Clinical Orthopaedics and Related Research®

, Volume 470, Issue 11, pp 3164–3170 | Cite as

Aggressive Early Débridement for Treatment of Acutely Infected Cemented Total Hip Arthroplasty

  • Mohamed SukeikEmail author
  • Shelain Patel
  • Fares Sami Haddad
Symposium: Papers Presented at the 2011 Meeting of the International Hip Society



Up to 2% of THAs are complicated by infection, leading to dissatisfied patients with poor function and major social and economic consequences. The challenges are control of infection, restoration of full function, and prevention of recurrence. Irrigation and débridement with or without exchange of modular components remains an attractive alternative to two-stage reimplantation in acutely infected THAs but with variable results from previous studies.


We therefore determined the rate at which aggressive early débridement with exchange of modular components controlled acutely infected cemented THAs.


We retrospectively studied all 26 patients presenting with acutely infected cemented THAs (16 primaries, 10 revisions) occurring within 6 weeks of the index operation or of hematogenous spread from a confirmed source of infection elsewhere between 1999 and 2006. Microbiology confirmed bacterial colonization in all patients, with 18 early postoperative infections and eight acute hematogenous infections. Patients underwent aggressive débridement with open complete synovectomy, exchange of all mobile parts, débridement of all aspects of the joint, irrigation with antiseptic solutions, and pulsatile lavage. Minimum followup was 5 years (mean, 6.6 years; range, 5–11 years).


Eight patients had multiple washouts with control of infection in four at latest followup. Five patients underwent two-stage revisions and one patient was placed on long-term antibiotic suppression. Twenty patients returned to their expected functional level with no radiographic evidence of prosthetic failure. At minimum 5-year followup, we had a 77% infection control rate.


Our data confirm current literature and suggest there may be a role for aggressive early débridement in controlling acute postoperative and hematogenous infections after cemented THA.

Level of Evidence

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.


Infection Control Late Followup Periprosthetic Infection Modular Component Infection Control Rate 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Aboltins CA, Dowsey MM, Buising KL, Peel TN, Daffy JR, Choong PF, Stanley PA. Gram-negative prosthetic joint infection treated with debridement, prosthesis retention and antibiotic regimens including a fluoroquinolone. Clin Microbiol Infect. 2011;17:862–867.PubMedCrossRefGoogle Scholar
  2. 2.
    Aboltins CA, Page MA, Buising KL, Jenney AW, Daffy JR, Choong PF, Stanley PA. Treatment of staphylococcal prosthetic joint infections with debridement, prosthesis retention and oral rifampicin and fusidic acid. Clin Microbiol Infect. 2007;13:586–591.PubMedCrossRefGoogle Scholar
  3. 3.
    Ahlberg A, Carlsson AS, Lindberg L. Hematogenous infection in total joint replacement. Clin Orthop Relat Res. 1978;137:69–75.PubMedGoogle Scholar
  4. 4.
    Antti-Poika I, Santavirta S, Konttinen YT, Honkanen V. Outcome of the infected hip arthroplasty: a retrospective study of 36 patients. Acta Orthop Scand. 1989;60:670–675.PubMedCrossRefGoogle Scholar
  5. 5.
    Azzam KA, Seeley M, Ghanem E, Austin MS, Purtill JJ, Parvizi J. Irrigation and debridement in the management of prosthetic joint infection: traditional indications revisited. J Arthroplasty. 2010;25:1022–1027.PubMedCrossRefGoogle Scholar
  6. 6.
    Berdal JE, Skramm I, Mowinckel P, Gulbrandsen P, Bjornholt JV. Use of rifampicin and ciprofloxacin combination therapy after surgical debridement in the treatment of early manifestation prosthetic joint infections. Clin Microbiol Infect. 2005;11:843–845.PubMedCrossRefGoogle Scholar
  7. 7.
    Brandt CM, Sistrunk WW, Duffy MC, Hanssen AD, Steckelberg JM, Ilstrup DM, Osmon DR. Staphylococcus aureus prosthetic joint infection treated with debridement and prosthesis retention. Clin Infect Dis. 1997;24:914–919.PubMedCrossRefGoogle Scholar
  8. 8.
    Canner GC, Steinberg ME, Heppenstall RB, Balderston R. The infected hip after total hip arthroplasty. J Bone Joint Surg Am. 1984;66:1393–1399.PubMedGoogle Scholar
  9. 9.
    Charnley J. A clean-air operating enclosure. Br J Surg. 1964;51:202–205.PubMedCrossRefGoogle Scholar
  10. 10.
    Cobo J, Miguel LG, Euba G, Rodriguez D, Garcia-Lechuz JM, Riera M, Falgueras L, Palomino J, Benito N, del Toro MD, Pigrau C, Ariza J. Early prosthetic joint infection: outcomes with debridement and implant retention followed by antibiotic therapy. Clin Microbiol Infect. 2011;17:1632–1637.PubMedCrossRefGoogle Scholar
  11. 11.
    Crockarell JR, Hanssen AD, Osmon DR, Morrey BF. Treatment of infection with debridement and retention of the components following hip arthroplasty. J Bone Joint Surg Am. 1998;80:1306–1313.PubMedGoogle Scholar
  12. 12.
    Davis JS. Management of bone and joint infections due to Staphylococcus aureus. Intern Med J. 2005;35:S79–S96.PubMedCrossRefGoogle Scholar
  13. 13.
    DeLee JG, Charnley J. Radiological demarcation of cemented sockets in total hip replacement. Clin Orthop Relat Res. 1976;121:20–32.PubMedGoogle Scholar
  14. 14.
    Della Valle CJ, Zuckerman JD, Di Cesare PE. Periprosthetic sepsis. Clin Orthop Relat Res. 2004;420:26–31.PubMedCrossRefGoogle Scholar
  15. 15.
    Dreghorn CR, Hamblen DL. Revision arthroplasty: a high price to pay. BMJ. 1989;298:648–649.PubMedCrossRefGoogle Scholar
  16. 16.
    Estes CS, Beauchamp CP, Clarke HD, Spangehl MJ. A two-stage retention debridement protocol for acute periprosthetic joint infections. Clin Orthop Relat Res. 2010;468:2029–2038.PubMedCrossRefGoogle Scholar
  17. 17.
    Gruen TA, McNeice GM, Amstutz HC. “Modes of failure” of cemented stem-type femoral components: a radiographic analysis of loosening. Clin Orthop Relat Res. 1979;141:17–27.PubMedGoogle Scholar
  18. 18.
    Harkness JW, Crockarell JR. Arthroplasty of the hip. In: Canale ST, Beaty JH, eds. Campbell’s Operative Orthopaedics. Volume 1. 11th ed. Philadelphia, PA: Mosby; 2008:427.Google Scholar
  19. 19.
    Kaltsas DS. Infection after total hip arthroplasty. Ann R Coll Surg Engl. 2004;86:267–271.PubMedCrossRefGoogle Scholar
  20. 20.
    Klouche S, Lhotellier L, Mamoudy P. Infected total hip arthroplasty treated by an irrigation-debridement/component retention protocol: a prospective study in a 12-case series with minimum 2 years’ follow-up. Orthop Traumatol Surg Res. 2011 March 7 [Epub ahead of print].Google Scholar
  21. 21.
    Kneif D, Downing M, Ashcroft GP, Gibson P, Knight D, Ledingham W, Hutchison J. Peri-acetabular radiolucent lines: inter- and intra-observer agreement on post-operative radiographs. Int Orthop. 2005;29:152–155.PubMedCrossRefGoogle Scholar
  22. 22.
    Kraemer WJ, Saplys R, Waddell JP, Morton J. Bone scan, gallium scan, and hip aspiration in the diagnosis of infected total hip arthroplasty. J Arthroplasty. 1993;8:611–616.PubMedCrossRefGoogle Scholar
  23. 23.
    Krasin E, Goldwirth M, Hemo Y, Gold A, Herling G, Otremski I. Could irrigation, debridement and antibiotic therapy cure an infection of a total hip arthroplasty? J Hosp Infect. 2001;47:235–238.PubMedCrossRefGoogle Scholar
  24. 24.
    Lachiewicz PF, Rogers GD, Thomason HC. Aspiration of the hip joint before revision total hip arthroplasty: clinical and laboratory factors influencing attainment of a positive culture. J Bone Joint Surg Am. 1996;78:749–754.PubMedGoogle Scholar
  25. 25.
    Little JP. Consistency of ASA grading. Anaesthesia. 1995;50:658–659.PubMedGoogle Scholar
  26. 26.
    Luessenhop CP, Higgins LD, Brause BD, Ranawat CS. Multiple prosthetic infections after total joint arthroplasty: risk factor analysis. J Arthroplasty. 1996;11:862–868.PubMedCrossRefGoogle Scholar
  27. 27.
    Marculescu CE, Berbari EF, Hanssen AD, Steckelberg JM, Harmsen SW, Mandrekar JN, Osmon DR. Outcome of prosthetic joint infections treated with debridement and retention of components. Clin Infect Dis. 2006;42:471–478.PubMedCrossRefGoogle Scholar
  28. 28.
    Martinez-Pastor JC, Munoz-Mahamud E, Vilchez F, Garcia-Ramiro S, Bori G, Sierra J, Martinez JA, Font L, Mensa J, Soriano A. Outcome of acute prosthetic joint infections due to gram-negative bacilli treated with open debridement and retention of the prosthesis. Antimicrob Agents Chemother. 2009;53:4772–4777.PubMedCrossRefGoogle Scholar
  29. 29.
    McCaskie AW, Brown AR, Thompson JR, Gregg PJ. Radiological evaluation of the interfaces after cemented total hip replacement: interobserver and intraobserver agreement. J Bone Joint Surg Br. 1996;78:191–194.PubMedGoogle Scholar
  30. 30.
    Meehan AM, Osmon DR, Duffy MC, Hanssen AD, Keating MR. Outcome of penicillin-susceptible streptococcal prosthetic joint infection treated with debridement and retention of the prosthesis. Clin Infect Dis. 2003;36:845–849.PubMedCrossRefGoogle Scholar
  31. 31.
    Moyad TF, Thornhill T, Estok D. Evaluation and management of the infected total hip and knee. Orthopedics. 2008;31:581–588; quiz 589–590.Google Scholar
  32. 32.
    Poss R, Thornhill TS, Ewald FC, Thomas WH, Batte NJ, Sledge CB. Factors influencing the incidence and outcome of infection following total joint arthroplasty. Clin Orthop Relat Res. 1984;182:117–126.PubMedGoogle Scholar
  33. 33.
    Spangehl MJ, Masri BA, O’Connell JX, Duncan CP. Prospective analysis of preoperative and intraoperative investigations for the diagnosis of infection at the sites of two hundred and two revision total hip arthroplasties. J Bone Joint Surg Am. 1999;81:672–683.PubMedGoogle Scholar
  34. 34.
    Stinchfield FE, Bigliani LU, Neu HC, Goss TP, Foster CR. Late hematogenous infection of total joint replacement. J Bone Joint Surg Am. 1980;62:1345–1350.PubMedGoogle Scholar
  35. 35.
    Sukeik M, Haddad FS. Two-stage procedure in the treatment of late chronic hip infections—spacer implantation. Int J Med Sci. 2009;6:253–257.PubMedCrossRefGoogle Scholar
  36. 36.
    Sukeik MT, Haddad FS. Management of periprosthetic infection in total hip arthroplasty. Orthopaedics and Trauma. 2009;23:342–349.CrossRefGoogle Scholar
  37. 37.
    Tattevin P, Cremieux AC, Pottier P, Huten D, Carbon C. Prosthetic joint infection: when can prosthesis salvage be considered? Clin Infect Dis. 1999;29:292–295.PubMedCrossRefGoogle Scholar
  38. 38.
    Tintle SM, Forsberg JA, Potter BK, Islinger RB, Andersen RC. Prosthesis retention, serial debridement, and antibiotic bead use for the treatment of infection following total joint arthroplasty. Orthopedics. 2009;32:87.PubMedGoogle Scholar
  39. 39.
    Tsukayama DT, Estrada R, Gustilo RB. Infection after total hip arthroplasty: a study of the treatment of one hundred and six infections. J Bone Joint Surg Am. 1996;78:512–523.PubMedGoogle Scholar
  40. 40.
    Van Kleunen JP, Knox D, Garino JP, Lee GC. Irrigation and débridement and prosthesis retention for treating acute periprosthetic infections. Clin Orthop Relat Res. 2010;468:2024–2028.PubMedCrossRefGoogle Scholar
  41. 41.
    Zicat B, Engh C A, Gokcen E. Patterns of osteolysis around total hip components inserted with and without cement. J Bone Joint Surg Am. 1995;77:432–439.PubMedGoogle Scholar
  42. 42.
    Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med. 2004;351:1645–1654.PubMedCrossRefGoogle Scholar
  43. 43.
    Zimmerli W, Widmer AF, Blatter M, Frei R, Ochsner PE. Role of rifampin for treatment of orthopedic implant-related staphylococcal infections: a randomized controlled trial. Foreign-Body Infection (FBI) Study Group. JAMA. 1998;279:1537–1541.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2012

Authors and Affiliations

  • Mohamed Sukeik
    • 1
    Email author
  • Shelain Patel
    • 1
  • Fares Sami Haddad
    • 1
  1. 1.Department of Trauma and OrthopaedicsUniversity College London HospitalLondonUnited Kingdom

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