Aims. The duration of systemic antibiotic treatment following first-stage revision surgery for periprosthetic joint infection (PJI) after total hip arthroplasty (THA) is contentious. Our philosophy is to perform an aggressive debridement, and to use a high local concentration of targeted antibiotics in cement beads and systemic prophylactic antibiotics alone. The aim of this study was to assess the success of this philosophy in the management of PJI of the hip using our two-stage protocol. Methods. The study involved a retrospective review of our prospectively collected database from which we identified all patients who underwent an intended two-stage revision for PJI of the hip. All patients had a diagnosis of PJI according to the major criteria of the Musculoskeletal Infection Society (MSIS) 2013, a minimum five-year follow-up, and were assessed using the MSIS working group outcome-reporting tool. The outcomes were grouped into ‘successful’ or ‘unsuccessful’. Results. A total of 299 two-stage revision THAs in 289 patients met the inclusion criteria, of whom 258 (86%) proceeded to second-stage surgery. Their mean age was 68.1 years (28 to 92). The median follow-up was 10.7 years (interquartile range (IQR) 6.3 to 15.0). A 91% success rate was seen in those patients who underwent reimplantation, decreasing to 86% when including those who did not proceed to reimplantation. The median duration of postoperative systemic antibiotics following the first stage was five days (IQR 5 to 9). There was no significant difference in outcome between those patients who were treated with antibiotics for ≤ 48 hours (p = 0.961) or ≤ five days (p = 0.376) compared with those who were treated with longer courses. Greater success rates were seen for Gram-positive PJIs (87%) than for Gram-negative (84%) and mixed-Gram PJIs (72%; p = 0.098). Conclusion. Aggressive surgical debridement with a high local concentration of targeted antibiotics at the time of first-stage revision surgery for PJI of the hip, without prolonged systemic antibiotics, provides a high rate of success, responsible antibiotic stewardship, and reduced hospital costs. Cite this article: Bone Joint J 2023;105-B(5):511–517

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

The duration of systemic antibiotics following first-stage surgery is contentious. Our Institution's philosophy is to perform an aggressive debridement, high concentration of targeted antibiotics through cement beads and systemic prophylactic antibiotics alone. In the presence of significant soft tissue infection or microbiological diagnostic uncertainty; systemic antibiotics may be prescribed for 5 days whilst awaiting tissue culture results. The aim of this study was to assess the success of our philosophy for two-stage hip revision. A retrospective review of our Institution's prospective database was performed to identify all intended two-stage hip revision procedures for PJI. All patients had a confirmed PJI as per MSIS 2013 criteria, minimum 5-years follow up and outcomes according to the MSIS working group outcome-reporting tool; then grouped into “successful” or “unsuccessful” (suppressive antibiotics, further revision for infection, death within 1 year). 383 intended two-stage hip revisions were identified; of which 299 met our inclusion criteria, in 289 patients (6 repeat ipsilateral two-stage, 4 bilateral two-stage). Median follow up was 10.7 years (IQR 6.3 – 15.0). 258 (86%) patients proceeded to 2. nd. stage surgery. 91% success rate was observed for those patients who underwent reimplantation, although dropping to 86% when including the patients who did not proceed to second stage. The median duration of post-operative systemic antibiotics was 5 days (IQR 5–9). No significant difference was observed in patients who received either; < / = 48 hours (86%; n=70) compared to > 48 hours antibiotics (86%; n=229; p=0.96) or </= 5 days of antibiotics (88%; n=202) compared to > 5 days antibiotics (82%; p=0.38). A significant majority had gram-positive (88%) infection with 30% being polymicrobial. Greater success rates were observed with two-stage exchange or gram-positive PJI (86%); than for gram-negative PJI (81%) and polymicrobial infection (74%) (p=0.36). Fungal PJI was observed to have a significantly reduced rate of success (n=3; 33%; p=0.03). Aggressive surgical debridement with high concentration, targeted local antibiotic delivery at time of first stage to manage PJI of the hip provides a high rate of success, responsible antibiotic stewardship and reduced hospital costs

Aims. The increasing infection burden after total hip arthroplasty (THA) has seen a rise in the use of two-stage exchange arthroplasty and the use of increasingly powerful antibiotics at the time of this procedure. As a result, there has been an increase in the number of failed two-stage revisions during the past decade. The aim of this study was to clarify the outcome of repeat two-stage revision THA following a failed two-stage exchange due to recurrent prosthetic joint infection (PJI). Patients and Methods. We identified 42 patients who underwent a two-stage revision THA having already undergone at least one previous two stage procedure for infection, between 2000 and 2015. There were 23 women and 19 men. Their mean age was 69.3 years (48 to 81). The outcome was analyzed at a minimum follow-up of two years. Results. A satisfactory control of infection and successful outcome was seen in 26 patients (57%). There therefore remained persistent symptoms that either required further surgery or chronic antibiotic suppression in 16 patients (38%). One-third of patients had died by the time of two years’ follow-up. Conclusion. The rate of failure and complication rate of repeat two-stage exchange THA for PJI is high and new methods of treatment including host optimization, immunomodulation, longer periods between stages, and new and more powerful forms of antimicrobial treatment should be investigated. Cite this article: Bone Joint J 2019;101-B(6 Supple B):110–115

Aims. Recurrent infection following two-stage revision total hip arthroplasty (THA) for prosthetic joint infection (PJI) is a devastating complication. The purpose of this study was to report the survival of repeat two-stage revision hip arthroplasty, describe complications, and identify risk factors for failure. Patients and Methods. We retrospectively identified 19 hips (19 patients) that had undergone repeat two-stage revision THA for infection between 2000 to 2013. There were seven female patients (37%) and the mean age was 60 years (30 to 85). Survival free from revision was assessed via Kaplan–Meier analysis. The patients were classified according to the Musculoskeletal Infection Society (MSIS) system, and risk factors for failure were identified. Mean follow-up was four years (2 to 11). Results. Gram-positive bacteria were responsible for 16/17 (94%) of the re-infections where microbes were identified. Following the repeat two-stage exchange arthroplasty, survival free from any revision was 74% (95% confidence interval (CI) 56% to 96%, 14 at risk) at two years and 45% (95% CI 25% to 75%, five at risk) at five years. Failure to control infection resulted in re-operation or revision in 42%A of patients (8/19). Survival free from revision was not dependent on host grade. Conclusion. Re-infection after two-stage exchange hip arthroplasty for PJI presents a challenging scenario. Repeat two-stage exchange arthroplasty has a low survival free from revision at five years (45%) and a high rate of re-infection (42%). Cite this article: Bone Joint J 2018;100-B:1157–61

There is a paucity of long-term data on modular fluted tapered (MFT) stems for two-stage reimplantation following periprosthetic joint infection (PJI). The purpose of this study was to evaluate implant survivorship, radiographic results, and clinical outcomes in a large cohort of reimplantation THAs using MFT stems. We identified 236 reimplantation THAs from a single tertiary care academic institution from 2000 to 2020. Two designs of MFT stems were used as part of an established two-stage exchange protocol for the treatment of PJI. Mean age at reimplantation was 65 years, mean BMI was 32 kg/m. 2. , and 46% were female. Median stem diameter was 19 mm, and median stem length was 195 mm. Mean follow-up was 7 years. A competing risk model accounting for death was utilized. The 15-year cumulative incidence of any revision was 24%. There were 48 revisions, with the most common reasons being dislocation (n=25) and PJI (n=16). The 15-year cumulative incidence of any reoperation was 28%. Only 13 revisions involved the fluted tapered portion of the component (FTC), for a 15-year cumulative incidence of any FTC revision of 8%. Only 2 FTCs were revised for aseptic loosening, resulting in a 15-year cumulative incidence of FTC revision for aseptic loosening of 1%. Stem subsidence >5 mm occurred in 2% of unrevised cases, and all stems were radiographically stable at most recent follow-up. Mean HHS was 77 at most recent follow-up. This series demonstrated that MFT stems were durable and reliable even in the setting of two-stage reimplantation for infection. While the incidence of aseptic loosening was very low, the incidence of any revision was 24% at 15 years, primarily caused by dislocation and recurrent PJI. Level of Evidence: IV

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

The increasing infection burden after hip arthroplasty has seen a growth of two-stage exchange and the use of increasingly powerful antibiotics at the time of this procedure. We have seen an increased number of failed two-stage revisions over the past decade. This study was aimed at clarifying the outcome of failed two-stage exchange arthroplasty after periprosthetic hip infection. We identified forty-two patients who had undergone at least one prior two-stage revision hip arthroplasty for periprosthetic infection between 2000 and 2012. These patients were referred to our center and treated with a further two-stage exchange. They have been analyzed with a minimum two-year follow-up. Control of infection at two-year follow-up was seen in 57% of patients. In 43% of patients there are still ongoing issues that either required further surgery or ongoing antibiotic suppression. A regression analysis was undertaken which suggested that the immunocompromised host and polymicrobial infection were the greatest predictors of failure. The number of previous interventions, the organism involved and the duration of antibiotic therapy after the initial two-stage revision were not linked to the ultimate outcome. The failure rate of repeat revision two-stage exchange is high and novel methods of treatment including host optimization, immunomodulation, longer interval periods, novel antimicrobial methods and more powerful antibiotic therapies should be investigated

We compared the safety and outcome of one-stage bilateral total hip arthroplasty with those of a two-stage procedure during different admissions in a prospective, randomised controlled trial in an Asian population. Of 168 patients included in the study, 83 had a single- and 85 a two-stage procedure. Most of the patients (59.9%) suffered from inflammatory arthritis. The intra-operative complications, early systemic complications, the operating time, positioning of the components, the functional score, restoration of limb length and survival rates at 96 months were similar in the two groups. The total estimated blood loss was significantly lower in patients undergoing a one-stage procedure than in patients who had a two-stage procedure, but the transfusion requirements were significantly higher in the former group (p = 0.001). The hospital stay was significantly shorter in the one-stage group, 7.25 days (. sd. 1.30; 5 to 20) compared with 10 days (. sd. 1.65; 8 to 24) in the two-stage group (p = 0.023). We believe that a one-stage procedure is safe and appropriate in our population

Introduction. Debridement, antibiotics, and implant retention (DAIR) for acute prosthetic hip infection is a popular low morbidity option despite less than optimal success rates. We theorized that the delay between DAIR and explantation in failed cases may complicate eradication due to biofilm maturation and entrenchment of bacteria in periprosthetic bone. We ask, what are the results of two-stage reimplantation after a failed DAIR versus an initial two-stage procedure?. Methods. 114 patients were treated with 2-stage exchange for periprosthetic hip infection. 65 were treated initially with a 2-stage exchange, while 49 underwent an antecedent DAIR prior to a 2-stage exchange. Patients were classified according to MSIS host criteria. Failure was defined as return to the OR for infection, a draining sinus, or systemic infection. Results. Treatment failure occurred in 42.9% (21 of 49) of patients treated with an antecedent DAIR. In contrast, treatment failure occurred in only 12.3% (8 of 65) of initial 2-stage procedures (p< 0.001). Relative Risk of return to the OR after a 2-stage reimplantation with an antecedent DAIR compared to initial resection was 4.52 (95% CI 1.71, 11.9). MSIS host grading was similar between groups and did not influence the rate of failure. The DAIR cohort had increased hospitalization length and greater number of operative procedures (p< 0.001). Conclusion. We have shown that if irrigation and debridement fails to treat acute prosthetic hip infection, subsequent attempts at two-stage reimplantation may be compromised. Additionally, in the antecedent DAIR group, the average number of infection-related procedures (5) was nearly twice that of those initially resected (2.7). This by nature implies a significantly greater burden to the patient and cost to the healthcare system

Patients considered suitable for total hip resurfacing arthroplasty often have bilateral disease. The peri-operative complications, transfusion requirements, hospital stay, outcome and costs in patients undergoing one-stage bilateral total hip resurfacing were compared with a group of patients undergoing a two-stage procedure. A total of 92 patients were included in the study, of which 37 (40%) had a one-stage and 55 (60%) had a two-stage resurfacing. There were no significant differences in age, gender, or American Society of Anaesthesiologists grade between the groups (p = 0.31, p = 0.23, p = 0.13, respectively). There were three systemic complications in the one-stage group (8.1%) and one in the two-stage group (1.8% of patients; 0.9% of procedures). There was no significant difference in the complication rate (p = 0.72) or the transfusion requirements (p = 0.32) between the two groups. The one-stage group had a reduced total hospital stay of five days (95% confidence interval 4.0 to 6.9; p < 0.001), reduced length of time to completion of all surgery of five months (95% confidence interval 2.6 to 8.3; p < 0.001), and the reduced cost was 35% less than that of a two-stage procedure. However, the total anaesthetic time was significantly longer for the one-stage group (p < 0.001; 95% confidence interval 31 to 52). This study demonstrates that consideration should be given to one-stage surgery for patients with bilateral symptomatic disease suitable for metal-on-metal hip resurfacing. A one-stage procedure appears to have benefits for both the patient and the hospital without additional complications

Introduction. Two-stage reimplantation for prosthetic joint infection (PJI) of the hip is the standard of care with a 5–10% recurrence at a minimum two-year follow-up. Compiling outcomes data for this standard of care is necessary in order to characterize long-term reinfection risk and the culpable microbiology. The purpose of this study was to determine the long-term success of two-stage reimplantation and identify the factors that affected the success. Methods. We performed a systematic review of randomized control trials, cohort studies, and case series through May 2019, searching Embase, Medline via PubMed, and Cochrane Library for the concept of two-stage reimplantation for the treatment of hip and knee PJIs, yielding 464 unique citations for abstract review, of which 135 were reviewed in full. Our parameters of interest included: reinfection and mortality events following successful reimplantation, the timing of these events, and the microbiology of index and recurrent infections. Results. Meeting our criteria were 59 studies with 4,494 patients (1,842 hips) who had completed reimplantation. Among successfully reimplanted hips, 4.76% (95% CI, 2.00–8.41) were reinfected by 24 months, 6.84% (4.92–9.02) were reinfected by final follow-up, 1.6% (0.32–3.52) were reinfected with an identical organism(s) with identical resistance, and 2.55% (0.77–5.03) were reinfected with a novel organism(s) or novel resistance. In 24 studies with reinfected patients and sufficient data, 8 studies reported an average interval from reimplantation to reinfection greater than 24 months, and 14 reported at least 1 patient with a reinfection event greater than 48 months following reimplantation. Conclusion. The results from this review determined that the host of an index PJI faces ongoing risk of recurrent infection years into the post-operative period despite initial eradication and that novel microbiology is the cause of a significant proportion of failures. For any tables or figures, please contact the authors directly

Infection after total hip arthroplasty (THA) is a devastating complication. With an ageing population and increased demands for THA, prosthetic joint infection (PJI) is expected to become an even greater problem in the future. In late PJI a one- or two-stage revision procedure is most often used. Factors determining the outcomes are not fully understood and there is controversy in the choice between the two methods. The, two-stage method in infected THA is regarded as more resource demanding and is associated with a high distress in the patients. The aim of this study was to compare the risk for second revision (re-revision) between one- and two-stage revision. During 1979–2015, 1659 first-time revisions performed due to infection were reported to the Swedish Hip Arthroplasty Register. Two-stage revision was the most common procedure (n=1255). Risk for a re-revision was compared between one- and two-stage revision using Cox-regression analysis adjusted for age, sex, diagnosis and method of fixation. The primary end-point was a re-revision regardless of cause. Aseptic loosening, infection, and dislocation necessitating re-revision were used as secondary outcomes. There was no difference in risk of re-revision regardless of cause (HR (one-stage/two-stage)=0.9, 95% C.I.=0.7–1.1, p=0.3), re-revision due to aseptic loosening (HR=1.1, 95% C.I.=0.7–1.6, p=0.7) or re-revision due to infection (HR=0.7, 95% C.I.=0.5–1.1, p=0.2). Dislocation necessitating a re-revision was less common in the one-stage group (HR=0.4, 95% C.I.=0.2–0.9, p=0.03). In this analysis re-revision rates were similar in the two groups. When analysed specifically for infection, risk of re-revision did not differ between one and two stage revision. Our findings confirm recent systematic reviews on the matter. This observational study supports increased utilisation of the one-stage approach. However prospective randomized studies are needed to validate these findings

Aims. We aimed to report the mid- to long-term rates of septic and aseptic failure after two-stage revision surgery for periprosthetic joint infection (PJI) following total hip arthroplasty (THA). Methods. We retrospectively reviewed 96 cases which met the Musculoskeletal Infection Society criteria for PJI. The mean follow-up was 90 months (SD 32). Septic failure was assessed using a Delphi-based consensus definition. Any further surgery undertaken for aseptic mechanical causes was considered as aseptic failure. The cumulative incidence with competing risk analysis was used to predict the risk of septic failure. A regression model was used to evaluate factors associated with septic failure. The cumulative incidence of aseptic failure was also analyzed. Results. There were 23 septic failures at final follow-up, with a cumulative incidence of 14% (95% confidence interval (CI) 8% to 22%) at one year, 18% (95% CI 11% to 27%) at two years, 22% (95% CI 14% to 31%) at five years, and 23% (95% CI 15% to 33%) at ten years. Having at least one positive culture (hazard ratio (HR) 2.38 (interquartile range (IQR) 1.19 to 4.74); p = 0.013), or a positive intraoperative frozen section (HR 2.55 (IQR 1.06 to 6.15); p = 0.037) was significantly associated with septic failure after reimplantation. With dislocation being the most common cause of aseptic revision (5.2%), the cumulative incidence of aseptic failure was 1% (95% CI 0% to 5%) at one year, 6% (95% CI 1% to 8%) at five years, and 8% (95%CI 3% to 17%) at ten years. Conclusion. If there is no recurrent infection in the five years following reimplantation, the chances of further infection thereafter are remote. While the results of a frozen section may be a reliable guide to the timing of reimplantation, intraoperative culture has, currently, only prognostic value. Surgeons should be aware that instability remains a potential indication for further revision surgery. Cite this article: Bone Joint J 2021;103-B(1):79–86

Aims. To explore the effect of different types of articulating antibiotic-loaded cement spacers in two-stage revision for chronic hip prosthetic joint infection (PJI). Methods. A retrospective cohort study was performed involving 36 chronic PJI patients treated with different types of articulating antibiotic-loaded cement spacers between January 2014 and December 2017. The incidence of complications and the therapeutic effects of different types of antibiotic-loaded articulating cement spacers were compared. Results. A total of 36 patients with chronic hip PJI were included. Of these, 13 patients were treated with spacers with Kirschner wires as an endoskeleton (group I), ten patients were treated with spacers with a cemented femoral prosthesis as an endoskeleton (group II), and 13 patients were treated with cemented femoral prostheses combined with polyethylene sockets as a spacer (group III). All patients were followed for 12 to 60 months, with a mean follow-up period of 26.44 months (SEM 14.09). Infection was controlled in 34 patients (94.44%), and there were no significant differences in the eradication rate among the three groups (p = 0.705), but the risk of complications related to the spacer in group III was significantly lower than that in groups I and II (p = 0.006). Conclusion. Articulating antibiotic-loaded cement spacers is effective in the treatment of chronic hip PJI, but we must pay attention to the occurrence of spacer fracture and dislocation, which can lead to poor joint function. The risk of spacer-related mechanical complications is low, and better joint function can be achieved when using cemented femoral prostheses combined with polyethylene sockets as spacers. Cite this article: Bone Joint Res 2020;9(8):484–492

Introduction. Single-stage resection and reimplantation for periprosthetic joint infection (PJI) in total hip arthroplasty (THA) is of recent interest, yet outcomes may be skewed by selected populations with healthier patients and less virulent organisms. This study quantified the effectiveness of a contemporary, evidence-based and standardized two-stage treatment protocol in patients with THA PJI including chronically infected, poor hosts. Methods. Sixty-one consecutive two-stage resection and reimplantation THAs for PJI between 2011 and 2017 were retrospectively reviewed in a prospectively collected registry database. Patients were categorized with McPherson's Staging System and infection was defined by MSIS criteria. Contemporary standardized protocols were adhered to including implant resection and meticulous surgical debridement, six-week intravenous antibiotics with a high-dose antibiotic spacer, a two-week drug holiday, and laboratory assessment of infection eradication prior to reimplantation. Extended antibiotics after reimplantation were not routinely used. Successful treatment was defined as reimplantation with component retention at minimum two-year follow-up. Results. After exclusions for confounds, 43 of 47 patients had obtained minimum two-year follow-up (mean 50.9 months). 54% were male with an average BMI of 31 kg/m2. 56% were chronically infected poor hosts (Stage III-B/C). Three patients required repeat debridement and/or spacer exchange prior to final reimplantation. Treatment success rate was 95% at two-year follow-up. Success did not vary based on patient sex, age, BMI, or multi-organism PJI (p ≥ 0.117). There were no failures in the early postoperative PJI group (stage I), and both failures occurred in the late chronic PJI group (stage III). Conclusion. Our success rate with the two-stage procedure equals or exceeds that of single-stage treatment, even in an unselected cohort of chronically infected poor hosts. More rigorous scientific comparative studies are warranted prior to indiscriminate adoption of the single-stage treatment approach for PJI in THA

Two-stage exchange remains the gold standard for treatment of peri-prosthetic joint infection after total hip replacement (THR). In the first stage, all components and associated cement if present are removed, an aggressive debridement is undertaken including a complete synovectomy, and an antibiotic-loaded cement spacer is put in place. Patients are then treated with six weeks of parenteral antibiotics, followed by an ‘antibiotic free period’ to help ensure the infection has been eradicated. If the clinical evaluation and serum inflammatory markers suggest the infection has resolved, then the second stage can be completed, which involves removal of the cement spacer, repeat debridement, and placement of a new THR. Cite this article: Bone Joint J 2013;95-B, Supple A:84–7

We report the outcome at ten to 15 years of two-stage revision for hip infection in 99 patients using the Prostalac articulated hip spacer system. All the patients were contacted to determine their current functional and infection status using the Oxford-12, Short form-12, and Western Ontario and McMaster University Osteoarthritis Index questionnaires. A total of 11 of the 99 patients had a further infection, of whom seven responded to repeat surgery with no further sequelae. The mean interval between the stages was five months (1 to 36). We were able to review 48 living patients, with a mean age of 72 years (46 to 86), 34 (71%) of whom provided health-related quality-of-life outcome scores. The mean follow-up was 12 years (10 to 15). The long-term success rate was 89% and with additional surgery this rose to 96%. The mean global Western Ontario and McMaster University Osteoarthritis Index score was 80.6 (. sd. 18.3). The mean Oxford-12 score was 74.0 (. sd. 22.3), and the mean Short form-12 score was 53.1 (. sd. 9.4) (mental) and 33.5 (. sd. 13.5) (physical). The mean satisfaction score was 90.5 (. sd. 15.3). Two-stage revision for hip infection using a Prostalac interim spacer offers a predictable and lasting solution for patients with this difficult problem

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

The removal of all prosthetic material and a two-stage revision procedure is the established standard management of an infected total hip replacement (THR). However, the removal of well-fixed femoral cement is time-consuming and can result in significant loss of bone stock and femoral shaft perforation or fracture. We report our results of two-stage revision THR for treating infection, with retention of the original well-fixed femoral cement mantle in 15 patients, who were treated between 1989 and 2002. Following partial excision arthroplasty, patients received local and systemic antibiotics and underwent reconstruction and re-implantation at a second-stage procedure, when the infection had resolved. The mean follow-up of these 15 patients was 82 months (60 to 192). Two patients had positive microbiology at the second stage and were treated with six weeks of appropriate antibiotics; one of these developed recurrent infection requiring further revision. Successful eradication of infection was achieved in the remaining 14 patients. We conclude that when two-stage revision is used for the treatment of peri-prosthetic infection involving a THR, a well-fixed femoral cement mantle can be safely left in situ, without compromising the treatment of infection. Advantages of this technique include a shorter operating time, reduced loss of bone stock and a technically more straightforward second-stage procedure