[Two-stage reimplantation using spacers--the method of choice in treatment of hip joint prosthesis-related infections. Comparison with methods used from 1979 to 1998]

Abstract

Purpose of the study: Several therapies are available for the treatment of deep infection in total hip arthroplasty but none is completely successful; there is no consensus on an optimal method. The aim of this study was to evaluate the treatment used in our institution and its outcomes over the last 20 years. In each method, the success of treatment was evaluated in terms of both infection control and restoration of function in the treated joint.

Material: A total of 172 patients with infected total hip replacements were treated at the First Orthopedic Clinic of the First Faculty of Medicine, Charles University, Prague, between 1979 and 1998. Our sample consisted of 132 patients, 92 men and 40 women. Resection arthroplasty was performed in 62 patients. Two-stage reimplantation was used in 64 patients. Two-stage reimplantation involving skeletal traction was applied in 35 and a block spacer was used in 29 patients. The remaining patients were treated by other techniques.

Methods: The type of infection was classified according to the Coventry system. The outcome of surgery was assessed on the basis of the Tsukayma rating system, radiographic findings and the Harris hip score.

Results: The average follow-up time from the definitive operation was 70.8 months. In the patients who had resection arthroplasty only, the cure rate of infection was 91.9%. However, an increase in the Harris hip score, as compared with the condition before surgery, was low (9.7 points). In the patients treated by the two-stage reimplantation without a spacer but with skeletal traction, the cure rate of infection was 94.3% and the Harris score increased by 20 points. The patients who were treated by two-stage reimplantation with a spacer showed an infection cure rate of 96.5% and an increase in the Harris score by 29 points. This increase was higher by 9 points in comparison with the patients who had reimplantation without the use of a spacer. An even greater difference (28.2 points) was found when the outcomes of this technique were compared with those of resection arthroplasty. The incidence of spacer dislocation in 21% of the cases was an unexpected finding.

Discussion: No great differences in outcome in terms of infection cure rate were found among the methods used, i.e., two-stage reimplantation facilitated a better function for the hip joint than Girdlestone's operation. The use of a spacer in two-stage reimplantation ensured a greater comfort for the patient during treatment and gave better results in terms of joint function than treatment without a spacer. The use of a cemented spacer is an optimal method that not only ensures the stability of a limb during the period necessary for infection control but also provides conditions for the prospective implantation of a new prosthesis. The spacer also permits delivery of high-dose local antibiotics released from the cement as well as makes space for a long-term application of antibiotic-containing lavage.

Conclusions: The rate of success in the treatment of an infected hip arthroplasty and the possibility of preserving the implant and thus enabling the patient to move comfortably are currently high. The prerequisite is early diagnosis and a radical surgical approach that involves the use of a method leading to the most effective eradication of infection and the maintenance of a good function for the joint. The reimplantation of a new prosthesis, after removal of the previous one and debridement of all infected tissue and material, combined with a targeted antibiotic therapy, is the method of choice for both the patient and the surgeon.