Infection: Two-Stage Techniques

Infection: Two-Stage Techniques

Timothy S. Brown

Kevin I. Perry

Key Concepts

  • Two-stage exchange for chronic periprosthetic joint infection (PJI) of the hip is the gold standard treatment in North America.

  • The first stage entails removal of all of the hip implants and cement, a thorough debridement of the necrotic and infected materials, a thorough irrigation of the wound, followed (usually) by placement of an antibiotic loaded spacer.

  • Three distinct types of antibiotic spacers exist: a nonarticulating antibiotic spacer, a prefabricated articulated antibiotic spacer, and an articulated spacer fabricated at the time of surgery.

  • Prefabricated spacers (Figure 40.1) contain low-dose antibiotics and need to be supplemented with high-dose antibiotic cement if they are to be used.

  • Spacers fabricated at the time of surgery (Figure 40.2) allow the surgeon to control the type of antibiotic and dosage used in the spacer.

  • Dislocation of antibiotic spacer is not uncommon and is probably underreported (Figure 40.3).

  • Postoperatively, the patient should receive a course of intravenous antibiotics targeted at the offending microorganism guided by an infectious disease specialist.

  • After completion of the antibiotics, the patient should undergo a period of time off of antibiotics to ensure the infection has been cleared before proceeding with hip reimplantation.

  • During hip reimplantation, multiple cultures should be obtained and intraoperative pathology should be sent to ensure the infection has been cleared.

Sterile Instruments and Implants

Resection and Spacer Insertion

  • Routine hip retractors

  • Large oscillating saw (if performing an osteotomy)

  • Pencil-tipped burr (short and long)

  • Thin osteotomes for removal of uncemented implants

  • Ultrasonic cement removal devices if removing a cemented stem


  • Antibiotic spacer molds (if fabricating spacer at the time of surgery)

  • Cement gun for antibiotic dowel fabrication (if utilizing nonarticulating spacer)

  • Luque wires

Figure 40.1 ▪ Example of a prefabricated antibiotic spacer.

Figure 40.2 ▪ Intraoperative photo demonstrating an antibiotic spacer fabricated with high-dose antibiotics at the time of surgery.


  • Osteotomes and rongeurs to remove cement

  • High-speed burrs and curettes to remove cement

  • Wire cutters if cerclage wires are in place

  • Routine hip retractors

  • Revision total hip arthroplasty acetabular and femoral revision implants

  • Consider high-stability bearings

Figure 40.3 ▪ AP pelvis demonstrating dislocation of an articulating antibiotic spacer.

Figure 40.4 ▪ AP radiograph of infected total hip arthroplasty.


  • Lateral decubitus position or supine position based on surgeon’s preference.

Surgical Approaches

  • Removal of the hip implants can be accomplished from either an anterolateral or posterolateral approach depending on surgeon preference.

  • If an extended trochanteric osteotomy will be utilized for femoral implant removal, the posterolateral approach to the hip is preferred.

Preoperative Planning

Dec 14, 2019 | Posted by in ORTHOPEDIC | Comments Off on Infection: Two-Stage Techniques
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