Explantation, Followed by Serial Debridement Without Antibiotic Spacers and Subsequent Revision With Cementless Components, Is Associated With High Remission Rates and Low Mortality in Periprosthetic Hip Joint Infections

Abstract

Background: In difficult-to-treat cases, it is necessary to add debridement steps in prosthesis-free interval of 2-stage exchange. We aimed to analyze the functional and clinical outcome of patients treated with a multistage exchange of total hip arthroplasty without the use of spacers, rather only cementless implants.

Methods: Between 2009 and 2018, 84 patients (mean age: 67.3 [39-90] years) suffering chronic late-onset periprosthetic joint infection (PJI) were treated using a multistage prosthesis exchange without spacers. The mean follow-up was 70 ± 45.3 [14-210] months. The treatment included prosthesis exchange and at least 1 additional revision step before a reimplantation, owing to ongoing acute infection in the prosthesis-free interval. High-efficiency antimicrobial therapy was administered in between, which was discontinued after cementless revision implantation.

Results: The mean number of revisions between explantation and implantation was 2.6 (1-9). The most common microorganism was Staphylococcus epidermidis (53.6%) followed by Staphylococcus aureus (16.7%) and Cutibacterium acnes (11.9%). The bacterial load was more than one bacterium per patient in 38% of cases. All patients could be treated using a cementless implant. PJI remission was achieved in 92% of cases. Overall, 9 prostheses (11%) were replaced because of an ongoing PJI or fracture. The mean modified Harrison Hip Score was 63.4 (22-88) points. No patient died.

Conclusion: Multistage total hip arthroplasty exchange showed high remission rates and low mortality in difficult-to-treat cases. Spacer-free and multistage treatment had no negative effect on the success rate or functional outcome, consistent with the results of published 2-stage exchange studies. Implantation of an uncemented press-fit prosthesis was possible in all patients with no elevated periprosthetic fracture rate.

Keywords: exchange total hip arthroplasty; multiple-stage exchange; periprosthetic joint infection; spacer; two-stage exchange.