Two-stage treatment of hip periprosthetic joint infection is associated with a high rate of infection control but high mortality

Abstract

Background: 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.

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

Methods: 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).

Results: 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%.

Conclusion: 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.

Fig. 1

In this patient, a nonarticulating spacer of antibiotic-laden cement was used.

Fig. 2A–C

(A) The earliest type of articulating spacer used was a hand-molded hemiarthroplasty of antibiotic-laden cement, as shown. (B) Articulating spacers evolved to devices incorporating actual implants with antibiotic-laden cement such as the construct shown. (C) Current technology for articulating spacers is shown, which involves intraoperatively created antibiotic-laden spacers using prefabricated molds with endoskeleton implants.

Fig. 3

Spacer type use over the time of the study has evolved from static to articulating spacers.