Management

 

Zimmer Girdlestone

 

Tsukayama Classification

 

1.  Early post-operative infection < 1 month

- < 1/12

- febrile patient with red discharging wound

 

2.  Late chronic infection > 1 month

- indolent (low virulent)

- well patient with a healed wound and worsening of pain

 

3.  Acute hematogenous

- previously well functioning THA now very painful

- secondary to another source of infection

 

4. Positive intra-operative culture

- revision for aseptic loosening

- intraoperative cultures comes back positive (2 out of 5)

 

Options

 

Antibiotic suppression

Debridement and prosthesis retention

One stage revision

Two stage revision

Resection arthroplasty

 

Antibiotic Suppression

 

Indications

 

Elderly and frail

Not suitable for surgery

 

Require

 

Known sensitive organism

Stable prosthesis

Tolerable oral antibiotics

 

Results

 

Pavoni et al Clin Microbiol Infect 2004

- infection suppression with antibiotics in 34 patients

- failure of treatment in 13 patients

 

Debridement, Antibiotics, Implant Retention (DAIR)

 

Indications

 

Acute infection, < 4/52, no sinus

 

Stable, well-fixed prosthesis

 

Known sensitive organism

- reduced efficacy with S. aureus unless rifampicin used

- poor results with MRSA

 

Technique

 

Surgery

 

Excision of all necrotic and infected tissue

- ensure implant well fixed

- exchange liner (if uncemented)

- wash +++

 

Antibiotics

 

IV antibiotics 4 - 6 weeks

 

Results

 

Tsang et al Bone Joint J 2017

- systematic review of 1300 PPI hip treated with DAIR

- infection eradication 72%

- < 7 days: infection eradication 76%

- exchange modular implants: infection eradication 78%

 

One-Stage Revision

 

Infected THR Pre One stage revisionInfected THR Post One Stage RevisionInfected THR Kiwi Hip Spacer

 

Concept

 

Remove prosthesis, debride and replace at single sitting

- meticulous debridement critical

- antibiotic cement both femur and acetabulum

 

Technique

 

Debridement + removal of implants and all cement

- wash +++

- re-drape, new instruments

 

Implant cemented polished femur and all poly cup

- must use antibiotic cement

- guidance on antibiotic choice from multidisciplinary team (ID)

- for example add powder form vancomycin 

- 2-3 gram vancomycin in each 40g packet of cement

 

Results

 

Lange et al Clin Epidemiol 2012

- systematic review of one- versus two-stage revision for hip PJI

- recurrent infection 13% one-stage

- recurrent infection 10% two-stage

 

Two-Stage Revision

 

Technique

 

First stage

- debridement + removal of implants and all cement

- insert antibiotic impregnated cement spacer

 

Types of spacers

- hand made +/- metal reinforcement

- moulds +/- metal reinforcement

- prefabricated

- antibiotic-coated prosthesis

 

Infected THR Cement BallInfected THR Cement Spacer Fracture

Ball antibiotic cement                         Mold                                          

 

Infected THR Dislocated ProstalacHandmade spacer

Prefabricated                                 Handmade

 

Zimmer mouldZimmer mouldZimmer spacer

Zimmer StageOne Select Hip Cement Spacer Molds

 

Second stage

- definitive revision

- at least 2 - 4 weeks off antibiotics and normal CRP / ESR

- consider hip aspiration

- intra-operative FFS at time of surgery

 

Complications

 

Dislocation / bone loss / prosthesis fracture / femur fracture

 

Infected THR Prostalac SpacerProstalac Femur FractureInfected THR Dislocated Prostalac

 

Jones et al J Arthroplasty 2019

- 185 antibiotic cement spacers

- 53% molds / 30% antibiotic coated prosthesis / 12% handmade / 4% prefabricated

- 9% dislocation

- 8% spacer fracture

- 7% periprosthetic fracture

 

Results

 

Kildow et al J Clin Med 2022

- 221 patients with two-stage revision average 6 year follow up

- 12% recurrent infection

- risk factors for recurrent infection polymicrobial infection and resistant organisms

- revision rate 26%

- mortality rate 41%

 

Resection Arthroplasty / Girdlestone

 

Infected THR GIrdlestonesGirdlestone

 

Indications

- medically unfit for further revision surgery

- refusal for further revision surgery

- sepsis control / virulent bug

- unrevisable due to bone loss

- unlikely to become mobile

 

Advantage

 

Effective control of infection (95%)

 

Disadvantage

 

Poor function

- pain /  limp

- require walking aid

- 5cm average LLD

 

Amputation / Hip disarticulation