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Orthopaedic Surgery Hip
Two-stage Revision of Septic Hip Prosthesis
a report by
Enzo Meani and Carlo L Romanò
Department of Orthopaedic Surgery COS, Istituto Ortopedico Gaetano Pini
Infection after total hip arthroplasty is a serious complication, and several after joint arthroplasty. Nevertheless, many Gram-positive and -negative
treatment strategies have been proposed.
1–5
Two-stage reimplantation organisms are resistant to Gentamycin. Therapeutic levels of vancomycin
using an interval spacer of antibiotic-impregnated bone cement has been and Gentamycin have been found in vitro and in drainage fluid after they
investigated previously as a method to eradicate infection and prevent were used with cement.
24–30
In the authors’ series, vancomycin was added
limb shortening.
6–10
Duncan and Beauchamp,
6
who introduced the to the cement used to fix the spacer implant and with a drilling technique
concept of the interval spacer in a two-stage procedure for the treatment in the spacer itself. Levels of vancomycin in serum after the use of
of infected total hip arthroplasty (THA), developed a more refined interval vancomycin-loaded cement have been shown to be negligible, and an
spacer (prosthesis of antibiotic-loaded acrylic cement, PROSTALAC). The association between the use of vancomycin in cement and the isolation
eradication rate of infection was 93.5%. The merits of PROSTALAC were of vancomycin-resistant Enterococcus has not been shown.
7,30
a decrease in hip pain and the ability of patients to walk between the two 2. Prosthetic components removal, including all cement, surgical
stages. Preformed antibiotic-loaded spacers (Spacer G, Tecres Spa, Italy) debridement and intra-operative specimens collection for
offer pain-free hip mobility, known mechanical resistance, early weight- cultural examination.
bearing and (protected) walking ability,
11,12
predictable antibiotic release,
13
3. Implant of a preformed antibiotic-loaded cement spacer (short or long
and reduced surgical time,
14
while long stem shapes allow proximal femoral stem as needed), fixed only proximally with antibiotic-loaded cement,
bone loss to be overcome.
15
Revision surgery of infected hip prosthesis is in to prevent spacer rotational instability.
fact often associated with femoral bone loss, either due to the loosening of 4. Systemic antibiotic therapy for six weeks, with two antibiotics.
the prosthesis, the septic process and/or surgical debridement or intra- Systemic antibiotic administration has been performed for
operative fractures cement and/or well fixed prosthesis removal (see figure approximately six weeks after the first- and second-stage operation. In
1).
16–22
Long stem spacers usually provide, even in these challenging cases, the lack of comparative studies it is not possible to derive any
enough primary stability and mechanical resistance to allow partial weight conclusion as to whether this prolonged systemic antibiotic treatment
bearing, while the range of movement and limb length are maintained.
15
was an over-treatment or, on the contrary and as the authors suggest,
whether it may have played a role in the overall good success rate in
The Authors’ Strategy Includes the Following 10 Steps this series of patients. Four patients (9%) had side effects due to
1. Identify the micro-organism – Staphylococcus aureus and S. epidermidis antibiotics, including temporary liver dysfunction and bone marrow
are the predominant organisms of infection after joint arthroplasty. depression. These side effects might be related to post-operative
Methicillin-resistant Staphylococcus has been identified as an important intravenous (IV) antibiotics or antibiotics used in the cement spacer (or
pathogen in patients who have an infection at the site of a joint prosthesis both). However, the safety of the antibiotic delivery from the cement
and this also occurred in the authors’ series with a relative prevalence of spacer has been previously established
7
and the side effects resolved
47%.
23
Vancomycin is the most potent agent against methicillin-resistant after temporary withdrawal of IV antibiotics in all the patients.
Staphylococcus. Gentamycin is potent against Enterobacteriaceae and 5. 5–10kg weight-bearing, with two crutches.
Pseudomonas aeruginosa, which are common pathogens of infection 6. After eight to 12 weeks, clinical + laboratory testing + X-ray +
sonography. If infection recurrence is suspected, joint aspiration,
cultural examination and white blood cell count of the sinovial fluid
Enzo Meani is Director of the Osteoarticular Infection
should be performed.
Department at the Istituto Ortopedico Gaetano Pini, Milan,
and Adjunct Professor in Orthopaedics at the University of 7. Reimplantation with modular non-cemented hip prosthesis. Possibility of
Milan. He was President of the European Bone and Joint
using large-diameter ball and sockets. Cementless revision arthroplasty
Infection Society from 2003 to 2005 and President of the
Italian Study Group on Osteoarticular Infections from 1996
provided a higher success rate than the cemented revision in a similar
to 1999. He completed his specialisation in orthopaedics follow-up in aseptic loosening in different studies
31–34
and long-term
and traumatology in 1973 and his Laurea in Medicine in
survivorship of antibiotic-loaded cemented prosthesis has been shown to
1970, both from the University of Milan.
be rather low.
1
In the revision of the infected hip prosthesis, however, the
E: meani@gpini.it
cementless system may have a possible disadvantage because antibiotics
Carlo L Romanò is Adjunct Professor in Orthopaedics at the University of Milan and is responsible cannot be impregnated without using the cement. On the other hand,
for the Septic Hip Prosthesis Unit at the G. Pini Orthopaedic Institute, Milan. He is President of
one may argue that if the antibiotic in the cement spacer did not provide
the Italian Study Group on Osteoarticular Infections, a Board Member of the European Bone and
Joint Infection Society and Secretary of the Lumbard Regional Society of Orthopaedics (SLOTO).
local antibiotic levels able to eradicate infection during a two- to three-
He achieved his specialisation in orthopaedics and traumatology cum laude in 1993, and his
month period, this will not be achieved by the necessarily lower levels of
Laurea cum laude in medicine in 1988, both from the University of Milan.
antibiotics added to the cement used for fixation of a revision prosthesis.
Relatively few studies have reported the results of two-stage
76 © TOUCH BRIEFINGS 2007
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