Prosthetic joint infection (PJI) is a challenging complication following total hip arthroplasty (THA). Two-stage exchange arthroplasty is preferred for treating chronic PJI of THA, although specialized centers have reported comparable outcomes with protocol-based, 1-stage exchange arthroplasty. A main requirement is presurgical determination of the infecting organism’s sensitivity. The therapeutic goal is control of the infection and maintenance of joint function. It offers advantages, including a single operative procedure, fewer antibiotics, and reduced hospitalization time and relative overall costs.
Key points
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The preoperative protocol of diagnostics includes joint aspiration and blood tests.
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The causative organisms and known susceptibility must be identified.
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All foreign material requires radical debridement and removal.
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Targeted antibiotic therapy is required both locally and systemically.
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Strict treatment protocol includes early mobilization with full weightbearing.
Introduction: nature of the problem
Prosthetic joint infection (PJI) is a most challenging complication following total hip arthroplasty (THA). Despite all efforts to prevent this complication, infections occur in about 0.5% to 1.9% of primary hip arthroplasty; and in 8% to 10% after revisions. Although the definitive diagnosis of PJI remains the key for success, a designated concept of preoperative planning and treatment is mandatory. Treatment options can include irrigation and debridement with retention of implants for acute infections and exchange arthroplasty either as a 1-stage or 2-stage procedure for deep, late infections. In patients who fail all reconstructive options, consideration is given to salvage operations, including a Girdlestone-like resection arthroplasty or disarticulation. Currently, the 2-stage exchange arthroplasty is the preferred method of treating chronic PJI of THA, whereas a protocol-based, 1-stage exchange arthroplasty is advocated by a few specialized centers and has comparable outcomes.
The therapeutic goal in 1-stage exchange arthroplasty is control of the infection in combination with the maintenance of joint function with a single surgery. This technique is a viable option and, depending on the status of the patient, the surgeon’s expertise, and the hospital set-up should be used. The main objective is to reduce the bioburden by performing extensive and radical soft tissue debridement and removal of the biofilm-covered prosthesis.
Evaluating the current available literature and guidelines for the treatment of PJI, there is no clear evidence that a 2-stage exchange arthroplasty has a higher success rate than a 1-stage approach. Although the 2-stage technique is described in many articles as the gold standard for management of chronic PJI, there are several unknowns regarding this procedure. Most important is the optimal timing of the reimplantation.
The 1-stage exchange offers some advantages, including the need for only 1 operative procedure, reduced time on antibiotics, reduced hospitalization time, and reduced relative overall costs. The reported outcome of this procedure is comparable to the 2-stage exchange arthroplasty. Therefore, the 1-stage exchange at PJI of THA is getting more and more popular worldwide. There is, however, a need for randomized, prospective studies that can compare the outcome of these procedures.
This article provides a detailed description of current practice regarding the management of PJI of the hip, including diagnostics, preoperative planning, surgical treatment algorithm, possible complications, and postoperative care.
Introduction: nature of the problem
Prosthetic joint infection (PJI) is a most challenging complication following total hip arthroplasty (THA). Despite all efforts to prevent this complication, infections occur in about 0.5% to 1.9% of primary hip arthroplasty; and in 8% to 10% after revisions. Although the definitive diagnosis of PJI remains the key for success, a designated concept of preoperative planning and treatment is mandatory. Treatment options can include irrigation and debridement with retention of implants for acute infections and exchange arthroplasty either as a 1-stage or 2-stage procedure for deep, late infections. In patients who fail all reconstructive options, consideration is given to salvage operations, including a Girdlestone-like resection arthroplasty or disarticulation. Currently, the 2-stage exchange arthroplasty is the preferred method of treating chronic PJI of THA, whereas a protocol-based, 1-stage exchange arthroplasty is advocated by a few specialized centers and has comparable outcomes.
The therapeutic goal in 1-stage exchange arthroplasty is control of the infection in combination with the maintenance of joint function with a single surgery. This technique is a viable option and, depending on the status of the patient, the surgeon’s expertise, and the hospital set-up should be used. The main objective is to reduce the bioburden by performing extensive and radical soft tissue debridement and removal of the biofilm-covered prosthesis.
Evaluating the current available literature and guidelines for the treatment of PJI, there is no clear evidence that a 2-stage exchange arthroplasty has a higher success rate than a 1-stage approach. Although the 2-stage technique is described in many articles as the gold standard for management of chronic PJI, there are several unknowns regarding this procedure. Most important is the optimal timing of the reimplantation.
The 1-stage exchange offers some advantages, including the need for only 1 operative procedure, reduced time on antibiotics, reduced hospitalization time, and reduced relative overall costs. The reported outcome of this procedure is comparable to the 2-stage exchange arthroplasty. Therefore, the 1-stage exchange at PJI of THA is getting more and more popular worldwide. There is, however, a need for randomized, prospective studies that can compare the outcome of these procedures.
This article provides a detailed description of current practice regarding the management of PJI of the hip, including diagnostics, preoperative planning, surgical treatment algorithm, possible complications, and postoperative care.
One-stage exchange arthroplasty
For obvious reasons, 1-stage exchange arthroplasty carries many advantages compared with the 2-stage exchange. The 1-stage exchange arthroplasty, though commonly performed in specialized centers in Europe, has also been gaining popularity in North America. One-stage exchange arthroplasty is a viable option for most patients with PJI. At the Endo Klinik, approximately 85% of patients with PJI are treated with 1-stage exchange arthroplasty. A main requirement for 1-stage exchange arthroplasty is that the infecting organism and its sensitivity must be determined before surgery. This allows for delivery of local antibiotics, which are added to the cement.
Indications for one-stage septic exchange of the hip
One-stage septic exchange is in indicated by the following:
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PJI after THA in which infection is proven based on the International Consensus Group on Periprosthetic Infection of PJI (1 major or 3 minor criteria)
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Late or chronic infection more than 30 days postoperatively or hematogenous infection more than 30 days after onset of the symptoms
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Known germ with known susceptibility based on microbiological diagnostics
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Proper bone stock for cemented or, in some cases, uncemented reconstruction
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Possibility of primary wound closure.
Contraindications of one-stage procedure
One-stage procedure is contraindicated by the following:
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Culture-negative PJI
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Lack of appropriate antibiotics
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Systemic sepsis of the patient
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Failure of 2 or more previous 1-stage procedures
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Infection involving the neurovascular bundles (femoral or sciatic nerve, iliac vessels)
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Extensive soft tissue involvement that would prevent closure of the wound
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Infection with a highly virulent organism, especially cases for which appropriate antibiotic impregnated cement is not available.
Surgical technique
The outcome of 1-stage exchange arthroplasty is technique-dependent. This procedure largely depends on the efficiency by which debridement and bioburden reduction is performed. The technique of 1-stage exchange arthroplasty is briefly outlined.
Preoperative Planning
In every case, preoperative plain radiographs (anteroposterior and lateral views) are performed ( Fig. 1 A). In some difficult cases with massive bone loss, computed tomography may be indicated. Preoperative templating using personal computer–based software (MediCAD, Hectec, Landshut, Germany) is done to reconstruct the proper leg-length, the lateral offset, and the center of rotation of the hip (see Fig. 1 B). The proper implant sizes are templated, which can be intraoperatively double-checked.
Preparation and Patient Positioning
Patients are placed in the lateral decubitus position with a well-fixed pelvis and with a special cushion between the legs providing a stable positioning with the involved leg freely moved in all planes. The skin is prepped 4 times with an alcoholic (propanol) solution (Cutasept G, Bode Chemie, Hamburg, Germany); the acting time should be at least 2 minutes. If the skin is dry again after the disinfection, a standard hip draping is performed with single-use materials. The length of incision and possible extension of the surgical approach should be considered so there is enough space for extensive surgical preparation.
Surgical Approach
The authors recommend a posterolateral approach to the infected hip. Old scars and draining sinuses should be integrated into the approach, if possible. Detachment of the maximus sling (attachment of the gluteus maximus muscle) allows for better access to the posterior aspect of the joint and avoids the lesion of the sciatic nerve; rotational forces are also reduced and, therefore, periprosthetic femoral fracture can be avoided. With extra-articular preparation, the joint capsule is opened as late as possible to avoid contamination of the soft tissues. All capsule, synovia, and infective tissue are excised.
The advantage of the posterior approach is wide and unlimited access to all parts of the acetabulum and to the whole femur. Both endomedullary and periosteal preparation is easily performed. The approach can be extended to either direction; an access to the distal part of the femur can be achieved by preparation along the intermuscular septum. A neurolysis of the sciatic nerve can be performed, if necessary. Positioning of both the acetabular and femoral components is reported to be safer and more reliable when using the posterolateral approach. The disadvantage of the approach is a reportedly higher risk of dislocation, which can be avoided by proper positioning of the implants.
Surgical procedure
Step 1. Debridement and Explantation
The debridement begins by excising the previous scar. The sinus, if present, should be integrated into the skin incision and radically excised down to the joint capsule. All nonbleeding tissues and related bone need to be radically excised. During the radical debridement, multiple tissue samples (4–6 for microbiology and 2 for pathohistology) are obtained and sent for further investigation.
For removal of long and cemented stems, special instruments, such as curved chisels, long forceps, curetting instruments, long drills, high-speed burrs, and cement taps, are needed ( Fig. 2 ). All implants and foreign material are removed ( Figs. 3 and 4 ). Solid femoral implants may require a longitudinal osteotomy or, rarely, an extended trochanteric osteotomy. All cement and restrictors need to be removed. Generally, the debridement of bone and surrounding soft tissues must be as radical as possible. It must include all areas of bone loss and nonviable bone. Occasionally, resection of the greater trochanter or the proximal part of the femur becomes necessary, which necessitates the use of tumor-type, fully cemented, modular, long-stemmed revision implants and, sometimes, a higher level of constraint, such as a constrained liner or a dual-mobility cup.
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