-up and excluded from the study. We devided the rest of 84 patients into two groups: culture-negative group (n: 27) and culture-positive group (n: 57). We compared all relevant medical records and the treatment outcome between the two groups. Results. The mean of follow-up was 29.5 months (range, 12–78) in culture-negative group and 30.9 months (range, 12–71) in culture-positive group (p = 0.74). The overall negative culture finding rate was 30.8%. There was no significant difference on baseline data between the two groups including: age, gender, body mass index, preoperative C-reactive protein (CRP), preoperative erythrocyte sedimentation rate and preoperative white blood count, type of hip arthroplasty, previous history of irrigation and debridement (I & D), and preoperative Harris hip score (HHS). However, culture-negative group has significantly higher number on history of preoperative antibiotic use (p = 0.003). The reimplantation rate was 96.3% and 91.2% in culture-negative and culture-positive group, respectively (p= 0.39). The infection recurrency rate after reimplantation was 7.7% and 15.4% in culture-negative and culture-positive group, respectively (p= 0.33). The overall infection control rate was 92.6% (25/27) and 82.4% (47/57) in culture-negative and culture-positive group, respectively (p = 0.21). We also observed no significant difference on the time interval between stage, time to normal CRP, time to recurrency and complications rate between the two groups. A higher postoperative HHS was obtained in culture-negative group (p = 0.04). Conclusions. Negative culture finding was not resulted in an inferior treatment outcome compared to culture-positive group in periprosthetic joint infection of the hip which treated with two-stage revision arthroplasty

INTRO. Two-stage revision arthroplasty for PJI may make use of an antibiotic-loaded cement spacer (ACS), as successful long- term prevention of reinfection have been reported using this technique.[i] However, there is little data on systemic complications of high-dose antibiotic spacers. Acute kidney injury (AKI) is of clinical significance, as the drugs most commonly utilized, vancomycin and aminoglycosides, can be nephrotoxic. We intended to determine the incidence of AKI in patients that underwent staged revision arthroplasty with an ACS, as well as to identify potential predisposing risk factors for the disease. METHODS. Local databases of six different orthopaedic surgeons were retrospectively reviewed for insertion of either a static or articulating antibiotic cement spacer by from 2007–2017. Dose of antibiotic powder implanted, as well as IV antibiotic used, was collected from operative records. Demographics, comorbidities, and preoperative and postoperative creatinine and hemoglobin values were recorded from the EHR. AKI was defined by a more than 50% rise in serum creatinine from preoperative baseline to at least 1.4 mg/dL, as described by Menge et al.[ii] Variables were analyzed for the primary outcome of AKI within the same hospital stay as insertion of the ACS. Categorical variables were analyzed with Chi-Square test, and continuous variables with univariate logistic regression. RESULTS. 75 patients (39 M, 36 F) receiving an ACS were identified, with a mean age of 70.0 (SD=10.6) and a mean BMI of 31.3 (SD=7.3). Incidence of in-hospital AKI was 13.3%. Patients reached AKI at a mean 6.7 days (SD=4.5), during a median length of stay of 13.5 days (IQR=21.8). No significant correlation was found between AKI and the variables of age (p=.430), BMI (p=.569) or gender (p=.181). AKI was also not associated with increased dose of vancomycin (p=.416), tobramycin (p=.440), or gentamycin (p=.846) within the cement spacer, or the comorbidities of hypertension (p=.094), diabetes (p=.146), coronary artery disease (p=1.00) and renal disease (p=.521). However, decreased baseline hemoglobin showed significantly increased risk for AKI (OR=1.67, p =.049), and increased creatinine showed a trend (OR=2.9, p=.059). Percentage of hemoglobin decrease (preoperative to postoperative) did not increase odds for AKI (p=.700). CONCLUSION. The incidence of acute kidney injury in patients that receive antibiotic cement spacers is relatively high when compared to the data reported in primary TKA. ii,[iii]. Our results suggest that patient related risk factors, such as low preoperative hemoglobin, may be involved in the etiology of AKI in this population. Therefore, it may be clinically appropriate to monitor anemic patients for AKI when implanting an ACS

Two-stage revision arthroplasty is the gold standard for treatment of infection after total hip Arthroplasty and end stage septic arthritis of the hip. In the first stage we used a modified technique to insert an inexpensive modular femoral component coated with antibiotic-impregnated polymethylmethacrylate articulating with a polyethylene liner. The construct was used in 8 patients with infected arthroplasty, and 6 patients with septic arthritis of the hip. Two patients were excluded (no second stage). Of the remaining 12 patients, only one patient had persistent infection after the first stage; 11 patients received a successful re-implantation at the second-stage. The technique provide a construct that can be used safely and successfully in the awaiting period between the two stages of revision arthroplasty

The Control of Infection Committee at a specialist orthopaedic hospital prospectively collected data on all episodes of bacteriologically-proven deep infection arising after primary hip and knee replacements over a 15-year period from 1987 to 2001.

There were 10 735 patients who underwent primary hip or knee replacement. In 34 of 5947 hip replacements (0.57%) and 41 of 4788 knee replacements (0.86%) a deep infection developed. The most common infecting micro-organism was coagulase-negative staphylococcus, followed by Staphylococcus aureus, enterococci and streptococci. Of the infecting organisms, 72% were sensitive to routine prophylactic antimicrobial agents.

Of the infections, 29% (22) arose in the first three months following surgery, 35% between three months and one year (26), and 36% (27) after one year. Most cases were detected early and treated aggressively, with eradication of the infection in 96% (72). There was no significant change in the infection rate or type of infecting micro-organism over the course of this study.

These results set a benchmark, and importantly emphasise that only 64% of peri-prosthetic infections arise within one year of surgery. These results also illustrate the advantages of conducting joint replacement surgery in the isolation of a specialist hospital.