Clinical Orthopaedics and Related Research®

, Volume 471, Issue 2, pp 510–518 | Cite as

Two-stage Treatment of Hip Periprosthetic Joint Infection Is Associated With a High Rate of Infection Control but High Mortality

  • Keith R. BerendEmail author
  • Adolph V. LombardiJr
  • Michael J. Morris
  • Adam G. Bergeson
  • Joanne B. Adams
  • Michael A. Sneller
Symposium: Papers Presented at the Annual Meetings of The Hip Society



Periprosthetic infection after total hip arthroplasty (THA) is a devastating complication. Reported rates of infection control range from 80% to 95% but mortality rates associated with treatment of infected THA are also substantial and we suspect underreported.


For patients selected for two-stage treatment of infected THA we therefore determined (1) mortality; (2) rate of reimplantation; and (3) rate of reinfection.


We identified 202 patients (205 hips) with infected primary or revision THA treated with a two-stage protocol between 1996 and 2009 in our prospectively collected practice registry. Patients underwent two-stage treatment for infection, including removal of all implants and foreign material with implantation of an antibiotic-laden cement spacer in the first stage followed by intravenous culture-specific antibiotics for a minimum of 6 weeks. Second-stage reimplantation was performed if erythrocyte sedimentation rate and C-reactive protein were trending toward normal and the wound was well healed. Thirteen patients (13 hips) were lost to followup before 24 months. The minimum followup in surviving patients was 24 months or failure (average, 53 months; range, 24–180 months).


Fourteen patients (7%; 14 hips) died before reimplantation and two were not candidates because of medical comorbidities. The 90-day mortality rate after the first-stage débridement was 4% (eight patients). Of the 186 patients (189 hips) who underwent reimplantation, 157 (83%) achieved control of the infection. Including all patients who underwent the first stage, survival and infection control after two-stage reimplantation was 76%.


Two-stage treatment of deep infection in primary and revision THA is associated with substantial mortality and a substantial failure rate from both reinfection and inability to perform the second stage.

Level of Evidence

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


Infection Control Periprosthetic Joint Infection Synovial Fluid Analysis Infection Control Rate Durable Pain Relief 
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.
    Buttaro MA, Pusso R, Piccaluga F. Vancomycin-supplemented impacted bone allografts in infected hip arthroplasty. J Bone Joint Surg Br. 2005;87:314–319.PubMedCrossRefGoogle Scholar
  2. 2.
    Cabrita HB, Croci AT, de Camargo OP, de Lima ALLM. Prospective study of the treatment of infected hip arthroplasties with or without the use of an antibiotic-loaded cement spacer. Clinics (Sao Paulo). 2007;62:99–108.PubMedCrossRefGoogle Scholar
  3. 3.
    Cordero-Ampuero J, Esteban J, Garcia-Cimbrelo E. Oral antibiotics are effective for highly resistant hip arthroplasty infections. Clin Orthop Relat Res. 2009;467:2335–2342.PubMedCrossRefGoogle Scholar
  4. 4.
    Evans RP. Successful treatment of total hip and knee infection with articulating antibiotic components. Clin Orthop Relat Res. 2004;427:37–46.PubMedCrossRefGoogle Scholar
  5. 5.
    Fehring TK, Calton TF, Griffin WL. Cementless fixation in 2-stage reimplantation for periprosthetic sepsis. J Arthroplasty. 1999;14:175–181.PubMedCrossRefGoogle Scholar
  6. 6.
    Fink B, Grossmann A, Fuerst M, Schafer P, Fromelt L. Two-stage cementless revision of infected hip endoprostheses. Clin Orthop Relat Res. 2009;467:1848–1858.PubMedCrossRefGoogle Scholar
  7. 7.
    Garvin KL, Hanssen AD. Infection after total hip arthroplasty: past, present, and future. J Bone Joint Surg Am. 1995;77:1576–1588.PubMedGoogle Scholar
  8. 8.
    Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am. 1969;51:737–755.PubMedGoogle Scholar
  9. 9.
    Hofmann AA, Goldberg TD, Tanner AM, Cook TM. Ten-year experience using an articulating antibiotic cement hip spacer for the treatment of chronically infected total hip. J Arthroplasty. 2005;20:874–879.PubMedCrossRefGoogle Scholar
  10. 10.
    Incavo SJ, Russell RD, Mathis KB, Adams H. Initial results of managing severe bone loss in infected total joint arthroplasty using customized articulating spacers. J Arthroplasty. 2009;24:607–613.PubMedCrossRefGoogle Scholar
  11. 11.
    Katz JN, Losina E, Barrett J, Phillips CB, Mahomed NN, Lew RA, Guadagnoli E, Harris WH, Poss R, Baron JA. Association between hospital and surgeon procedure volume and outcomes of total hip replacement in the United States Medicare population. J Bone Joint Surg Am. 2001;83:1622–1629.PubMedCrossRefGoogle Scholar
  12. 12.
    Klouche S, Sariali E, Mamoudy P. Total hip arthroplasty revision due to infection: a cost analysis approach. Orthop Traumatol Surg Res. 2010;96:124–132.PubMedCrossRefGoogle Scholar
  13. 13.
    Koo K-H, Yang J-W, Cho S-H, Song H-R, Park H-B, Ha Y-C, Chang J-D, Kim S-Y, Kim Y-H. Impregnation of vancomycin, gentamicin, and cefotaxime in a cement spacer for two-stage cementless reconstruction in infected total hip arthroplasty. J Arthroplasty. 2001;16:882–892.PubMedCrossRefGoogle Scholar
  14. 14.
    Kurtz SM, Lau E, Schmier J, Ong KL, Zhao K, Parvizi J. Infection burden for hip and knee arthroplasty in the United States. J Arthroplasty. 2008;23:984–991.PubMedCrossRefGoogle Scholar
  15. 15.
    Lange J, Troelsen A, Thomsen RW, Soballe K. Chronic infections in hip arthroplasties: comparing risk of reinfection following one-stage and two-stage revision: a systematic review and meta-analysis. Clin Epidemiol. 2012;4:57–73.PubMedGoogle Scholar
  16. 16.
    Lee PTH, Clayton RA, Safir OA, Backstein DJ, Gross AE. Structural allograft as an option for treating infected hip arthroplasty with massive bone loss. Clin Orthop Relat Res. 2011;469:1016–1023.PubMedCrossRefGoogle Scholar
  17. 17.
    Leung F, Richards CJ, Garbuz DS, Masri BA, Duncan CP. Two-stage total hip arthroplasty: how often does it control methicillin-resistant infection? Clin Orthop Relat Res. 2011;469:1009–1015.PubMedCrossRefGoogle Scholar
  18. 18.
    Lieberman JR, Callaway GH, Salvati EA, Pellicci PM, Brause BD. Treatment of the infected total hip arthroplasty with a two-stage reimplantation protocol. Clin Orthop Relat Res. 1994;301:205–212.PubMedGoogle Scholar
  19. 19.
    Lim S-J, Park J-C, Moon Y-W, Park Y-S. Treatment of periprosthetic hip infection caused by resistant microorganisms using 2-stage reimplantation protocol. J Arthroplasty. 2009;24:1264–1269.PubMedCrossRefGoogle Scholar
  20. 20.
    Magnan B, Regis D, Biscaglia R, Barolozzi P. Preformed acrylic bone cement spacer loaded with antibiotics. Acta Orthop Scand. 2001;72:591–594.PubMedCrossRefGoogle Scholar
  21. 21.
    McDonald DJ, Fitzgerald RH, Ilstrup DM. Two-stage reconstruction of a total hip arthroplasty because of infection. J Bone Joint Surg Am. 1989;71:828–834.PubMedGoogle Scholar
  22. 22.
    Nestor BJ, Hanssen AD, Ferrer-Gonzalez R, Fitzgerald RH. The use of porous prosthesis in delayed reconstruction of total hip replacements that have failed because of infection. J Bone Joint Surg Am. 1994;76:349–359.PubMedGoogle Scholar
  23. 23.
    Nusem J, Morgan DAF. Structural allografts for bone stock reconstruction in two-stage revision for infected total hip arthroplasty. Acta Orthop. 2006;77:92–97.PubMedCrossRefGoogle Scholar
  24. 24.
    Pulido L, Ghanem E, Joshi A, Purtill JJ, Parvizi J. Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res. 2008;466:1710–1715.PubMedCrossRefGoogle Scholar
  25. 25.
    Romano CL, Romano D, Logoluso N, Meani E. Long-stem versus short-stem preformed antibiotic-loaded cement spacers for two stage revision of infected total hip arthroplasty. Hip Int. 2010;20:26–33.PubMedGoogle Scholar
  26. 26.
    Sanchez-Sotelo J, Berry DJ, Hanssen AD, Cabanela ME. Midterm to long-term followup of staged reimplantation for infected hip arthroplasty. Clin Orthop Relat Res. 2009;467:219–224.PubMedCrossRefGoogle Scholar
  27. 27.
    Scharfenberger A, Clark M, Lavoie G, O’Connor G, Masson E, Beaupre LA. Treatment of an infected total hip replacement with the PROSTALAC system. Part 1: infection resolution. Can J Surg. 2007;50:24–28.PubMedGoogle Scholar
  28. 28.
    Stockley I, Mockford BJ, Hoad-Reddick A, Norman P. The use of two-stage exchange arthroplasty with depot antibiotics in the absence of long-term antibiotic therapy in infected total hip replacement. J Bone Joint Surg Br. 2008;90:145–148.PubMedGoogle Scholar
  29. 29.
    Takigami I, Yoshiki I, Ishimaru D, Ogawa H, Mori N, Shimizu T, Terabayashi N, Shimizu K. Two-stage revision surgery for hip prosthesis infection using antibiotic-loaded porous hydroxyapatite blocks. Arch Orthop Trauma Surg. 2010;130:1221–1226.PubMedCrossRefGoogle Scholar
  30. 30.
    Toulson C, Walcott-Sapp S, Hur J, Salvati EA, Bostrum M, Brause BD, Westrich GH. Treatment of infected total hip arthroplasty with a 2-stage reimplantation protocol. J Arthroplasty. 2009;24:1051–1060.PubMedCrossRefGoogle Scholar
  31. 31.
    Tsukayama DT, Estrada R, Gustilo RB. Infection after total hip arthroplasty. J Bone Joint Surg Am. 1996;78:512–523.PubMedGoogle Scholar
  32. 32.
    Wang J-W, Chen C-E. Reimplantation of infected hip arthroplasties using bone allografts. Clin Orthop Relat Res. 1997;335:202–210.PubMedCrossRefGoogle Scholar
  33. 33.
    Whittaker JP, Warren RE, Jones RS, Gregson PA. Is prolonged systemic antibiotic treatment essential in two-stage revision hip replacement for chronic Gram-positive infection? J Bone Joint Surg Br. 2009;91:44–51.PubMedGoogle Scholar
  34. 34.
    Wolf CF, Gu NY, Doctor JN, Manner PA, Leopold SS. Comparison of one and two-stage revision of total hip arthroplasty complicated by infection. J Bone Joint Surg Am. 2011;93:631–639.PubMedCrossRefGoogle Scholar
  35. 35.
    Yamamoto K, Miyagawa N, Masaoka T, Katori Y, Shishido T, Imakiire A. Clinical effectiveness of antibiotic-impregnated cement spacers for the treatment of infected implants of the hip joint. J Orthop Sci. 2003;8:823–828.PubMedCrossRefGoogle Scholar
  36. 36.
    Younger ASE, Duncan CP, Masri BA, McGraw RW. The outcome of two-stage arthroplasty using a custom-made interval spacer to treat the infected hip. J Arthroplasty. 1997;12:615–623.PubMedCrossRefGoogle Scholar
  37. 37.
    Zhan C, Kaczmarek R, Loyo-Berrios N, Sangl J, Bright RA. Incidence and short-term outcomes of primary and revision hip replacement in the United States. J Bone Joint Surg Am. 2007;89:526–533.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2012

Authors and Affiliations

  • Keith R. Berend
    • 1
    • 2
    • 3
    Email author
  • Adolph V. LombardiJr
    • 1
    • 2
    • 3
    • 4
  • Michael J. Morris
    • 1
    • 3
  • Adam G. Bergeson
    • 1
    • 3
  • Joanne B. Adams
    • 1
  • Michael A. Sneller
    • 1
  1. 1.Joint Implant Surgeons, IncNew AlbanyUSA
  2. 2.Department of OrthopaedicsThe Ohio State UniversityColumbusUSA
  3. 3.Mount Carmel Health SystemNew AlbanyUSA
  4. 4.Department of Biomedical EngineeringThe Ohio State UniversityColumbusUSA

Personalised recommendations