Infection of total hip replacement (THR) is a serious complication, usually necessitating complete removal of implants and thorough debridement of the site. Mostly implant removal is followed by several weeks of antibiotic therapy before a new prosthesis is inserted. One stage exchange using antibiotic containing cement did not gain widespread use because of several risks, although the possible clinical and economic advantages are evident. Uncemented revision techniques seem to provide better long term results, however in septic cases its use so far has been restricted to two stage procedures. Allograft bone impregnated with high loads of antibiotics using a special technique (antibiotic bone compound ABC) is likely to create markedly higher concentrations of antibiotics in its surrounding than cement.

Between 1998 and 2004 37 patients with infected THR were treated using a standardized protocol. Patients were 17 male and 20 female, their age at revision was 42–83 yrs with a mean of 68,5yrs. After removal of the implants a radical debridement and intensive pulsed lavage was performed. Bone deficiencies were filled with cancellous bone, impregnated with high loads of Vancomycin or (in cases with gramnegative cultures) a combination with Tobramycin (ABC). After impaction uncemented implants were anchored following the principles of press-fit fixation, all without cement; usually we preferred a rectangular diameter titanium stem and a hemispherical cup. Additional ABC was placed around eventually uncovered parts of the implants and impacted for good stability. Wounds were drained and closed immediately; rehabilitation was performed as after non-septic surgery. Cultures taken intraoperatively revealed growth of coag.neg.staph (19x), s.aureus (11x), MRSA (5x), enterococci (8x) and other grampositive pathogens (6x), respectively. In 8 hips gramnegative germs were found additionally. Patients were evaluated prospectively 2 weeks, 6 weeks, 3 months, 6 months and one year after surgery. After the first year evaluation was retrospective. Follow up included clinical and radiological examination and laboratory data (CRP, ESR, blood count, urea and creatinine).

Three hips required re-revision because of re-infection, the remaining 34 hips (92%) stayed infect free and stable throughout a follow up period between 2 and 8 years (mean 4,4yrs). No adverse side effects could be found. Incorporation of grafted bone followed the same patterns as known from unimpregnated grafts.

Infected THRs may be exchanged within a single procedure using antibiotic impregnated allograft bone, providing biological reconstruction of bone stock, stable insertion of an uncemented implant and control of infection. Since only one intervention is necessary rehabilitation of patients is improved and costs are markedly reduced. Improved long term results may be expected.

Infection of total knee replacement (TKR) is considered a devastating complication, which necessitates complete removal and thorough debridement of the site. Usually long term antibiotic treatment and a multitude of surgical interventions within a period of several months are required until a definitive supply can be achieved. Osseous defects are common in such conditions and need to be addressed during re-implantation. Managing removal, debridement, reconstruction and re-implantation within a single operation is the ideal solution, both for the patient and the treating team, but rarely executed due to the fear of re-infection. Allograft bone may be impregnated with high loads of antibiotics using a special incubation technique. The resulting antibiotic bone compound (ABC) provides high and long lasting antibiotic levels at the site of infection and is likely to restore bone stock. We have investigated the results of one-stage exchange of infected TKR using ABC together with uncemented implants.

Between 1998 and 2004 nineteen exchange procedures of infected TKRs were performed in a single stage, all of them without the use of bone cement. After removal of the implants and radical debridement bone voids were filled with ABC using a modified impaction technique. Consequently, new uncemented implants were inserted. We mainly used the revision type of the LCS knee (DePuy, J& J) as long as ligamentary stability was considered sufficient. Otherwise, we used a custom-made uncemented version of the LINK Rotational Endo Model. Joints were drained and closed immediately; rehabilitation did not differ from uninfected revision.

One knee required re-revision because of persisting infection. The remaining 18 patients stayed infect-free for a period between 2 and 8 years after surgery. In two knees loosening was found after one year, once of the tibial and once of the femoral component. Both were found infect-free at the time of re-revision. All could be successfully revised using the same technique again. No adverse side effects could be found. Incorporation appeared as after grafting with unimpregnated bone grafts.

Using antibiotic-impregnated allografts eradication of pathogens, grafting of defects and re-insertion of an uncemented prosthesis may be accomplished in a one-stage procedure. Since the graft gradually is replaced by healthy own bone, improved long-term results may be expected as well as improved conditions in the case of another revision.

Infection of a total hip replacement (THR) requires component removal and thorough local debridement. Usually, long-term antibiotic treatment in conjunction with a two-stage revision is required. This may take several months. One-stage revision using antibiotic-loaded cement has not gained widespread use, although the clinical and economic advantages are obvious. Allograft bone may be impregnated with high levels of antibiotics, and in revision of infected THR, act as a carrier providing a sustained high local concentration.

We performed 37 one-stage revision of infected THRs, without the use of cement. There were three hips which required further revision because of recurrent infection, the remaining 34 hips (92%) stayed free from infection and stable at a mean follow-up of 4.4 years (2 to 8). No adverse effects were identified. Incorporation of bone graft was comparable with unimpregnated grafts.

Antibiotic-impregnated allograft bone may enable reconstruction of bone stock, insertion of an uncemented implant and control of infection in a single operation in revision THR for infection.