Periprosthetic Infection: Revision Arthroplasty

  • Eustathios Kenanidis
  • Iakovos Vlastos
  • Fares E. Sayegh
  • Eleftherios Tsiridis
  • Rihard Trebše
  • Luigi Zagra
  • Eleonora Caboni
  • Gösta Ullmark


It is a severe complication of TJA with laborious management [1]. The main characteristics of the disease that compromise the treatment are:
  1. 1.
    The heterogeneity of the disease concerning:
    1. (a)

      Species and sensitivity of the bacteria involved among countries and hospitals

    2. (b)

      Patient’s characteristics

    3. (c)

      Lack of uniform classification

    4. (d)

      The timing of infection and local tissue presentation

    5. (e)

      Diagnosis of the disease

    6. (f)

      Creation of a universal effective treatment protocol

  2. 2.
    The existing studies:
    1. (a)

      Lack of high-quality prospective randomized studies [2].

    2. (b)

      Studies are mainly focused on the time free of infection but not to the functional improvement and mechanical failure [3].

    3. (c)

      The recent meta-analyses are based on data of low-quality previous studies where the virulence of microbes was different [3].



  1. 1.
    Enayatollahi MA, Parvizi J. Diagnosis of infected total hip arthroplasty. Hip Int. 2015;25(4):294–300.CrossRefPubMedGoogle Scholar
  2. 2.
    Senthi S, Munro JT, Pitto RP. Infection in total hip replacement: meta-analysis. International Orthopaedics. 2011;35:253–60.CrossRefPubMedGoogle Scholar
  3. 3.
    Karachalios T, Koutalos A, Komnos G. Management strategies for infected total hip arthroplasty. A critical appreciation of problems and techniques. Hip Int. 2014;24(Suppl 10):S44–S4.CrossRefPubMedGoogle Scholar
  4. 4.
    Pivec R, Johnson AJ, Mears SC, Mont MA. Hip arthroplasty. Lancet. 2012;380(9855):1768–77.CrossRefPubMedGoogle Scholar
  5. 5.
    Kuzyk PRT, Dhotar HS, Sternheim A, Gross AE, Safir O, Backstein D. Two-stage revision arthroplasty for management of chronic periprosthetic hip and knee infection: techniques, controversies, and outcomes. J Am Acad Orthop Surg. 2014;22:153–64.CrossRefPubMedGoogle Scholar
  6. 6.
    Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780–5.PubMedGoogle Scholar
  7. 7.
    Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am. 2009;91(1):128–33.CrossRefPubMedGoogle Scholar
  8. 8.
    Jafari SM, Coyle C, Mortazavi SMJ, Sharkey PF, Parvizi J. Revision hip arthroplasty: infection is the most common cause of failure. Clin Orthop Relat Res. 2010;468(8):2046–51.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Ong KL, Kurtz SM, Lau E, Bozic KJ, Berry DJ, Parvizi J. Prosthetic joint infection risk after total hip arthroplasty in the Medicare population. J Arthroplast. 2009;24(6):105–9.CrossRefGoogle Scholar
  10. 10.
    Parvizi J, Zmistowski B, Berbari EF, et al. New definition for Periprosthetic joint infection: from the workgroup of the musculoskeletal infection society. Clin Orthop Relat Res. 2011;469(11):2992–4.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Zmistowski B, Della Valle C, Bauer TW, et al. Diagnosis of Periprosthetic joint infection. J Arthroplast. 2014;29(2):77–83.CrossRefGoogle Scholar
  12. 12.
    CDC - ACH Surveillance for Surgical Site Infection (SSI) Event - NHSN. Accessed 07 Mar 2015.
  13. 13.
    Della Valle C, Parvizi J, Bauer TW. American Academy of Orthopaedic Surgeons. et al. Diagnosis of periprosthetic joint infections of the hip and knee. J Am Acad Orthop Surg. 2010;18(12):760–70.CrossRefPubMedGoogle Scholar
  14. 14.
    Ghanem E, Antoci V Jr, Pulido L, Joshi A, Hozack W, Parvizi J. The use of receiver operating characteristics analysis in determining erythrocyte sedimentation rate and C-reactive protein levels in diagnosing periprosthetic infection prior to revision total hip arthroplasty. Int J Infect Dis. 2009;13(6):e444–9.CrossRefPubMedGoogle Scholar
  15. 15.
    Urquhart DM, Hanna FS, Brennan SL, Wluka AE, Leder K, Cameron PA, Graves SE, Cicuttini FM. Incidence and risk factors for deep surgical site infection after primary total hip arthroplasty: a systematic review. J Arthroplast. 2010;25(8):1216–22.CrossRefGoogle Scholar
  16. 16.
    Schinsky MF, Della Valle CJ, Sporer SM, Paprosky WG. Perioperative testing for joint infection in patients undergoing revision total hip arthroplasty. J Bone Joint Surg Am. 2008;90(9):1869–75.CrossRefPubMedGoogle Scholar
  17. 17.
    Cipriano CA, Brown NM, Michael AM, Moric M, Sporer SM, Della Valle CJ. Serum and synovial fluid analysis for diagnosing chronic periprosthetic infection in patients with inflammatory arthritis. J Bone Joint Surg Am. 2012;94(7):594–600.CrossRefPubMedGoogle Scholar
  18. 18.
    Parvizi J, Jacovides C, Antoci V, Ghanem E. Diagnosis of periprosthetic joint infection: the utility of a simple yet unappreciated enzyme. J Bone Joint Surg Am. 2011;93(24):2242–8.CrossRefPubMedGoogle Scholar
  19. 19.
    Deirmengian C, Kardos K, Kilmartin P, et al. The alpha-defensin test for periprosthetic joint infection outperforms the leukocyte esterase test strip. Clin Orthop Relat Res. 2015;473(1):198–203.CrossRefPubMedGoogle Scholar
  20. 20.
    Schäfer P, Fink B, Sandow D, Margull A, Berger I, Frommelt L. Prolonged bacterial culture to identify late periprosthetic joint infection: a promising strategy. Clin Infect Dis. 2008;47(11):1403–9.CrossRefPubMedGoogle Scholar
  21. 21.
    Shahi A, Deirmengian C, Higuera C, et al. Premature therapeutic antimicrobial treatments can compromise the diagnosis of late periprosthetic joint infection. Clin Orthop Relat Res. 2015;473(7):2244–9.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Tsaras G, Maduka-Ezeh A, Inwards CY, et al. Utility of intraoperative frozen section histopathology in the diagnosis of periprosthetic joint infection: a systematic review and metaanalysis. J Bone Joint Surg Am. 2012;94(18):1700–11.CrossRefPubMedGoogle Scholar
  23. 23.
    Diaz-Ledezma C, Lamberton C, Lichstein P, Parvizi J. Diagnosis of periprosthetic joint infection: the role of nuclear medicine may be overestimated. J Arthroplast. 2015;30(6):1044–9.CrossRefGoogle Scholar
  24. 24.
    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;78:512–23.CrossRefPubMedGoogle Scholar
  25. 25.
    Toms AD, Davidson D, Masri BA, Duncan CP. The management of peri-prosthetic infection in total joint replacement. J Bone Joint Surg Br. 2006;88:149–55.CrossRefPubMedGoogle Scholar
  26. 26.
    Krismer M. Definition of infection. Hip Int. 2012;22(Suppl 8):S2–4.CrossRefPubMedGoogle Scholar
  27. 27.
    Trebse R, Pisot V, Trampuz A. Treatment of infected retained implants. J Bone Joint Surg Br. 2005;87(2):249–56.CrossRefPubMedGoogle Scholar
  28. 28.
    Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med. 2004;351(16):1645–54.CrossRefPubMedGoogle Scholar
  29. 29.
    Byren I, Bejon P, Atkins BL, Angus B, Masters S, McLardy-Smith P, Gundle R, Berendt A. One hundred and twelve infected arthroplasties treated with ‘DAIR’ (debridement, antibiotics and implant retention): antibiotic duration and outcome. J Antimicrob Chemother. 2009;63:1264–71.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Estes CS, Beauchamp CP, Clarke HD, Spangehl MJ. A two-stage retention débridement protocol for acute Periprosthetic joint infections. Clin Orthop Relat Res. 2010;468:2029–38.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Chen AF, Heller S, Parvizi J. Prosthetic joint infections. Surg Clin North Am. 2014;94(6):1265–81.CrossRefPubMedGoogle Scholar
  32. 32.
    Jackson WO, Schmalzried TP. Limited role of direct exchange arthroplasty in the treatment of infected total hip replacements. Clin Orthop Relat Res. 2000;381:101–5.CrossRefGoogle Scholar
  33. 33.
    Rudelli S, Uip D, Honda E, Lima ALLM. One-stage revision of infected total hip arthroplasty with bone graft. J Arthroplast. 2008;23:1165–77.CrossRefGoogle Scholar
  34. 34.
    Winkler H, Stoiber A, Kaudela K, Winter F, Menschik F. One stage uncemented revision of infected total hip replacement using cancellous allograft bone impregnated with antibiotics. J Bone Joint Surg Br. 2008;90:1580–5.CrossRefPubMedGoogle Scholar
  35. 35.
    Yoo JJ, Kwon YS, Koo KH, Yoon KS, Kim YM, Kim HJ. One-stage cementless revision arthroplasty for infected hip replacements. Int Orthop. 2009;33:1195–201.CrossRefPubMedGoogle Scholar
  36. 36.
    Camurcu Y, Sofu H, Buyuk AF, Gursu S, Kaygusuz MA, Sahin V. Two-stage cementless revision total hip arthroplasty for infected primary hip arthroplasties. J Arthroplast. 2015;30:1597–601.CrossRefGoogle Scholar
  37. 37.
    Luu A, Syed F, Raman G, Bhalla A, Muldoon E, Hadley S, Smith E, Rao M. Two-stage arthroplasty for prosthetic joint infection a systematic review of acute kidney injury, systemic toxicity and infection. J Arthroplast. 2013;28:1490–8.CrossRefGoogle Scholar
  38. 38.
    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(2):145–8.CrossRefPubMedGoogle Scholar
  39. 39.
    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;91:44–5.CrossRefPubMedGoogle Scholar
  40. 40.
    McKenna PB, O’Shea K, Masterson EL. Two-stage revision of infected hip arthroplasty using a shortened postoperative course of antibiotics. Arch Orthop Trauma Surg. 2009;129:489–94.CrossRefPubMedGoogle Scholar
  41. 41.
    Hsieh PH, Shih CH, Chang YH, Lee MS, Shih HN, Yang WE. Two-stage revision hip arthroplasty for infection: comparison between the interim use of antibiotic-loaded cement beads and a spacer prosthesis. J Bone Joint Surg Am. 2004;86:1989.CrossRefPubMedGoogle Scholar
  42. 42.
    Leonard HAC, Liddle AD, Burke O, Murray DW, Pandit H. Single- or two-stage revision for infected total hip arthroplasty? A systematic review of the literature. Clin Orthop Relat Res. 2014;472:1036–42.CrossRefPubMedGoogle Scholar
  43. 43.
    Kunutsor SK, Whitehouse MR, Blom AW, Beswick AD. INFORM team Re-infection outcomes following one- and two-stage surgical revision of infected hip prosthesis: a systematic review and meta- analysis. Plos One. 2015; doi: 10.1371/journal.pone.0139166.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Lange J, Troelsen A, Thomsen RW, Søballe 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.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Engesæter LB, Dale H, Schrama JC, Hallan G, Lie SA. Surgical procedures in the treatment of 784 infected THAs reported to the Norwegian Arthroplasty register. Acta Orthop. 2011;82(5):530–7.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Beswick AD, Elvers KT, Smith AJ, Gooberman-Hill R, Lovering A, Blom AW. What is the evidence base to guide surgical treatment of infected hip prostheses? Systematic review of longitudinal studies in unselected patients. BMC Med. 2012;10(1):18.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    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(6):823–8.CrossRefPubMedGoogle Scholar
  48. 48.
    Barrack RL. Rush pin technique for temporary antibiotic-impregnated cement prosthesis for infected total hip arthroplasty. J Arthroplast. 2002;17(5):600–3.CrossRefGoogle Scholar
  49. 49.
    Durbhakula SM, Czajka J, Fuchs MD, Uhl RL. Spacer endoprosthesis for the treatment of infected total hip arthroplasty. J Arthroplast. 2004;19(6):760–7.CrossRefGoogle Scholar
  50. 50.
    Hsieh PH, Chen LH, Chen CH, Lee MS, Yang WE, Shih CH. Two-stage revision arthroplasty for infection with a custom made, antibiotic-loaded, cement prosthesis as an interim spacer. J Trauma. 2004;56(6):1247–52.CrossRefPubMedGoogle Scholar
  51. 51.
    Pattyn C, De Geest T, Ackerman P, Audenaert E. Preformed gentamicin spacers in two-stage revision hip arthroplasty: functional results and complications. Int Orthop. 2011;35(10):1471–6.CrossRefPubMedGoogle Scholar
  52. 52.
    D’Angelo F, Negri L, Binda T, Zatti G, Cherubino P. The use of a preformed spacer in two-stage revision of infected hip arthroplasties. Musculoskelet Surg. 2011;95(2):115–20.CrossRefPubMedGoogle Scholar
  53. 53.
    Jung J, Schmid NV, Kelm J, Schmitt E, Anagnostakos K. Complications after spacer implantation in the treatment of hip joint infections. Int J Med Sci. 2009;6(5):265–73.CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    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;50:24–8.PubMedPubMedCentralGoogle Scholar
  55. 55.
    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 Arthroplast. 2005;20:874–9.CrossRefGoogle Scholar
  56. 56.
    Iarikov D, Demian H, Rubin D, Alexander J, Nambiar S. Choice and doses of antibacterial agents for cement spacers in treatment of prosthetic joint infections: review of published studies. Clin Infect Dis. 2012;55(11):1474–80.CrossRefPubMedGoogle Scholar
  57. 57.
    Trebše R. The diagnostic protocol for evaluation of periprosthetic joint infection. Hip Int. 2012;22(Suppl. 8):S25–35.CrossRefPubMedGoogle Scholar
  58. 58.
    Sendi P, Frei R, Maurer TB, Trampuz A, Zimmerli W, Graber P. Escherichia coli variants in periprosthetic joint infections: diagnostic challenges with sessile bacteria and sonication. J Clin Mic. 2010;48:1720–5.CrossRefGoogle Scholar
  59. 59.
    Zahar A, Gehrke TA. One stage revision for infected total hip arthroplasty. Orthop Clin North Am. 2016;47(1):11–8.CrossRefPubMedGoogle Scholar
  60. 60.
    Ilchmann T, Zimmerli W, Ochsner PE, Kessler B, Zwicky L, Graber P, Clauss M. One stage revision of infected hip arthroplasty. Outcome of 39 consecutive hips. Int Orthop. 2016;40(5):913–8.CrossRefPubMedGoogle Scholar
  61. 61.
    Wolf M, Clar H, Friesenbichler J, Schwantzer G, Bernhardt G, Gruber G, Glehr M, Leithner A, Sadoghi P. Prosthetic joint infection following total hip replacement: results of one-stage versus two-stage exchange. Int Orthop. 2014;38(7):1363–8. doi: 10.1007/s00264-014-2309-y.CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    van Diemen MP, Colen S, Dalemans AA, Stuyck J, Mulier M. Two-stage revision of an infected total hip arthroplasty: a follow-up of 136 patients. Hip Int. 2013;23(5):445–50. doi: 10.5301/hipint.5000049.CrossRefPubMedGoogle Scholar
  63. 63.
    Ullmark G, Hovelius L, Strindberg L, Wallner A. Reduced bleeding through temporary balloon occlusion in hip and knee revision surgery. Acta Orthop Scand. 2000;71(1):51–4.CrossRefPubMedGoogle Scholar
  64. 64.
    Ullmark G, Hallin G, Nilsson O. Impacted corticocancellous allografts and cement for femoral revision of total hip arthroplasty using Lubinus and Charnley prostheses. J Arthroplasty. 2002;17(3):325–34.CrossRefPubMedGoogle Scholar
  65. 65.
    Ullmark G, Obrant KJ. Histology of impacted bone-graft incorporation. J Arthroplasty. 2002;17(2):150–7.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Eustathios Kenanidis
    • 1
  • Iakovos Vlastos
    • 1
  • Fares E. Sayegh
    • 2
  • Eleftherios Tsiridis
    • 2
  • Rihard Trebše
    • 3
  • Luigi Zagra
    • 4
  • Eleonora Caboni
    • 4
  • Gösta Ullmark
    • 5
    • 6
  1. 1.Academic Orthopaedic UnitAristotle University Medical SchoolThessalonikiGreece
  2. 2.Academic Orthopaedic UnitPapageorgiou General Hospital, Aristotle University Medical SchoolThessalonikiGreece
  3. 3.Valdoltra Orthopedic HospitalAnkaranSlovenia
  4. 4.Hip DepartmentIstituto Ortopedico Galeazzi IRCCSMilanItaly
  5. 5.Uppsala UniversityUppsalaSweden
  6. 6.Department of OrthopaedicGävle hospitalGävleSweden

Personalised recommendations