Skip to main content
SpringerLink
Log in

Two-stage Cementless Revision of Infected Hip Endoprostheses

  • Original Article
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Cementless two-stage revision of infected total hip prostheses lacks the possibility of local antibiotic protection of the implant at the time of reimplantation, which leads to the concern that this protocol may not sufficiently eradicate periprosthetic infection. Moreover, early implant loosening as much as 18% and stem subsidence as much as 30% have been reported. To determine whether a cementless revision could eradicate infection and achieve sufficient implant stability, we prospectively followed 36 patients with two-stage revisions for septic hip prostheses. We used a uniform protocol of a 6-week spacer interval, specific local and systemic antibiotic therapies, and cementless modular revision stems. The minimum followup was 24 months (mean, 35 months; range, 24–60 months). In one patient, the spacer was changed when the C-reactive protein value failed to normalize after 6 weeks, and the reimplantation was performed after an additional 6 weeks. No infections recurred. There was no implant loosening and a 94% bone-ingrowth fixation of stems. Subsidence occurred in two patients. The Harris hip score increased from a preoperative mean of 41 to 90 at 12 months after reimplantation and later. Using cementless prostheses in two-stage revisions of periprosthetic infections of the hip in combination with a specific local and systemic antibiotic therapy seems to eradicate infection and provide implant stability.

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

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1A–D
Fig. 2A–F

Similar content being viewed by others

References

  1. Ali F, Wilkinson JM, Cooper JR, Kerry RM, Hamer AJ, Norman P, Stockley I. Accuracy of joint aspiration for the preoperative diagnosis of infection in total hip arthroplasty. J Arthroplasty. 2006;21:221–226.

    Article  PubMed  Google Scholar 

  2. Atkins BL, Athanasou N, Deeks JJ, Crook DW, Simpson H, Peto TE, McLardy-Smith P, Berendt AR. Prospective evaluation of criteria for microbiological diagnosis of prosthetic-joint infection at revision arthroplasty. J Clin Microbiol. 1998;36:2932–2939.

    PubMed  CAS  Google Scholar 

  3. Böhm P, Bischel O. Femoral revision with the Wagner SL revision stem: evaluation of one hundred and twenty-nine revisions followed for a mean of 4.8 years. J Bone Joint Surg Am. 2001;83:1023–1031.

    Article  PubMed  Google Scholar 

  4. Böhm P, Bischel O. The uncemented diaphyseal fixation of femoral revision stems in case of large bone defects: analysis of twelve years experience with the Wagner SL revision stem [in German]. Z Orthop Ihre Grenzgeb. 2001;139:229–239.

    Article  PubMed  Google Scholar 

  5. Böhm P, Bischel O. The use of tapered stems for femoral revision surgery. Clin Orthop Relat Res. 2004;420:148–159.

    Article  PubMed  Google Scholar 

  6. Callaghan JJ, Salvati EA, Pellicci PM, Wilson PD, Ranawat CS. Results of revision for mechanical failure after cemented total hip replacement, 1979 to 1982: a two to five-year follow-up. J Bone Joint Surg Am. 1985;67:1074–1085.

    PubMed  CAS  Google Scholar 

  7. Cordero-Ampuero J, Garcia-Cimbrelo E, Munuera L. Fixation of cementless acetabular cups: a radiographic 4-8-year study of 102 porous-coated components. Acta Orthop Scand. 1994;65:263–266.

    PubMed  CAS  Google Scholar 

  8. Costerton JW. Biofilm theory can guide the treatment of device-related orthopaedic infections. Clin Orthop Relat Res. 2005;437:7–11.

    Article  PubMed  Google Scholar 

  9. Cui Q, Mihalko WM, Shields JS, Ries M, Saleh HJ. Antibiotic-impregnated cement spacers for the treatment of infection associated with total hip or knee arthroplasty. J Bone Joint Surg Am. 2007;89:871–882.

    Article  PubMed  Google Scholar 

  10. DeLee JG, Charnley J. Radiological demarcation of cementless sockets in total hip replacement. Clin Orthop Relat Res. 1976;121:20–32.

    PubMed  Google Scholar 

  11. Dohmae Y, Bechthold JE, Sherman RE, Puno RM, Gustilo RB. Reduction in cement-bone interface shear strength between primary and revision arthroplasty. Clin Orthop Relat Res. 1988;236:214–220.

    PubMed  Google Scholar 

  12. Duncan CP, Masri BA. The role of antibiotic-loaded cement in the treatment of an infection after a hip replacement. Instr Course Lect. 1995;44:305–313.

    PubMed  CAS  Google Scholar 

  13. Engh CA, Glassman AH, Suthers KE. The case of porous-coated hip implants: the femoral side. Clin Orthop Relat Res. 1990;261:63–81.

    PubMed  Google Scholar 

  14. Ensing GT, van Horn JR, van der Mei HC, Busscher HJ, Neut D. Copal bone cement is more effective in preventing biofilm formation than Palacos R-G. Clin Orthop Relat Res. 2008;466:1492–1498.

    Article  PubMed  Google Scholar 

  15. Evans RP. Successful treatment of total hip and knee infection with articulating antibiotic components: a modified treatment method. Clin Orthop Relat Res. 2004;427:37–46.

    Article  PubMed  Google Scholar 

  16. Fehring TK, Calton TF, Griffin WL. Cementless fixation in 2-stage reimplantation for periprosthetic sepsis. J Arthroplasty. 1999;14:175–181.

    Article  PubMed  CAS  Google Scholar 

  17. Feldman DS, Lonner JH, Desai P, Zuckerman JD. The role of intraoperative frozen sections in revision total joint arthroplasty. J Bone Joint Surg Am. 1995;77:1807–1813.

    PubMed  CAS  Google Scholar 

  18. Fink B, Grossmann A, Schubring S, Schulz MS, Fuerst M. A modified transfemoral approach using modular cementless revision stems. Clin Orthop Relat Res. 2007;462:105–114.

    Article  PubMed  Google Scholar 

  19. Fink B, Grossmann A, Schubring S, Schulz MS, Fuerst M. Short-term results of hip revisions with a curved cementless modular stem in association with the surgical approach. Arch Orthop Trauma Surg. 2008 April 4. [Epub ahead of print].

  20. Fink B, Hahn M, Fuerst M, Thybaut L, Delling G. Principle of fixation of the cementless modular revision stem Revitan. Unfallchirurg. 2005;108:1029–1037.

    Article  PubMed  CAS  Google Scholar 

  21. Fink B, Makowiak C, Fuerst M, Berger I, Schäfer P, Frommelt L. The value of synovial biopsy, joint aspiration and C-reactive protein in the diagnosis of late peri-prosthetic infection of total knee replacements. J Bone Joint Surg Br. 2008;90:874–878.

    Article  PubMed  CAS  Google Scholar 

  22. Fitzgerald RH Jr. Infected total hip arthroplasty: diagnosis and treatment. J Am Acad Orthop Surg. 1995;3:249–262.

    PubMed  Google Scholar 

  23. Frommelt L, Kühn KD. Properties of bone cement: antibiotic-loaded cement. In: Breusch SJ, Malchau H, eds. The Well-Cemented Total Hip Arthroplasty: Theory and Practice. Heidelberg, Germany: Springer-Verlag; 2005:86–92.

    Chapter  Google Scholar 

  24. Gallo J, Kolár M, Novotný R, Riháková P, Tichá V. Pathogenesis of prosthesis-related infection. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2003;147:27–35.

    PubMed  Google Scholar 

  25. Garvin KL, Evans BG, Salvati EA, Brause BD. Palacos gentamicin for the treatment of deep periprosthetic hip infections. Clin Orthop Relat Res. 1994;298:97–105.

    PubMed  Google Scholar 

  26. Garvin KL, Hanssen AD. Current concepts review: infection after total hip arthroplasty. Past, present, and future. J Bone Joint Surg Am. 1995;77:1576–1588.

    CAS  Google Scholar 

  27. Gollwitzer H, Diehl P, Gerdesmeyer L, Mittelmeier W. Diagnostic strategies in cases of suspected periprosthetic infection of the knee: a review of the literature and current recommendations. Orthopäde. 2006;35:904–916.

    Article  PubMed  CAS  Google Scholar 

  28. Grünig R, Morscher E, Ochsner PE. Three- to 7-year results with the uncemented SL femoral revision prosthesis. Arch Orthop Trauma Surg. 1997;116:187–197.

    Article  PubMed  Google Scholar 

  29. Gustilo RB, Pasternak HS. Revision total hip arthroplasty with titanium ingrowth prosthesis and bone grafting for failed cemented femoral component loosening. Clin Orthop Relat Res. 1988;235:111–119.

    PubMed  Google Scholar 

  30. Haddad FS, Muirhead-Allwood SK, Manktelow AR, Bacarese-Hamilton I. Two-stage uncemented revision hip arthroplasty for infection. J Bone Joint Surg Br. 2000;82:689–694.

    Article  PubMed  CAS  Google Scholar 

  31. Hanssen AD, Osmon DR. Evaluation of a staging system for infected hip arthroplasty. Clin Orthop Relat Res. 2002;403:16–22.

    Article  PubMed  Google Scholar 

  32. Hanssen AD, Spangehl MJ. Practical applications of antibiotic-loaded bone cement for treatment of infected joint replacements. Clin Orthop Relat Res. 2004;427:79–85.

    Article  PubMed  Google Scholar 

  33. 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.

    PubMed  CAS  Google Scholar 

  34. Hedley AK, Gruen TA, Ruoff DP. Revision of failed total hip arthroplasties with uncemented porous-coated anatomic components. Clin Orthop Relat Res. 1988;235:75–90.

    PubMed  Google Scholar 

  35. 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.

    Article  PubMed  Google Scholar 

  36. Hsieh PH, Chen LH, Chen CH, Lee MS, Yang WE, Shih CH. Two-stage revision hip arthroplasty for infection with a custom-made, antibiotic-loaded, cement prosthesis as an interim spacer. J Trauma. 2004;56:1247–1252.

    Article  PubMed  Google Scholar 

  37. Hsieh PH, Shih CH, Chang YH, Lee MD, 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;86:1989–1997.

    PubMed  Google Scholar 

  38. Ince A, Rupp J, Frommelt L, Katzer A, Gille J, Löhr JF. Is “aseptic” loosening of the prosthetic cup after total hip replacement due to nonculturable bacterial pathogens in patients with low-grade infection? Clin Infect Dis. 2004;39:1599–1603.

    Article  PubMed  CAS  Google Scholar 

  39. 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.

    Article  PubMed  Google Scholar 

  40. Koo KH, Yang JW, Cho SH, Song HR, Park HB, Ha YC, Chang JD, Kim SY, Kim YH. Impregnation of vancomycin, gentamicin, and cefotaxime in the cement spacer for two-stage cementless reconstruction in infected total hip arthroplasty. J Arthroplasty. 2001;16:882–892.

    Article  PubMed  CAS  Google Scholar 

  41. Kraay MJ, Goldberg VM, Fitzgerald SJ, Salata MJ. Cementless two-staged total hip arthroplasty for deep periprosthetic infection. Clin Orthop Relat Res. 2005;441:243–249.

    Article  PubMed  Google Scholar 

  42. Lai KA, Shen WJ, Yang CY, Lin RM, Lin CJ, Jou IM. Two-stage cementless revision THR after infection: 5 recurrences in 40 cases followed 2.5–7 years. Acta Orthop Scand. 1996;67:325–328.

    Article  PubMed  CAS  Google Scholar 

  43. Lieberman JR, Callaway GH, Salvati EA, Pellici PM, Brause BD. Treatment of the infected total hip arthroplasty with a two staged reimplantation protocol. Clin Orthop Relat Res. 1994;301:205–212.

    PubMed  Google Scholar 

  44. Lonner JH, Desai P, Dicesare PE, Steiner G, Zuckerman JD. The reliability of analysis of intraoperative frozen sections for identifying active infection during revision hip or knee arthroplasty. J Bone Joint Surg Am. 1996;78:1553–1558.

    PubMed  CAS  Google Scholar 

  45. Masri BA, Panagiotopoulos KP, Greidanus NV, Garbuz DS, Duncan CP. Cementless two-stage exchange arthroplasty for infection after total hip arthroplasty. J Arthroplasty. 2007;22:72–78.

    Article  PubMed  Google Scholar 

  46. McInnis DP, Horne G, Devane PA. Femoral revision with a fluted, tapered, modular stem: seventy patients followed for a mean of 3.9 years. J Arthroplasty. 2006;21:372–380.

    Article  PubMed  Google Scholar 

  47. Mirra JM, Amstutz HC, Matos M, Gold R. The pathology of the joint tissues and its clinical relevance in prosthetic failure. Clin Orthop Relat Res. 1976;117:221–240.

    PubMed  Google Scholar 

  48. Mirra JM, Marder RA, Amstutz HC. The pathology of failed total joint arthroplasty. Clin Orthop Relat Res. 1982;170:175–183.

    PubMed  Google Scholar 

  49. Mjöberg B, Selvik G, Hansson LI, Rosenqvist R, Önnerfält R. Mechanical loosening of total hip prostheses: a radiographic and roentgen stereogrammatic study. J Bone Joint Surg Br. 1986;68:770–774.

    PubMed  Google Scholar 

  50. Mont MA, Waldman BJ, Hungerford DS. Evaluation of preoperative cultures before second-stage reimplantation of a total knee prosthesis complicated by infection: a comparison-group study. J Bone Joint Surg Am. 2000;82:1552–1557.

    PubMed  Google Scholar 

  51. Nestor BJ, Hanssen AD, Ferrer-Bonzalez R, Fitzgerald RH. The use of porous prostheses in delayed reconstruction of total hip replacements that have failed because of infection. J Bone Joint Surg Am. 1994;76:349–359.

    PubMed  CAS  Google Scholar 

  52. Neut D, van Horn JR, van Kooten TG, van der Mei HC, Busscher HJ. Detection of biomaterial-associated infections in orthopaedic joint implants. Clin Orthop Relat Res. 2003;413:261–268.

    Article  PubMed  Google Scholar 

  53. Nunn D, Freeman MA, Hil PF, Evans SJ. The measurement of migration of the acetabular component of hip prostheses. J Bone Joint Surg Br. 1989;71:629–631.

    PubMed  CAS  Google Scholar 

  54. Pak JH, Paprosky WG, Jablonsky WS, Lawrence JM. Femoral strut allografts in cementless revision total hip arthroplasty. Clin Orthop Relat Res. 1993;295:172–178.

    PubMed  Google Scholar 

  55. Pandey R, Drakouilakis E, Athanasou NA. An assessment of the histological criteria used to diagnose infection in hip revision arthroplasty tissues. J Clin Pathol. 1999;52:118–123.

    Article  PubMed  CAS  Google Scholar 

  56. Paprosky WG, Greidanus NV, Antoniou J. Minimum 10-year results of extensively porous-coated stems in revision hip arthroplasty. Clin Orthop Relat Res. 1999;369:230–242.

    Article  PubMed  Google Scholar 

  57. 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.

    Article  PubMed  CAS  Google Scholar 

  58. Peters G, Hermann M, von Eiff C. The changing pattern of coagulase-negative staphylococci as infectious pathogens. Curr Opin Infect Dis. 1995;8(suppl):S12–S19.

    Article  Google Scholar 

  59. Salgado CD, Dash S, Cantey R, Marculescu CE. Higher risk of failure of methicillin-resistant Staphylococcus aureus prosthetic joint infections. Clin Orthop Relat Res. 2007;461:48–53.

    PubMed  Google Scholar 

  60. Steinbrink K, Frommelt L. Treatment of periprosthetic infection of the hip using one-stage exchange surgery. Orthopäde. 1995;24:335–343.

    PubMed  CAS  Google Scholar 

  61. Stockley I, Mockford BJ, Hoad-Reddick, 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.

  62. Trampuz A, Zimmerli W. New strategies for the treatment of infectious associated with prosthetic joints. Curr Opin Investig Drugs. 2005;6:185–190.

    PubMed  CAS  Google Scholar 

  63. Virolainen P, Lahteenmaki H, Hiltunen A, Sipola E, Meurman O, Nelimarkka O. The reliability of diagnosis of infection during revision arthroplasties. Scand J Surg. 2002;91:178–181.

    PubMed  CAS  Google Scholar 

  64. Warren PJ, Thompson P, Flechter MD. Transfemoral implantation of the Wagner SL stem: the abolition of subsidence and enhancement of osteotomy union rate using Dall-Miles cables. Arch Orthop Trauma Surg. 2002;122:557–560.

    PubMed  CAS  Google Scholar 

  65. Weber M, Hempfing A, Orler R. Femoral revision using the Wagener stem: results at 2–9 years. Int Orthop. 2002;26:36–39.

    Article  PubMed  CAS  Google Scholar 

  66. Williams JL, Norman P, Stockley I. The value of hip aspiration versus tissue biopsy in diagnosing infection before exchange hip arthroplasty surgery. J Arthroplasty. 2004;19:582–586.

    Article  PubMed  Google Scholar 

  67. Wilson MG, Dorr LD. Reimplantation of infected total hip arthroplasties in the absence of antibiotic cement. J Arthroplasty. 1989;4:263–269.

    Article  PubMed  CAS  Google Scholar 

  68. Wirtz DC, Niethard FU. Etiology, diagnosis and therapy of aseptic hip prosthesis loosening: a status assessment. Z Orthop Ihre Grenzgeb. 1997;135:270–280.

    Article  PubMed  CAS  Google Scholar 

  69. Wroblewski BM. One-stage revision of infected cemented total hip arthroplasty. Clin Orthop Relat Res. 1986;211:103–107.

    PubMed  Google Scholar 

  70. Zimmerli W. The role of antimicrobial agents in the management of infected arthroplasties. Orthopäde. 1995;24:308–313.

    PubMed  CAS  Google Scholar 

  71. Zimmerli W. Infection and musculoskeletal conditions: prosthetic-joint-associated infections. Best Pract Res Clin Rheumatol. 2006;20:1045–1063.

    Article  PubMed  Google Scholar 

  72. Zimmerli W, Widmer AF, Blatter M, Frei R, Ochsner PE. Role of rifampicin for treatment of orthopedic implant-related staphylococcal infections: a randomized controlled trial. Foreign-Body Infection (FBI) Study Group. JAMA. 1998;279:1537–1541.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706, Markgröningen, Germany

    Bernd Fink MD & Alexandra Grossmann

  2. Orthopaedic Department, Rheumaklinik Bad Bramstedt, University Hospital Hamburg-Eppendorf, Bad Bramstedt, Germany

    Martin Fuerst MD

  3. MVZ Labor Ludwigsburg, Ludwigsburg, Germany

    Peter Schäfer MD

  4. Service for Infectious Diseases, Clinical Microbiology and Infection Control, ENDO-Klinik, Hamburg, Germany

    Lars Frommelt MD

Authors
  1. Bernd Fink MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Alexandra Grossmann
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Martin Fuerst MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Peter Schäfer MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Lars Frommelt MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Bernd Fink MD.

Additional information

Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

Each author certifies that his or her institution has approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent was obtained.

About this article

Cite this article

Fink, B., Grossmann, A., Fuerst, M. et al. Two-stage Cementless Revision of Infected Hip Endoprostheses. Clin Orthop Relat Res 467, 1848–1858 (2009). https://doi.org/10.1007/s11999-008-0611-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11999-008-0611-y

Keywords

Search

Navigation