Introduction: A 2-stage approach is often employed to treat infected TJA. Success rates have been reported between 85–100%. Other authors favor multiple routine debridements (I& D) to lower the infection rate. This study compares the relative effectiveness of 2-, 3- and 4 stage treatment approaches.

Methods: Between 1988 and 1998, all infected TJA at our institution were treated with a 2-, 3- or 4 stage approach. In the 2-stage approach, prosthesis removal was followed by 6 weeks of IV antibiotics and reimplantation. In the 3-stage approach, an additional I& D was added 5–7 days after prosthesis removal. In the 4-stage protocol, a third I& D was performed after completion of antibiotics. Negative cultures led to reimplantation. Positive cultures led to an additional 6-week course of antibiotics, and then repeat 3rd and 4th stages. Patients retained their components if free of infection, on chronic antibiotic suppression or after additional I& D. Patients were free of infection if no more treatment was needed.

Results: 83 patients with infected TJA were treated. Average follow-up was 25 months. Of the 2 stage patients, 9/10 (90%) retained their components, and 7/10 (70%) was free of infection. Of the 3 stage patients, 32/37 (86%) retained their components, and 28/37 (76%) was free of infection. Of the 4 stage patients, 34/36 (94%) retained their prosthesis, and 30/36 (83%) was free of infection. Seventeen additional patients in the 4-stage group had positive cultures at the third stage. After additional treatment 13/17 (76%) retained their components and 12/17 (71%) was free of infection. No correlation was found between infection severity (gram positive vs. negative organisms; single vs multiple organisms) or initial diagnosis.

Discussion. Our ten-year experience with infected THA suggests that multiple I& D are required for successful treatment. Repeat I& D assures a sterile wound, as tissue culture is more sensitive than aspiration. Importantly, persistent infection after three I& D and appropriate antibiotics led to poorer results, suggesting that other host factors may preclude these patients from reimplantation. Given the exorbitant costs of treating failed reimplantations, an additional routine I& D may in fact be cost-effective across an entire population of infected TJA patients. Further analysis will focus upon cemented versus cementless implants, cost-benefit ratios of multiple debridements, nutritional parameters, functional assessments of patients at latest follow-up, cost analysis, and the value of preoperative.

Conclusion: We recommend a 4-stage approach to the treatment of infected THA.