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Infections of the Hip Joint: One-Stage Approach Without Cement

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Periprosthetic Joint Infections

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Abstract

Problems with infection of a total hip replacement (THR) derive from the presence of biofilms with inherent resistance to usual antibiotic treatment and bone defects resulting from infection-induced osteolysis. Discussions on the choice of treatment mainly focus on the chance of eradicating the infection in either one or more stages. The advantages of only one operation regarding patients’ satisfaction, functional results and economical burden are evident. However, the fear of re-infection usually leads surgeons to multiple-stage procedures, mostly using antibiotic-loaded spacers in the interval. Antibiotic concentrations eluted from spacers have no effect on biofilms and might be associated with a high rate of complications like breakage or dislocation.

One-stage revisions so far were mostly with cemented prostheses admixing antibiotics to the cement. Cemented revisions show several disadvantages: the addition of antibiotics to cement reduces its biomechanical properties with inferior long-term results compared to uncemented techniques. Efficient cementing techniques result in tight bonding with the underlying bone, making eventual removal time-consuming and possibly associated with further damage to the osseous structures. Uncemented implants appear more advantageous but are at risk of becoming colonized by eventually remaining biofilm fragments, requiring local application of antibiotics. Uncemented prostheses can be removed as easily as spacers in case of failure and may be left in place in case of success.

Allograft bone may be impregnated with high loads of antibiotics using special impregnation techniques, resulting in an antibiotic bone compound (ABC). ABC provides local concentrations exceeding those of cement by more than a 100-fold and efficient release is prolonged for several weeks. The same time it is most likely to restore bone stock, which usually is compromised after removal of an infected endoprosthesis. Effective local antimicrobial concentrations in combination with radical debridement may be suitable for eradicating infection with a single operation in the majority of cases.

Based on these considerations a new protocol for one-stage exchange of infected TJR has been established in our institution. Bone defects are filled with ABC, uncemented implants are fixed in original healthy bone. With ABC, providing a sustained antibiotic release with biofilm-active concentrations, microscopical remnants of biofilm may be eliminated. Results indicate an overall success rate of more than 90 % with one operation, without any adverse side effects. Incorporation of allografts appears as after grafting with unimpregnated bone, in the radiographic follow-up. One-stage revision using ABC together with uncemented implants should be at least comparably safe as multiple-stage procedures, offering clear advantages for the quality of life of patients as well as from economic standpoints.

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Authors and Affiliations

  1. Osteitis Zentrum, Privatklinik Döbling, Heiligenstaedter, Strasse 57-63A-1190, Wien, Austria

    Heinz Winkler MD

  2. Department of Traumatology, Landesklinikum Korneuburg, Wiener Ring 3–5, A-2100, Korneuburg, Austria

    Peter Haiden MD

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  1. Heinz Winkler MD
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  2. Peter Haiden MD
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Correspondence to Heinz Winkler MD .

Editor information

Editors and Affiliations

  1. HELIOS ENDO-Klinik Hamburg, Berlin, Germany

    Daniel Kendoff

  2. University Hospital of Wales, Cardiff, United Kingdom

    Rhidian Morgan-Jones

  3. University College London Hospitals, London, United Kingdom

    Fares S. Haddad

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Winkler, H., Haiden, P. (2016). Infections of the Hip Joint: One-Stage Approach Without Cement. In: Kendoff, D., Morgan-Jones, R., Haddad, F. (eds) Periprosthetic Joint Infections. Springer, Cham. https://doi.org/10.1007/978-3-319-30091-7_13

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  • DOI: https://doi.org/10.1007/978-3-319-30091-7_13

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-30089-4

  • Online ISBN: 978-3-319-30091-7

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