Aims. Adult patients with history of childhood infection pose a surgical challenge for total hip arthroplasty (THA) due to distorted bony anatomy, soft-tissue contractures, risk of reinfection, and relatively younger age. Therefore, the purpose of the present study was to determine clinical outcome, reinfection rate, and complications in patients with septic sequelae after THA. Methods. A retrospective analysis was conducted of 91 cementless THAs (57 male and 34 female) performed between 2008 and 2017 in patients who had history of hip infection during childhood. Clinical outcome was measured using Harris Hip Score (HHS) and Modified Merle d’Aubigne and Postel (MAP) score, and quality of life (QOL) using 12-Item Short Form Health Survey Questionnaire (SF-12) components: Physical Component Score (PCS) and Mental Component Score (MCS); limb length discrepancy (LLD) and radiological assessment of the prosthesis was performed at the latest follow-up. Reinfection and revision surgery after THA for any reason was documented. Results. There was significant improvement in HHS, Modified Merle d’Aubigne Postel hip score, and QOL index SF 12-PCS and MCS (p < 0.001) and there was no case of reinfection reported during the follow-up. The minimum follow-up for the study was three years with a mean of 6.5 (SD 2.3; 3 to 12). LLD decreased from a mean of 3.3 cm (SD 1) to 0.9 cm (SD 0.8) during follow-up. One patient required revision surgery for femoral component loosening. Kaplan-Meier survival analysis estimated revision-free survivorship of 100% at the end of five years and 96.9% (95% confidence interval 79.8 to 99.6) at the end of ten years. Conclusion. We found that cementless THA results in good to excellent functional outcomes in patients with a prior history of childhood infection. There is an exceedingly low rate of risk of reinfection in these patients, even though complications are not uncommon. Cite this article: Bone Jt Open 2022;3(4):314–320

Aims. The outcome of repeat septic revision after a failed one-stage exchange for periprosthetic joint infection (PJI) in total knee arthroplasty (TKA) remains unknown. The aim of this study was to report the infection-free and all-cause revision-free survival of repeat septic revision after a failed one-stage exchange, and to determine whether the Musculoskeletal Infection Society (MSIS) stage is associated with subsequent infection-related failure. Methods. We retrospectively reviewed all repeat septic revision TKAs which were undertaken after a failed one-stage exchange between 2004 and 2017. A total of 33 repeat septic revisions (29 one-stage and four two-stage) met the inclusion criteria. The mean follow-up from repeat septic revision was 68.2 months (8.0 months to 16.1 years). The proportion of patients who had a subsequent infection-related failure and all-cause revision was reported and Kaplan-Meier survival for these endpoints was determined. Patients were categorized according to the MSIS staging system, and the association with subsequent infection was analyzed. Results. At the most recent follow-up, 17 repeat septic revisions (52%) had a subsequent infection-related failure and the five-year infection-free survival was 59% (95% confidence interval (CI) 39 to 74). A total of 19 underwent a subsequent all-cause revision (58%) and the five-year all-cause revision-free survival was 47% (95% CI 28 to 64). The most common indication for the first subsequent aseptic revision was loosening. The MSIS stage of the host status (p = 0.663) and limb status (p = 1.000) were not significantly associated with subsequent infection-related failure. Conclusion. Repeat septic revision after a failed one-stage exchange TKA for PJI is associated with a high rate of subsequent infection-related failure and all-cause revision. Patients should be counselled appropriately to manage expectations. The host and limb status according to the MSIS staging system were not associated with subsequent infection-related failure. Cite this article: Bone Joint J 2022;104-B(3):386–393

Aims. To examine the rates of hamstring graft salvage with arthroscopic debridement of infected anterior cruciate ligament (ACL) reconstruction as reported in the literature and discuss functional outcomes. Materials and Methods. A search was performed without language restriction on PubMed, EMBASE, Ovid, CINAHL and Cochrane Register of Controlled Trials (CENTRAL) databases from their inception to April 2015. We identified 147 infected hamstring grafts across 16 included studies. Meta-analysis was performed using a random-effects model to estimate the overall graft salvage rate, incorporating two different definitions of graft salvage. Results. The graft salvage rate was 86% (95% confidence intervals (CI) 73% to 93%; heterogeneity: tau. 2. = 1.047, I. 2. = 40.51%, Q = 25.2, df = 15, p < 0.001), excluding ACL re-ruptures. Including re-ruptures as failures, the graft salvage rate was 85% (95% CI 76% to 91%; heterogeneity: tau. 2.  = 0.099, I. 2. = 8.15%, Q = 14.15, df = 13, p = 0.36). Conclusions. Arthroscopic debridement combined with antibiotic treatment can lead to successful eradication of infection and graft salvage, with satisfactory functional outcomes in many cases of septic arthritis following ACL reconstruction. Persistent infection despite repeat arthroscopic debridements requires graft removal with the intention of revision ACL surgery at a later stage. Take home message: Arthroscopic debridement combined with antibiotic therapy is an appropriate initial approach in most cases of septic arthritis following ACL reconstruction, achieving graft salvage rates of about 85%. Cite this article: Bone Joint J 2016;98-B:608–15

Aims

This study aimed to answer two questions: what are the best diagnostic methods for diagnosing bacterial arthritis of a native joint?; and what are the most commonly used definitions for bacterial arthritis of a native joint?

We report 11 patients having revision of total hip arthroplasty using massive structural allografts for failure due to sepsis and associated bone loss. All patients had a two-stage reconstruction and the mean follow-up was 47.8 months (24 to 72). Positive cultures were obtained at the first stage in nine of the 11 patients, with Staphylococcus epidermidis being the most common organism. The other two patients had draining sinuses with negative cultures. There was no recurrence of infection in any patient. The mean increase in the modified Harris hip score was 45 and all the grafts appeared to have united to host bone. Two patients required additional procedures, but only one was related to the allograft. Complications included an incomplete sciatic nerve palsy and one case of graft resorption. Our results support the use of massive allografts in failed septic hip arthroplasty in which there is associated bone loss

Knee arthrodesis is a potential salvage procedure for limb preservation after failure of total knee arthroplasty (TKA) due to infection. In this study, we evaluated the outcome of single-stage knee arthrodesis using an intramedullary cemented coupled nail without bone-on-bone fusion after failed and infected TKA with extensor mechanism deficiency. Between 2002 and 2012, 27 patients (ten female, 17 male; mean age 68.8 years; 52 to 87) were treated with septic single-stage exchange. Mean follow-up duration was 67.1months (24 to 143, n = 27) (minimum follow-up 24 months) and for patients with a minimum follow-up of five years 104.9 (65 to 143,; n = 13). A subjective patient evaluation (Short Form (SF)-36) was obtained, in addition to the Visual Analogue Scale (VAS). The mean VAS score was 1.44 (SD 1.48). At final follow-up, four patients had recurrent infections after arthrodesis (14.8%). Of these, three patients were treated with a one-stage arthrodesis nail exchange; one of the three patients had an aseptic loosening with a third single-stage exchange, and one patient underwent knee amputation for uncontrolled sepsis at 108 months. All patients, including the amputee, indicated that they would choose arthrodesis again. Data indicate that a single-stage knee arthrodesis offers an acceptable salvage procedure after failed and infected TKA.

Cite this article: Bone Joint J 2015;97-B:649–53.

We describe a technique of ‘cross-hip distraction’ to reduce a dislocated hip with subsequent reconstruction of the joint for septic arthritis with extensive femoral osteomyelitis. A 27-year-old woman presented with a dislocated, collapsed femoral head and chronic osteomyelitis of the femur. Examination revealed a leg-length discrepancy of 7 cm and an irritable hip. A staged technique was used with primary clearance of osteomyelitis and secondary reconstruction of the hip. A cross-hip monolateral external fixator was used to establish normal anatomy followed by an arthroplasty. A good functional outcome was achieved. The use of cross-hip distraction avoids soft-tissue and nerve damage and achieved improved abductor function before arthroplasty.

In this study of 41 patients, we used proteomic, Western blot and immunohistochemical analyses to show that several reactive oxygen species scavenging enzymes are expressed differentially in patients with primary osteoarthritis and those with non-loosening and aseptic loosening after total hip replacement (THR). The patients were grouped as A (n = 16, primary THR), B (n = 10, fixed THR but requiring revision for polyethylene wear) and C (n = 15, requiring revision due to aseptic loosening) to verify the involvement of the identified targets in aseptic loosening. When compared with Groups A and B, Group C patients exhibited significant up-regulation of transthyretin and superoxide dismutase 3, but down-regulation of glutathione peroxidase 2 in their hip synovial fluids. Also, higher levels of superoxide dismutase 2 and peroxiredoxin 2, but not superoxide dismutase 1, catalase and glutathione perioxidase 1, were consistently detected in the hip capsules of Group C patients.

We propose that dysregulated reactive oxygen species-related enzymes may play an important role in the pathogenesis and progression of aseptic loosening after THR.

Forty hips, which had previously been the site of tuberculous or pyogenic arthritis and which had later developed a degenerative arthritis, were treated by low-friction arthroplasty some forty years after the original infection. The results suggest that, when healing of the primary infection has been followed by a long period of quiescence with acceptable function before the onset of degenerative change, the arthroplasty can be confidently expected to result in greatly improved function and that this improvement is long-lasting.

The acute childhood diseases haematogenous staphylococcal osteomyelitis and septic arthritis were studied concurrently using avian models which closely resemble the human diseases. Ultrastructural studies during the initial stages of bone and joint infection showed that adherence of bacteria to cartilage, bacterial proliferation, cartilage destruction and subsequent bacterial spread along the vascular channels within cartilage were common to both disease processes. Histological studies revealed that transphyseal blood vessels were present in the growing chickens and were a likely explanation for the frequency of the concurrence of acute osteomyelitis and adjacent joint infection following intravenous injection of bacteria. Transphyseal vessels provide a direct connection between the growth plate (physis) and epiphyseal cartilage supplying a route for bacteria to spread from an osteomyelitic focus in the metaphysis to the epiphysis and subsequently to the joint lumen.

Aims. This study compares the re-revision rate and mortality following septic and aseptic revision hip arthroplasty (rTHA) in registry data, and compares the outcomes to previously reported data. Methods. This is an observational cohort study using data from the German Arthroplasty Registry (EPRD). A total of 17,842 rTHAs were included, and the rates and cumulative incidence of hip re-revision and mortality following septic and aseptic rTHA were analyzed with seven-year follow-up. The Kaplan-Meier estimates were used to determine the re-revision rate and cumulative probability of mortality following rTHA. Results. The re-revision rate within one year after septic rTHA was 30%, and after seven years was 34%. The cumulative mortality within the first year after septic rTHA was 14%, and within seven years was 40%. After multiple previous hip revisions, the re-revision rate rose to over 40% in septic rTHA. The first six months were identified as the most critical period for the re-revision for septic rTHA. Conclusion. The risk re-revision and reinfection after septic rTHA was almost four times higher, as recorded in the ERPD, when compared to previous meta-analysis. We conclude that it is currently not possible to assume the data from single studies and meta-analysis reflects the outcomes in the ‘real world’. Data presented in meta-analyses and from specialist single-centre studies do not reflect the generality of outcomes as recorded in the ERPD. The highest re-revision rates and mortality are seen in the first six months postoperatively. The optimization of perioperative care through the development of a network of high-volume specialist hospitals is likely to lead to improved outcomes for patients undergoing rTHA, especially if associated with infection. Cite this article: Bone Joint J 2024;106-B(6):565–572

Aims. Patients with a high comorbidity burden (HCB) can achieve similar improvements in quality of life compared with low-risk patients, but greater morbidity may deter surgeons from operating on these patients. Whether surgeon volume influences total hip arthroplasty (THA) outcomes in HCB patients has not been investigated. This study aimed to compare complication rates and implant survivorship in HCB patients operated on by high-volume (HV) and non-HV THA surgeons. Methods. Patients with Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiologists grade of III or IV, undergoing primary elective THA between January 2013 and December 2021, were retrospectively reviewed. Patients were separated into groups based on whether they were operated on by a HV surgeon (defined as the top 25% of surgeons at our institution by number of primary THAs per year) or a non-HV surgeon. Groups were propensity-matched 1:1 to control for demographic variables. A total of 1,134 patients were included in the matched analysis. Between groups, 90-day readmissions and revisions were compared, and Kaplan-Meier analysis was used to evaluate implant survivorship within the follow-up period. Results. Years of experience were comparable between non-HV and HV surgeons (p = 0.733). The HV group had significantly shorter surgical times (p < 0.001) and shorter length of stay (p = 0.009) than the non-HV group. The HV group also had significantly fewer 90-day readmissions (p = 0.030), all-cause revisions (p = 0.023), and septic revisions (p = 0.020) compared with the non-HV group at latest follow-up. The HV group had significantly greater freedom from all-cause (p = 0.023) and septic revision (p = 0.020) than the non-HV group. Conclusion. The HCB THA patients have fewer 90-day readmissions, all-cause revisions, and septic revisions, as well as shorter length of stay when treated by HV surgeons. THA candidates with a HCB may benefit from referral to HV surgeons to reduce procedural risk and improve postoperative outcomes. Cite this article: Bone Joint J 2024;106-B(3 Supple A):10–16

Aims. There is a paucity of long-term studies analyzing risk factors for failure after single-stage revision for periprosthetic joint infection (PJI) following total hip arthroplasty (THA). We report the mid- to long-term septic and non-septic failure rate of single-stage revision for PJI after THA. Methods. We retrospectively reviewed 88 cases which met the Musculoskeletal Infection Society (MSIS) criteria for PJI. Mean follow-up was seven years (1 to 14). Septic failure was diagnosed with a Delphi-based consensus definition. Any reoperation for mechanical causes in the absence of evidence of infection was considered as non-septic failure. A competing risk regression model was used to evaluate factors associated with septic and non-septic failures. A Kaplan-Meier estimate was used to analyze mortality. Results. The cumulative incidence of septic failure was 8% (95% confidence interval (CI) 3.5 to 15) at one year, 13.8% (95% CI 7.6 to 22) at two years, and 19.7% (95% CI 12 to 28.6) at five and ten years of follow-up. A femoral bone defect worse than Paprosky IIIA (hazard ratio (HR) 13.58 (95% CI 4.86 to 37.93); p < 0.001) and obesity (BMI ≥ 30 kg/m. 2. ; HR 3.88 (95% CI 1.49 to 10.09); p = 0.005) were significantly associated with septic failure. Instability and periprosthetic fracture were the most common reasons for mechanical failure (5.7% and 4.5%, respectively). The cumulative incidence of aseptic failure was 2% (95% CI 0.4 to 7) at two years, 9% (95% CI 4 to 17) at five years, and 12% (95% CI 5 to 22) at ten years. A previous revision to treat PJI was significantly associated with non-septic failure (HR 9.93 (95% CI 1.77 to 55.46); p = 0.009). At the five-year timepoint, 93% of the patients were alive (95% CI 84% to 96%), which fell to 86% (95% CI 75% to 92%) at ten-year follow-up. Conclusion. Massive femoral bone loss was associated with greater chances of developing a further septic failure. All septic failures occurred within the first five years following the one-stage exchange. Surgeons should be aware of instability and periprosthetic fracture being potential causes of further aseptic revision surgery. Cite this article: Bone Joint J 2021;103-B(7):1247–1253

Aims. Periprosthetic joint infections (PJIs) and fracture-related infections (FRIs) are associated with a significant risk of adverse events. However, there is a paucity of data on cardiac complications following revision surgery for PJI and FRI and how they impact overall mortality. Therefore, this study aimed to investigate the risk of perioperative myocardial injury (PMI) and mortality in this patient cohort. Methods. We prospectively included consecutive patients at high cardiovascular risk (defined as age ≥ 45 years with pre-existing coronary, peripheral, or cerebrovascular artery disease, or any patient aged ≥ 65 years, plus a postoperative hospital stay of > 24 hours) undergoing septic or aseptic major orthopaedic surgery between July 2014 and October 2016. All patients received a systematic screening to reliably detect PMI, using serial measurements of high-sensitivity cardiac troponin T. All-cause mortality was assessed at one year. Multivariable logistic regression models were applied to compare incidence of PMI and mortality between patients undergoing septic revision surgery for PJI or FRI, and patients receiving aseptic major bone and joint surgery. Results. In total, 911 consecutive patients were included. The overall perioperative myocardial injury (PMI) rate was 15.4% (n = 140). Septic revision surgery for PJI was associated with a significantly higher PMI rate (43.8% (14/32) vs 14.5% (57/393); p = 0.001) and one-year mortality rate (18.6% (6/32) vs 7.4% (29/393); p = 0.038) compared to aseptic revision or primary arthroplasty. The association with PMI persisted in multivariable analysis with an adjusted odds ratio (aOR) of 4.7 (95% confidence interval (CI) 2.1 to 10.7; p < 0.001), but was not statistically significant for one-year mortality (aOR 1.9 (95% CI 0.7 to 5.4; p = 0.240). PMI rate (15.2% (5/33) vs 14.1% (64/453)) and one-year mortality (15.2% (5/33) vs 9.1% (41/453)) after FRI revision surgery were comparable to aseptic long-bone fracture surgery. Conclusion. Patients undergoing revision surgery for PJI were at a risk of PMI and death compared to those undergoing aseptic arthroplasty surgery. Screening for PMI and treatment in specialized multidisciplinary units should be considered in major bone and joint infections. Cite this article: Bone Joint J 2022;104-B(6):696–702

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. Periprosthetic joint infection (PJI) demonstrates the most feared complication after total joint replacement (TJR). The current work analyzes the demographic, comorbidity, and complication profiles of all patients who had in-hospital treatment due to PJI. Furthermore, it aims to evaluate the in-hospital mortality of patients with PJI and analyze possible risk factors in terms of secondary diagnosis, diagnostic procedures, and complications. Methods. In a retrospective, cross-sectional study design, we gathered all patients with PJI (International Classification of Diseases (ICD)-10 code: T84.5) and resulting in-hospital treatment in Germany between 1 January 2019 and 31 December 2022. Data were provided by the Institute for the Hospital Remuneration System in Germany. Demographic data, in-hospital deaths, need for intensive care therapy, secondary diagnosis, complications, and use of diagnostic instruments were assessed. Odds ratios (ORs) with 95% confidence intervals (CIs) for in-hospital mortality were calculated. Results. A total of 52,286 patients were included, of whom 1,804 (3.5%) died. Hypertension, diabetes mellitus, and obesity, the most frequent comorbidities, were not associated with higher in-hospital mortality. Cardiac diseases as atrial fibrillation, cardiac pacemaker, or three-vessel coronary heart disease showed the highest risk for in-hospital mortality. Postoperative anaemia occurred in two-thirds of patients and showed an increased in-hospital mortality (OR 1.72; p < 0.001). Severe complications, such as organ failure, systemic inflammatory response syndrome (SIRS), or septic shock syndrome showed by far the highest association with in-hospital mortality (OR 39.20; 95% CI 33.07 to 46.46; p < 0.001). Conclusion. These findings highlight the menace coming from PJI. It can culminate in multi-organ failure, SIRS, or septic shock syndrome, along with very high rates of in-hospital mortality, thereby highlighting the vulnerability of these patients. Particular attention should be paid to patients with cardiac comorbidities such as atrial fibrillation or three-vessel coronary heart disease. Risk factors should be optimized preoperatively, anticoagulant therapy stopped and restarted on time, and sufficient patient blood management should be emphasized. Cite this article: Bone Jt Open 2024;5(4):367–373

Aims. The aim of this study was to report the long-term follow-up of cemented short Exeter femoral components when used in primary total hip arthroplasty (THA). Methods. We included all primary 394 THAs with a cemented short Exeter femoral component (≤ 125 mm) used in our tertiary referral centre between October 1993 and December 2021. A total of 83 patients (21%) were male. The median age of the patients at the time of surgery was 42 years (interquartile range (IQR) 30 to 55). The main indication for THA was a childhood hip disease (202; 51%). The median follow-up was 6.7 years (IQR 3.1 to 11.0). Kaplan-Meier survival analyses were performed to determine the rates of survival with femoral revision for any indication, for septic loosening, for fracture of the femoral component and for aseptic loosening as endpoints. The indications for revision were evaluated. Fractures of the femoral component were described in detail. Results. The 20-year rate of survival was 85.4% (95% confidence interval (CI) 73.9 to 92.0) with revision for any indication, 96.2% (95% CI 90.5 to 98.5) with revision for septic loosening and 92.7% (95% CI 78.5 to 97.6) with revision for fracture of the femoral component. No femoral components were revised for aseptic loosening. There were 21 revisions of the femoral component; most (seven) as part of a two-stage management of infection. Fracture of the femoral component occurred in four THAs (1.0%) at 6.6, 11.6, 16.5, and 18.2 years of follow-up, respectively. Three of these were transverse fractures and occurred at the level of the lesser trochanter. In one THA, there was a fracture of the neck of the component. Conclusion. THAs using cemented short Exeter femoral components showed acceptable rates of survival of the femoral component at long-term follow-up, in this young cohort of patients. Although fracture is a rare complication of these components, surgeons should be aware of their incidence and possible risk factors. Cite this article: Bone Joint J 2024;106-B(3 Supple A):137–142

Aims. The purpose of this study was to compare the clinical outcomes, mortalities, implant survival rates, and complications of total knee arthroplasty (TKA) in patients with or without hepatitis B virus (HBV) infection over at least ten years of follow-up. Methods. From January 2008 to December 2010, 266 TKAs were performed in 169 patients with HBV (HBV group). A total of 169 propensity score–matched patients without HBV were chosen for the control group in a one-to-one ratio. Then, the clinical outcomes, mortalities, implant survival rates, and complications of TKA in the two groups were compared. The mean follow-up periods were 11.7 years (10.5 to 13.4) in the HBV group and 11.8 years (11.5 to 12.4) in the control group. Results. The mean Knee Society scores in the HBV and control groups improved from 37.1 (SD 5.6) and 38.4 (SD 5.4) points preoperatively to 78.1 (SD 10.8) and 81.7 (SD 10.2) points at final follow-up (p = 0.314), while the mean function scores in the HBV and control groups improved from 36.2 and 37.3 points preoperatively to 77.8 and 83.2 points at final follow-up (p = 0.137). Nine knees in the HBV group required revision surgery, including seven due to septic loosening and two due to aseptic loosening. Four knees in the control group required revision surgery, including three due to septic loosening and one due to aseptic loosening. Kaplan–Meier survivorship analysis with the revision of either component as an endpoint in the HBV and control groups estimated 96.6% and 98.5% chances of survival for ten years, respectively (p = 0.160). Conclusion. TKA in patients with HBV infection resulted in good clinical outcomes and survivorship. However, there was a higher revision rate over a minimum ten-year follow-up period compared to TKA in patients without HBV infection. Cite this article: Bone Jt Open 2022;3(6):470–474

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. Methods. We have analyzed patients undergoing this cement-in-cement technique for femoral revision in infection, and present a consecutive series of 89 patients. Follow-up was undertaken at a mean of 56.5 months (24.0 to 134.7) for the surviving cases. Results. Seven patients (7.9%) required further revision for infection. Ten patients died of causes unrelated to their infection before their two-year review (mean 5.9 months; 0.9 to 18.6). One patient was lost to follow-up at five months after surgery, and two patients died of causes unrelated to their hip shortly after their two-year review was due without attending. Of the remaining patients, 69 remained infection-free at final review. Radiological review confirms the mechanical success of the procedure as previously described in aseptic revision, and postoperative Oxford Hip Scores suggest satisfactory functional outcomes. Conclusion. In conclusion, we found that retaining a well-fixed femoral cement mantle in the presence of infection and undertaking a cement-in-cement revision was successful in 82 of the patients (92.1%) in our series of 89, both in terms of eradication of infection and component fixation. These results are comparable to other more invasive techniques and offer significant potential benefits to the patient. Cite this article: Bone Joint J 2022;104-B(2):212–220