Clinical Orthopaedics and Related Research®

, Volume 471, Issue 10, pp 3214–3222 | Cite as

Outcome of One-stage Cementless Exchange for Acute Postoperative Periprosthetic Hip Infection

  • Erik Hansen
  • Matthew Tetreault
  • Benjamin Zmistowski
  • Craig J. Della Valle
  • Javad ParviziEmail author
  • Fares S. Haddad
  • William J. Hozack
Symposium: 2012 Musculoskeletal Infection Society



Acute postoperative infection after total hip arthroplasty (THA) is typically treated with irrigation and débridement and exchange of the modular femoral head and acetabular liner. Given a rate of failure exceeding 50% in some series, a one-stage exchange has been suggested as a potential alternative because it allows more thorough débridement and removal of colonized implants. To date, most studies published on the one-stage exchange have used microbe-specific antibiotic-laden bone cement with only one small single-institution series that reported outcomes after a cementless one-stage exchange.


We determined whether a one-stage cementless exchange for treating acute postoperative infection after THA would result in infection control with component retention and normalization of infection markers.


We retrospectively identified 27 patients who underwent a one-stage exchange performed for an acute (≤ 6 weeks) postoperative infection after THA from April 2004 to December 2009. Primary cementless components were used both at the time of the index arthroplasty and the revision in all patients. Surgery was followed by a 6-week course of culture-specific antibiotics in all patients and a variable course of oral antibiotics. Our primary outcome was retention of the implants at most recent followup and our secondary outcome was normalization of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) at most recent followup. Patients were followed until failure or a minimum of 2 years.


At a minimum followup of 27 months (mean, 50 months; range, 27–89 months), 19 of the 27 patients (70%) retained their implants but four required further operative débridement with component retention at a mean of 3 weeks (range, 2–6 weeks) to obtain control of infection. Thus, an isolated single-stage exchange was successful in 15 of the 27 patients (56%). Eight patients (30%) ultimately had a two-stage exchange for persistent infection; seven of these patients required no further surgery, whereas one patient required a second two-stage exchange. Of those patients retaining their prosthesis after one-stage exchange and tracked with ESR and CRP, four (33% [four of 12]) had elevated values without other signs or symptoms of recurrent infection.


For acute postoperative infection after primary THA, a one-stage cementless exchange allowed 70% of patients to retain their implants at most recent followup. Of those patients who ultimately went on to a two-stage exchange, only one required a second two-stage exchange.

Level of Evidence

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


Periprosthetic Joint Infection Elevate Erythrocyte Sedimentation Rate Recent Followup Primary Implant Cementless Fixation 
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.



We thank Richard Berger MD, for contributing cases to this clinical series.


  1. 1.
    Aboltins CA, Page MA, Buising KL, Jenney AW, Daffy JR, Choong PF, Stanley PA. Treatment of staphylococcal prosthetic joint infections with débridement, prosthesis retention and oral rifampicin and fusidic acid. Clin Microbiol Infect. 2007;13:586–591.PubMedCrossRefGoogle Scholar
  2. 2.
    Arciola CR, Campoccia D, Speziale P, Montanaro L, Costerton JW. Biofilm formation in Staphylococcus implant infections. A review of molecular mechanisms and implications for biofilm-resistant materials. Biomaterials. 2012;33:5967–5982.PubMedCrossRefGoogle Scholar
  3. 3.
    Azzam KA, Seeley M, Ghanem E, Austin MS, Purtill JJ, Parvizi J. Irrigation and débridement in the management of prosthetic joint infection: traditional indications revisited. J Arthroplasty. 2010;25:1022–1027.PubMedCrossRefGoogle Scholar
  4. 4.
    Bedair H, Ting N, Bozic KJ, Della Valle CJ, Sporer SM. Treatment of early postoperative infections after THA: a decision analysis. Clin Orthop Relat Res. 2011;469:3477–3485.PubMedCrossRefGoogle Scholar
  5. 5.
    Bedair H, Ting N, Jacovides C, Saxena A, Moric M, Parvizi J, Della Valle CJ. The Mark Coventry Award: diagnosis of early postoperative TKA infection using synovial fluid analysis. Clin Orthop Relat Res. 2011;469:34–40.PubMedCrossRefGoogle Scholar
  6. 6.
    Berry DJ, Bozic KJ. Current practice patterns in primary hip and knee arthroplasty among members of the American Association of Hip and Knee Surgeons. J Arthroplasty. 2010;25:2–4.PubMedCrossRefGoogle Scholar
  7. 7.
    Bradbury T, Fehring TK, Taunton M, Hanssen A, Azzam K, Parvizi J, Odum SM. The fate of acute methicillin-resistant Staphylococcus aureus periprosthetic knee infections treated by open débridement and retention of components. J Arthroplasty. 2009;24:101–104.PubMedCrossRefGoogle Scholar
  8. 8.
    Brandt CM, Sistrunk WW, Duffy MC, Hanssen AD, Steckelberg JM, Ilstrup DM, Osmon DR. Staphylococcus aureus prosthetic joint infection treated with débridement and prosthesis retention. Clin Infect Dis. 1997;24:914–919.PubMedCrossRefGoogle Scholar
  9. 9.
    Brigden ML. Clinical utility of the erythrocyte sedimentation rate. Am Fam Physician. 1999;60:1443–1450.PubMedGoogle Scholar
  10. 10.
    Buchholz HW, Elson RA, Engelbrecht E, Lodenkamper H, Rottger J, Siegel A. Management of deep infection of total hip replacement. J Bone Joint Surg Br. 1981;63:342–353.PubMedGoogle Scholar
  11. 11.
    Callaghan JJ, Katz RP, Johnston RC. One-stage revision surgery of the infected hip. A minimum 10-year followup study. Clin Orthop Relat Res. 1999;369:139–143.PubMedCrossRefGoogle Scholar
  12. 12.
    Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–383.PubMedCrossRefGoogle Scholar
  13. 13.
    Crockarell JR, Hanssen AD, Osmon DR, Morrey BF. Treatment of infection with débridement and retention of the components following hip arthroplasty. J Bone Joint Surg Am. 1998;80:1306–1313.PubMedGoogle Scholar
  14. 14.
    Deirmengian C, Greenbaum J, Lotke PA, Booth RE Jr, Lonner JH. Limited success with open debridement and retention of components in the treatment of acute Staphylococcus aureus infections after total knee arthroplasty. J Arthroplasty. 2003;18:22–26.PubMedCrossRefGoogle Scholar
  15. 15.
    Hartman MB, Fehring TK, Jordan L, Norton HJ. Periprosthetic knee sepsis. The role of irrigation and débridement. Clin Orthop Relat Res. 1991;273:113–118.PubMedGoogle Scholar
  16. 16.
    Jackson WO, Schmalzried TP. Limited role of direct exchange arthroplasty in the treatment of infected total hip replacements. Clin Orthop Relat Res. 2000;381:101–105.PubMedCrossRefGoogle Scholar
  17. 17.
    Kilgus DJ, Howe DJ, Strang A. Results of periprosthetic hip and knee infections caused by resistant bacteria. Clin Orthop Relat Res. 2002;404:116–124.PubMedCrossRefGoogle Scholar
  18. 18.
    Koyonos L, Zmistowski B, Della Valle CJ, Parvizi J. Infection control rate of irrigation and débridement for periprosthetic joint infection. Clin Orthop Relat Res. 2011;469:3043–3048.PubMedCrossRefGoogle Scholar
  19. 19.
    Kurd MF, Ghanem E, Steinbrecher J, Parvizi J. Two-stage exchange knee arthroplasty: does resistance of the infecting organism influence the outcome? Clin Orthop Relat Res. 2010;468:2060–2066.PubMedCrossRefGoogle Scholar
  20. 20.
    Marculescu CE, Berbari EF, Hanssen AD, Steckelberg JM, Harmsen SW, Mandrekar JN, Osmon DR. Outcome of prosthetic joint infections treated with débridement and retention of components. Clin Infect Dis. 2006;42:471–478.PubMedCrossRefGoogle Scholar
  21. 21.
    Mittal Y, Fehring TK, Hanssen A, Marculescu C, Odum SM, Osmon D. Two-stage reimplantation for periprosthetic knee infection involving resistant organisms. J Bone Joint Surg Am. 2007;89:1227–1231.PubMedCrossRefGoogle Scholar
  22. 22.
    Odum SM, Fehring TK, Lombardi AV, Zmistowski BM, Brown NM, Luna JT, Fehring KA, Hansen EN. Irrigation and débridement for periprosthetic infections: does the organism matter? J Arthroplasty. 2011;26:114–118.PubMedCrossRefGoogle Scholar
  23. 23.
    Oussedik SI, Dodd MB, Haddad FS. Outcomes of revision total hip replacement for infection after grading according to a standard protocol. J Bone Joint Surg Br. 2010;92:1222–1226.PubMedGoogle Scholar
  24. 24.
    Paprosky WG, Perona PG, Lawrence JM. Acetabular defect classification and surgical reconstruction in revision arthroplasty. A 6-year follow-up evaluation. J Arthroplasty. 1994;9:33–44.PubMedCrossRefGoogle Scholar
  25. 25.
    Paprosky WW. Femoral defect classification: clinical application. Orthop Rev. 1990;19(Suppl 9):929–932.Google Scholar
  26. 26.
    Parvizi J, Ghanem E, Menashe S, Barrack RL, Bauer TW. Periprosthetic infection: what are the diagnostic challenges? J Bone Joint Surg Am. 2006;88(Suppl 4):138–147.PubMedCrossRefGoogle Scholar
  27. 27.
    Sherrell JC, Fehring TK, Odum S, Hansen E, Zmistowski B, Dennos A, Kalore N. The Chitranjan Ranawat Award: fate of two-stage reimplantation after failed irrigation and débridement for periprosthetic knee infection. Clin Orthop Relat Res. 2011;469:18–25.PubMedCrossRefGoogle Scholar
  28. 28.
    Silva M, Tharani R, Schmalzried TP. Results of direct exchange or débridement of the infected total knee arthroplasty. Clin Orthop Relat Res. 2002;430:125–131.CrossRefGoogle Scholar
  29. 29.
    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
  30. 30.
    Ure KJ, Amstutz HC, Nasser S, Schmalzried TP. Direct-exchange arthroplasty for the treatment of infection after total hip replacement. An average ten-year follow-up. J Bone Joint Surg Am. 1998;80:961–968.PubMedGoogle Scholar
  31. 31.
    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
  32. 32.
    Wroblewski BM. One-stage revision of infected cemented total hip arthroplasty. Clin Orthop Relat Res. 1986;211:103–107.PubMedGoogle Scholar
  33. 33.
    Yamada H, Yoshihara Y, Henmi O, Morita M, Shiromoto Y, Kawano T, Kanaji A, Ando K, Nakagawa M, Kosaki N, Fukaya E. Cementless total hip replacement: past, present, and future. J Orthop Sci. 2009;14:228–241.PubMedCrossRefGoogle Scholar
  34. 34.
    Yoo JJ, Kwon YS, Koo KH, Yoon KS, Kim YM, Kim HJ. One-stage cementless revision arthroplasty for infected hip replacements. Int Orthop. 2009;33:1195–1201.PubMedCrossRefGoogle Scholar
  35. 35.
    Yudkin JS, Stehouwer CD, Emeis JJ, Coppack SW. C-reactive protein in healthy subjects: associations with obesity, insulin resistance, and endothelial dysfunction: a potential role for cytokines originating from adipose tissue? Arterioscler Thromb Vasc Biol. 1999;19:972–978.PubMedCrossRefGoogle Scholar
  36. 36.
    Zmistowski B, Fedorka CJ, Sheehan E, Deirmengian G, Austin MS, Parvizi J. Prosthetic joint infection caused by Gram-negative organisms. J Arthroplasty. 2011;26:104–108.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2013

Authors and Affiliations

  • Erik Hansen
    • 1
  • Matthew Tetreault
    • 2
  • Benjamin Zmistowski
    • 1
  • Craig J. Della Valle
    • 2
  • Javad Parvizi
    • 1
    Email author
  • Fares S. Haddad
    • 3
  • William J. Hozack
    • 1
  1. 1.Rothman Institute of Orthopedics at Thomas Jefferson University HospitalPhiladelphiaUSA
  2. 2.Rush University Medical CenterChicagoUSA
  3. 3.University College HospitalLondonUK

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