Infection: Two-Stage Techniques
Timothy S. Brown
Kevin I. Perry
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)
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
Lateral decubitus position or supine position based on surgeon’s preference.
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.
Previous operative reports containing implant information is vital so that the appropriate instrumentation can be available for implant removal.
Preoperative radiographs should be obtained, including an anteroposterior (AP) pelvis, a lateral of the affected hip, and an AP view of the affected hip (Figure 40.4).
Consideration of surgical approach, necessity of osteotomy, and understanding the implants in place is imperative.
A plan regarding the use of a nonarticulating versus an articulating antibiotic spacer is useful preoperatively so that the appropriate instrumentation may be readily available.
No spacer (resection alone)
Predominately for patients who are very sick or immunocompromised or those who have already failed treatment with antibiotic spacers
Used in some cases, especially when extensive bone loss or soft tissue deficiency precludes the use of an articulating spacer
Advantages of nonarticulating spacer:
No risk of spacer dislocation
Little risk of bone erosion
Disadvantages of nonarticulating spacer:
Poorer patient function during resection interval
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