Two-Stage Revision Total Hip Arthroplasty Without Spacer Placement: A Viable Option to Manage Infection in Patients With Severe Bone Loss or Abductor Deficiency

Abstract

Background: High rates of spacer-related complications in two-stage exchange total hip arthroplasty (THA) have been reported. Patients with advanced bone defects and abductor deficiency may benefit from a nonspacer two-stage revision. This study reports on the clinical course of a contemporary twostage exchange for periprosthetic hip infection without spacer insertion. Methods: We reviewed 141 infected THAs with extensive bone loss or abductor damage who underwent two-stage exchange without spacer placement. The mean duration from resection arthroplasty to reimplantation was 9 weeks (2-29). Clinical outcomes included interim revision, reinfection, and aseptic revision rates. Restoration of leg-length and offset was assessed radiographically. Modified Harris hip scores were calculated. Mean follow-up was 5 years (3-7). Treatment success was defined using the modified Delphi consensus criteria. Results: Thirty-four patients (24%) had treatment failure, including 13 reinfections, 16 interim redebridements for persistent infection, 2 antibiotic suppressive therapies, and 3 prosthetic joint infection erelated deaths. Aseptic rerevision after reimplantation was necessary in 14 patients (10%). Dislocation accounted for most aseptic complications, with 20 dislocations occurring in 15 patients (11%). Leglength and offset were restored to preoperative measures. Mean modified Harris hip scores significantly improved from 35 points to 67 points. Conclusion: A nonspacer two-stage exchange is a viable option for managing chronically infected THA with severe bone loss or abductor deficiency, showing comparable rates of interim revision and recurrence of infection. Cementless reimplantation demonstrates good midterm survivorship with comparable functional outcomes and leg-length restoration. However, dislocation continues to be a major concern.

One-Stage Hip Revision Arthroplasty Using Megaprosthesis in Severe Bone Loss of The Proximal Femur Due to Radiological Diffuse Osteomyelitis

“…Most authors use temporary antibiotic-loaded cement spacers for the management of chronic PJI in two-stage procedures; nevertheless, there are some authors who described two-stage revision hip arthroplasty without a temporary spacer implanted in the first stage [3]. Hipfl et al [3] reported on 135 hip PJI cases: 28 patients had Paprosky femoral bone loss type ≥3A (14 patients, Paprosky type 3; 11 patients, Paprosky type 3B; and 3 patients, Paprosky type 4). The reported reinfection rate was 25% (7/28) in Paprosky femoral bone loss type ≥3A patients and 8.4% (9/107) in patients with femoral bone defect <3A according to the Paprosky classification.…”

“…The reported reinfection rate was 25% (7/28) in Paprosky femoral bone loss type ≥3A patients and 8.4% (9/107) in patients with femoral bone defect <3A according to the Paprosky classification. The reason for the difference in the reinfection rates shown was insufficient debridement of the osteolytic proximal femur and retention of devitalized bone with biofilm residues [3]. The authors avoided antibiotic-laden cement spacer implantation in complex and severe proximal femur bone defect cases due to the high mechanical complication rates presented, such as dislocation, periprosthetic fractures, and spacer fractures.…”

“…Currently, the standard management of chronic hip and knee prosthetic joint infection includes one-stage or two-stage revision, depending on different conditions (host and extremity status, surgeon experience, and pathogen). To date, there is no international gold standard treatment for chronic PJI of the hip; however, two-stage revision is the most widely used, and Spain is not an exception [3]. The literature review shows comparable results for one-and two-stage strategies [4,5], although this is not founded on comparative studies.…”

Two-stage revision for periprosthetic joint infection in cemented total hip arthroplasty: an increased risk for failure?

“…The potential of biological fixation and improved implant designs have led to an increasing worldwide use of cementless components in revision THA including two-stage exchange procedures for PJI. Studies have shown promising long-term durability without compromising infection eradication rates [2,8,[23][24][25]. Besides potential of long-term stability, it is also important to consider possible failure and further need for revision.…”

Extended Trochanteric Osteotomy with Intermediate Resection Arthroplasty Is Safe for Use in Two-Stage Revision Total Hip Arthroplasty for Infection

“…The major concerns of this surgical strategy are compromising infection eradication without having the local antibiotic effects of the spacer and hampering reimplantation due to resulting muscle contractures ultimately leading to worse functional outcomes [ 30 ]. However, the local antimicrobial effects of the spacer do not appear to play a significant role in infection eradication [ 31 ], and comparable functional results are achievable when long interim periods are avoided [ 32 , 33 , 34 ]. To date, only a few clinical studies have been reported regarding the use of ETO in the setting of two-stage revision THA with varying surgical regimens [ 18 , 19 , 20 , 21 , 22 ] and no study has specifically investigated the safety of ETO without spacer placement.…”