We caution readers of the limitations of our study. First patients were not recalled for examination, only phone survey for the purposes of study followup, and the data were collected from our prospectively collected database; therefore, the current status of all patients in terms of implant fixation and function cannot be definitively stated. However, we do report 90-day mortality separately from overall mortality rate, which is informative regarding death occurring in the early perioperative period that is more likely to be associated with the morbidity of the procedures. Second, there is not a comparison group; therefore, our study does not provide information regarding mortality rates of the two-stage procedure relative to an alternative treatment such as single-stage revision, and mortality rates should be interpreted as a result of treating this patient population and not necessarily as a result of the treatment. Third, during the timeframe of the study, the authors did not have exact criteria for proceeding with the second stage or determining control of the infection. We describe our protocol and the resultant outcomes only. Lastly, we do attempt to stratify mortality risk or control of infection according to patient comorbidities and there may be important variables not examined that are related to both. These shortcomings aside, the current report represents the largest in the literature regarding two-stage treatment of infection.
We noted high perioperative mortality. In patients who underwent the second-stage procedure, there was an 83% rate of infection control at an average of 53 months followup. This rate of infection control is on par with similar series reported in the literature (Table 2). Mortality associated with the two-stage treatment of periprosthetic hip infection appears to be high both in the perioperative period but also within the followup interval. Toulson et al.  reported a 25.8% rate of death before 2-year followup in their series of two-stage treatment. In the treatment of resistant organisms, a 24% mortality rate has also been reported . In the current series, 45% of patients had died at an average of 4.7 years after treatment. A slightly higher mortality rate of 50% was noted in those patients who had recurrent infection. A total of 14 patients (15 hips; 7%) died within 90 days of the first stage with seven patients (4%) dying after the first stage of treatment and before undergoing reimplantation.
We believe success of a two-stage treatment should include not only control of infection, but also consider those patients who did not undergo successful second-stage reimplantation as failures. Control of the infection is not achieved if death occurs before the second-stage operation and therefore death should not be considered a success in the rate of infection control. Many times authors only include those patients in whom the second stage was completed in their analysis of success. Thus, undergoing the second stage may be an important outcome measure in reporting of results. Lim et al.  reported that 92% of their cases underwent reimplantation with 8% requiring permanent resection as a result of continued sepsis. Eighty-two of 87 hips treated in another series were reimplanted for a rate of 94.3% . Similarly, 92% of hips in the current series underwent a second stage with the aforementioned 14 patients (15 hips) dying and two additional patients unfit medically for reimplantation.
Once death and the rate of successful second stage are considered, only then can a true rate of infection control for a treatment strategy be calculated. Toulson et al.  report an infection control rate of 95%, yet only 94.5% of hips underwent a second-stage reimplantation. Perhaps a more appropriate success rate in their series would be 78 of 82 patients, or a 90% true control rate with a two-stage protocol. Sanchez-Sotelo et al. , in a midterm to long-term series, appear to only report on their patients who underwent successful second-stage reimplantation but offer little information about patients who might not have undergone the second stage. In their series, the rate of infection control was 87.5% but mechanical failure of the second-stage reconstruction dropped their implant survivorship to 75.2%. We observed an 83% rate of infection control in patients successfully reconstructed, but this survival rate drops to 76% if mortality during the perioperative period is included.
With few exceptions, the ability to control highly virulent organisms or resistant strains is compromised compared with sensitive strains . We noted the highest failure rate in resistant strains with an infection control rate of 62%. This is compared with 86% and 82% success for treatment of sensitive staphylococcal and streptococcal strains, respectively. Lim et al.  noted this higher failure with all of their failed procedures falling into the resistant group (33% failure). Although most series have supported the notion that resistant strains have a higher failure rate, all 21 resistant infections in the series of Toulson et al.  were controlled at 2 years.
Although our belief was that the use of an articulating spacer would result in better outcomes, no differences in the use of these devices were observed. Neither control of infection nor final hip score was different. We noted average HHS of 65 and 63 with articulating and static, respectively. This is remarkably similar to the results of Scharfenberger et al.  and their report of the use of a PROSTALAC implant (DePuy Orthopaedics, Inc, Warsaw, IN, USA) during the first stage in which their average HHS was 62. Clearly, the final results of the two-stage treatment of periprosthetic hip infection are severely compromised compared with primary THA and revision THA regardless of the use of an articulating spacer. Whether the second stage is made simpler with the use of an articulating spacer deserves further study.
Periprosthetic infection is a devastating and complicated problem after THA. We highlight the substantial mortality also associated with this treatment strategy despite reimplantation rates and control of infection rates similar to those reported in the literature. Infection with highly virulent resistant organisms was controlled less frequently than sensitive strains and no particular advantage was noted with use of articulating versus static spacers. Along with the technical aspects of débridement and spacer creation, surgeons need to be familiar with these high rates of death. Perhaps better perioperative optimization of nutrition, smoking, and overall health status can lead to fewer deaths and better infection control rates.
1. Buttaro, MA., Pusso, R. and Piccaluga, F. Vancomycin-supplemented impacted bone allografts in infected hip arthroplasty. J Bone Joint Surg Br.
2005; 87: 314-319. 10.1302/0301-620X.87B3.14788
2. Cabrita, HB., Croci, AT., Camargo, OP. and Lima, ALLM. Prospective study of the treatment of infected hip arthroplasties with or without the use of an antibiotic-loaded cement spacer. Clinics (Sao Paulo).
2007; 62: 99-108. 10.1590/S1807-59322007000200002
3. Cordero-Ampuero, J., Esteban, J. and Garcia-Cimbrelo, E. Oral antibiotics are effective for highly resistant hip arthroplasty infections. Clin Orthop Relat Res.
2009; 467: 2335-2342. 10.1007/s11999-009-0808-8
4. Evans, RP. Successful treatment of total hip and knee infection with articulating antibiotic components. Clin Orthop Relat Res.
2004; 427: 37-46. 10.1097/01.blo.0000143739.07632.7c
5. Fehring, TK., Calton, TF. and Griffin, WL. Cementless fixation in 2-stage reimplantation for periprosthetic sepsis. J Arthroplasty.
1999; 14: 175-181. 10.1016/S0883-5403(99)90122-5
6. Fink, B., Grossmann, A., Fuerst, M., Schafer, P. and Fromelt, L. Two-stage cementless revision of infected hip endoprostheses. Clin Orthop Relat Res.
2009; 467: 1848-1858. 10.1007/s11999-008-0611-y
7. Garvin, KL. and Hanssen, AD. Infection after total hip arthroplasty: past, present, and future. J Bone Joint Surg Am.
1995; 77: 1576-1588.
8. Harris, WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am.
1969; 51: 737-755.
9. Hofmann, AA., Goldberg, TD., Tanner, AM. and Cook, TM. Ten-year experience using an articulating antibiotic cement hip spacer for the treatment of chronically infected total hip. J Arthroplasty.
2005; 20: 874-879. 10.1016/j.arth.2004.12.055
10. Incavo, SJ., Russell, RD., Mathis, KB. and Adams, H. Initial results of managing severe bone loss in infected total joint arthroplasty using customized articulating spacers. J Arthroplasty.
2009; 24: 607-613. 10.1016/j.arth.2008.03.017
11. Katz, JN., Losina, E., Barrett, J., Phillips, CB., Mahomed, NN., Lew, RA., Guadagnoli, E., Harris, WH., Poss, R. and Baron, JA. Association between hospital and surgeon procedure volume and outcomes of total hip replacement in the United States Medicare population. J Bone Joint Surg Am.
2001; 83: 1622-1629. 10.1302/0301-620X.83B3.10487
12. Klouche, S., Sariali, E. and Mamoudy, P. Total hip arthroplasty revision due to infection: a cost analysis approach. Orthop Traumatol Surg Res.
2010; 96: 124-132. 10.1016/j.otsr.2009.11.004
13. Koo, K.-H., Yang, J.-W., Cho, S.-H., Song, H.-R., Park, H.-B., Ha, Y.-C., Chang, J.-D., Kim, S.-Y. and Kim, Y.-H. Impregnation of vancomycin, gentamicin, and cefotaxime in a cement spacer for two-stage cementless reconstruction in infected total hip arthroplasty. J Arthroplasty.
2001; 16: 882-892. 10.1054/arth.2001.24444
14. Kurtz, SM., Lau, E., Schmier, J., Ong, KL., Zhao, K. and Parvizi, J. Infection burden for hip and knee arthroplasty in the United States. J Arthroplasty.
2008; 23: 984-991. 10.1016/j.arth.2007.10.017
15. Lange, J., Troelsen, A., Thomsen, RW. and Soballe, K. Chronic infections in hip arthroplasties: comparing risk of reinfection following one-stage and two-stage revision: a systematic review and meta-analysis. Clin Epidemiol.
2012; 4: 57-73.
16. Lee, PTH., Clayton, RA., Safir, OA., Backstein, DJ. and Gross, AE. Structural allograft as an option for treating infected hip arthroplasty with massive bone loss. Clin Orthop Relat Res.
2011; 469: 1016-1023. 10.1007/s11999-010-1673-1
17. Leung, F., Richards, CJ., Garbuz, DS., Masri, BA. and Duncan, CP. Two-stage total hip arthroplasty: how often does it control methicillin-resistant infection? Clin Orthop Relat Res.
2011; 469: 1009-1015. 10.1007/s11999-010-1725-6
18. Lieberman, JR., Callaway, GH., Salvati, EA., Pellicci, PM. and Brause, BD. Treatment of the infected total hip arthroplasty with a two-stage reimplantation protocol. Clin Orthop Relat Res.
1994; 301: 205-212.
19. Lim, S.-J., Park, J.-C., Moon, Y.-W. and Park, Y.-S. Treatment of periprosthetic hip infection caused by resistant microorganisms using 2-stage reimplantation protocol. J Arthroplasty.
2009; 24: 1264-1269. 10.1016/j.arth.2009.05.012
20. Magnan, B., Regis, D., Biscaglia, R. and Barolozzi, P. Preformed acrylic bone cement spacer loaded with antibiotics. Acta Orthop Scand.
2001; 72: 591-594. 10.1080/000164701317269003
21. McDonald, DJ., Fitzgerald, RH. and Ilstrup, DM. Two-stage reconstruction of a total hip arthroplasty because of infection. J Bone Joint Surg Am.
1989; 71: 828-834.
22. Nestor, BJ., Hanssen, AD., Ferrer-Gonzalez, R. and Fitzgerald, RH. The use of porous prosthesis in delayed reconstruction of total hip replacements that have failed because of infection. J Bone Joint Surg Am.
1994; 76: 349-359.
23. Nusem, J. and Morgan, DAF. Structural allografts for bone stock reconstruction in two-stage revision for infected total hip arthroplasty. Acta Orthop.
2006; 77: 92-97. 10.1080/17453670610045740
24. Pulido, L., Ghanem, E., Joshi, A., Purtill, JJ. and Parvizi, J. Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res.
2008; 466: 1710-1715. 10.1007/s11999-008-0209-4
25. Romano, CL., Romano, D., Logoluso, N. and Meani, E. Long-stem versus short-stem preformed antibiotic-loaded cement spacers for two stage revision of infected total hip arthroplasty. Hip Int.
2010; 20: 26-33.
26. Sanchez-Sotelo, J., Berry, DJ., Hanssen, AD. and Cabanela, ME. Midterm to long-term followup of staged reimplantation for infected hip arthroplasty. Clin Orthop Relat Res.
2009; 467: 219-224. 10.1007/s11999-008-0480-4
27. Scharfenberger, A., Clark, M., Lavoie, G., O’Connor, G., Masson, E. and Beaupre, LA. Treatment of an infected total hip replacement with the PROSTALAC system. Part 1: infection resolution. Can J Surg.
2007; 50: 24-28.
28. Stockley, I., Mockford, BJ., Hoad-Reddick, A. and Norman, P. The use of two-stage exchange arthroplasty with depot antibiotics in the absence of long-term antibiotic therapy in infected total hip replacement. J Bone Joint Surg Br.
2008; 90: 145-148.
29. Takigami, I., Yoshiki, I., Ishimaru, D., Ogawa, H., Mori, N., Shimizu, T., Terabayashi, N. and Shimizu, K. Two-stage revision surgery for hip prosthesis infection using antibiotic-loaded porous hydroxyapatite blocks. Arch Orthop Trauma Surg.
2010; 130: 1221-1226. 10.1007/s00402-009-0991-9
30. Toulson, C., Walcott-Sapp, S., Hur, J., Salvati, EA., Bostrum, M., Brause, BD. and Westrich, GH. Treatment of infected total hip arthroplasty with a 2-stage reimplantation protocol. J Arthroplasty.
2009; 24: 1051-1060. 10.1016/j.arth.2008.07.004
31. Tsukayama, DT., Estrada, R. and Gustilo, RB. Infection after total hip arthroplasty. J Bone Joint Surg Am.
1996; 78: 512-523.
32. Wang, J.-W. and Chen, C.-E. Reimplantation of infected hip arthroplasties using bone allografts. Clin Orthop Relat Res.
1997; 335: 202-210. 10.1097/00003086-199702000-00001
33. Whittaker, JP., Warren, RE., Jones, RS. and Gregson, PA. Is prolonged systemic antibiotic treatment essential in two-stage revision hip replacement for chronic Gram-positive infection? J Bone Joint Surg Br.
2009; 91: 44-51.
34. Wolf, CF., Gu, NY., Doctor, JN., Manner, PA. and Leopold, SS. Comparison of one and two-stage revision of total hip arthroplasty complicated by infection. J Bone Joint Surg Am.
2011; 93: 631-639. 10.2106/JBJS.I.01256
35. Yamamoto, K., Miyagawa, N., Masaoka, T., Katori, Y., Shishido, T. and Imakiire, A. Clinical effectiveness of antibiotic-impregnated cement spacers for the treatment of infected implants of the hip joint. J Orthop Sci.
2003; 8: 823-828. 10.1007/s00776-003-0722-y
36. Younger, ASE., Duncan, CP., Masri, BA. and McGraw, RW. The outcome of two-stage arthroplasty using a custom-made interval spacer to treat the infected hip. J Arthroplasty.
1997; 12: 615-623. 10.1016/S0883-5403(97)90133-9
37. Zhan, C., Kaczmarek, R., Loyo-Berrios, N., Sangl, J. and Bright, RA. Incidence and short-term outcomes of primary and revision hip replacement in the United States. J Bone Joint Surg Am.
2007; 89: 526-533. 10.2106/JBJS.F.00952