International Orthopaedics

, Volume 43, Issue 11, pp 2457–2466 | Cite as

Two-stage hip revision arthroplasty for periprosthetic joint infection without the use of spacer or cemented implants

  • Yves GramlichEmail author
  • Paul Hagebusch
  • Philipp Faul
  • Alexander Klug
  • Gerhard Walter
  • Reinhard Hoffmann
Original Paper



There is no gold standard for performing a two-stage exchange arthroplasty to treat periprosthetic joint infection (PJI). The use of spacers and the anchorage principles of the revision prosthesis remain controversial. Herein, we report the success rate of a two-stage total hip replacement procedure without using a spacer and only pressfit cementless implants.


Between 2009 and 2015, 57 patients with chronic late-onset PJI were treated using a two-stage prostheses exchange without spacer. The average age was 66.7 years (47–83 years). The mean follow-up was 53.9 ± 25 months. Treatment included microbiologic diagnostics and a high-efficiency antimicrobial therapy in between the operations for six weeks and a two week antibiotic-free interval before reimplantation of the cementless prostheses. After implantation, antibiotics were stopped. This study was approved by the institutional review board.


Ninety-six percent of the patients had prior unsuccessful PJI treatment in other hospitals. The most common microorganism was Staphylococcus epidermidis (50.9%), followed by Propionibacterium acnes (17.5%) and Staphylococcus aureus (14%). In 42.1% cases, mixed infections were found. All patients could be treated using a cementless implant. In 91.2%, PJI remission was achieved, while 8.6% had chronic PJI with implant retention. Overall, nine prostheses (15.8%) were replaced owing to ongoing PJI or fractures. Mean modified Harris Hip Score was 60.85 (range: 22–88). None of the patients died.


We demonstrated a high success rate for two-stage exchange of infected total hip arthroplasty. Spacer-free treatment does not negatively affect success rate or function. Implantation of an uncemented pressfit prosthesis was possible in all patients.


PJI Periprosthetic joint infection Two-stage exchange Cementless Pressfit Spacer 


Compliance with ethical standards

Study is based on institutional review board (IRB) approval.

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J (2012) Economic burden of periprosthetic joint infection in the United States. J Arthroplast 27(8 Suppl):61–65Google Scholar
  2. 2.
    Kapadia BH, Banerjee S, Cherian JJ, Bozic KJ, Mont MA (2016) The economic impact of Periprosthetic infections after total hip arthroplasty at a specialized tertiary-care center. J Arthroplast. PubMedGoogle Scholar
  3. 3.
    Kapadia BH, Berg RA, Daley JA, Fritz J, Bhave A, Mont MA (2016) Periprosthetic joint infection. Lancet 387(10016):386–394PubMedGoogle Scholar
  4. 4.
    Osmon D, Berbari E, Berendt A, Lew D, Zimmerli W, Steckelberg J, Rao N, Hanssen A, Wilson W (2013) Infectious diseases society of a: diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 56(1):e1–e25PubMedGoogle Scholar
  5. 5.
    Jung J, Schmid NV, Kelm J, Schmitt E, Anagnostakos K (2009) Complications after spacer implantation in the treatment of hip joint infections. Int J Med Sci 6(5):265PubMedPubMedCentralGoogle Scholar
  6. 6.
    Ma D, Shanks RM, Davis CM III, Craft DW, Wood TK, Hamlin BR, Urish KL (2018) Viable bacteria persist on antibiotic spacers following two-stage revision for periprosthetic joint infection. J Orthop Res 36(1):452–458PubMedGoogle Scholar
  7. 7.
    Neut D, van de Belt H, Stokroos I, van Horn JR, van der Mei HC, Busscher HJ (2001) Biomaterial-associated infection of gentamicin-loaded PMMA beads in orthopaedic revision surgery. J Antimicrob Chemother 47(6):885–891PubMedGoogle Scholar
  8. 8.
    DiCicco M, Duong T, Chu A, Jansen SA (2003) Tobramycin and gentamycin elution analysis between two in situ polymerizable orthopedic composites. J Biomed Mater Res B Appl Biomater 65(1):137–149. CrossRefPubMedGoogle Scholar
  9. 9.
    Gramlich Y (2018) Procedure for single stage implant retention for chronic periprosthetic infection using topical degradable calcium-based antibiotics. Int Orthop. PubMedGoogle Scholar
  10. 10.
    Gramlich Y, Walter G, Gils J, Hoffmann R (2017) Early results of adjuvant topical treatment of recurrent osteomyelitis with absorbable antibiotic carriers. Z Orthop Unfall 12(10):0042–112228Google Scholar
  11. 11.
    Fleiter N, Walter G, Bosebeck H, Vogt S, Buchner H, Hirschberger W, Hoffmann R (2014) Clinical use and safety of a novel gentamicin-releasing resorbable bone graft substitute in the treatment of osteomyelitis/osteitis. Bone Joint Res 3(7):223–229PubMedPubMedCentralGoogle Scholar
  12. 12.
    Gromov K, Pedersen AB, Overgaard S, Gebuhr P, Malchau H, Troelsen A (2015) Do Rerevision rates differ after first-time revision of primary THA with a cemented and cementless femoral component? Clin Orthop Relat Res 473(11):3391–3398PubMedPubMedCentralGoogle Scholar
  13. 13.
    Mäkelä KT, Matilainen M, Pulkkinen P, Fenstad AM, Havelin L, Engesaeter L, Furnes O, Pedersen AB, Overgaard S, Kärrholm J (2014) Failure rate of cemented and uncemented total hip replacements: register study of combined Nordic database of four nations. BMJ 348:f7592PubMedGoogle Scholar
  14. 14.
    Maggs J, Wilson M (2017) The relative merits of cemented and uncemented prostheses in total hip arthroplasty. Indian J Orthop 51(4):377–385PubMedPubMedCentralGoogle Scholar
  15. 15.
    Dohmae Y, Bechtold JE, Sherman RE, Puno RM, Gustilo RB (1988) Reduction in cement-bone interface shear strength between primary and revision arthroplasty. Clin Orthop Relat Res (236):214–220Google Scholar
  16. 16.
    Schinsky MF, Della Valle CJ, Sporer SM, Paprosky WG (2008) Perioperative testing for joint infection in patients undergoing revision total hip arthroplasty. J Bone Joint Surg Am 90(9):1869–1875PubMedGoogle Scholar
  17. 17.
    Gehrke T, Parvizi J (2014) Proceedings of the international consensus meeting on periprosthetic joint infection. J Arthroplast 29(2):4Google Scholar
  18. 18.
    Parvizi J, Zmistowski B, Berbari EF, Bauer TW, Springer BD, Della Valle CJ, Garvin KL, Mont MA, Wongworawat MD, Zalavras CG (2011) New definition for periprosthetic joint infection: from the workgroup of the musculoskeletal infection society. Clin Orthop Relat Res 469(11):2992–2994. CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Zimmerli W, Trampuz A, Ochsner PE (2004) Prosthetic-joint infections. N Engl J Med 351(16):1645–1654PubMedGoogle Scholar
  20. 20.
    Tande AJ, Gomez-Urena EO, Berbari EF, Osmon DR (2017) Management of prosthetic joint infection. Infect Dis Clin N Am 31(2):237–252Google Scholar
  21. 21.
    Bejon P, Berendt A, Atkins B, Green N, Parry H, Masters S, McLardy-Smith P, Gundle R, Byren I (2010) Two-stage revision for prosthetic joint infection: predictors of outcome and the role of reimplantation microbiology. J Antimicrob Chemother 65(3):569–575PubMedPubMedCentralGoogle Scholar
  22. 22.
    Frommelt L (2004) Guidelines on antimicrobial therapy in situations of periprosthetic THR infection. Orthopade 33(7):822–828. CrossRefPubMedGoogle Scholar
  23. 23.
    Tande AJ, Patel R (2014) Prosthetic joint infection. Clin Microbiol Rev 27(2):302–345PubMedPubMedCentralGoogle Scholar
  24. 24.
    Tice AD, Rehm SJ, Dalovisio JR, Bradley JS, Martinelli LP, Graham DR, Gainer RB, Kunkel MJ, Yancey RW, Williams DN (2004) Practice guidelines for outpatient parenteral antimicrobial therapy. Clin Infect Dis 38(12):1651–1671PubMedGoogle Scholar
  25. 25.
    Gramlich Y, Walter G, Klug A, Harbering J, Kemmerer M, Hoffmann R (2018) Procedure for single-stage implant retention for chronic periprosthetic infection using topical degradable calcium-based antibiotics. Int Orthop:1–8. PubMedGoogle Scholar
  26. 26.
    Nilsdotter A, Bremander A (2011) Measures of hip function and symptoms: Harris hip score (HHS), hip disability and osteoarthritis outcome score (HOOS), Oxford hip score (OHS), Lequesne index of severity for osteoarthritis of the hip (LISOH), and American Academy of Orthopedic Surgeons (AAOS) hip and knee questionnaire. Arthritis Care Res 63(S11):S200–S207Google Scholar
  27. 27.
    Edwards PK, Queen RM, Butler RJ, Bolognesi MP, Lowry Barnes C (2016) Are range of motion measurements needed when calculating the Harris hip score? J Arthroplast 31(4):815–819Google Scholar
  28. 28.
    Wang J, Wang Q, Shen H, Zhang X (2018) Comparable outcome of culture-negative and culture-positive periprosthetic hip joint infection for patients undergoing two-stage revision. Int Orthop 42(3):469–477PubMedGoogle Scholar
  29. 29.
    Renz N, Trampuz A (2015) Periprothetische Infektionen: aktueller Stand der Diagnostik und Therapie. Orthopädie & Rheuma 18(6):20–28Google Scholar
  30. 30.
    Giulieri SG, Graber P, Ochsner PE, Zimmerli W (2004) Management of infection associated with total hip arthroplasty according to a treatment algorithm. Infection 32(4):222–228PubMedGoogle Scholar
  31. 31.
    Pulcini C, Couadau T, Bernard E, Lorthat-Jacob A, Bauer T, Cua E, Mondain V, Chichmanian R-M, Dellamonica P, Roger P-M (2008) Adverse effects of parenteral antimicrobial therapy for chronic bone infections. Eur J Clin Microbiol Infect Dis 27(12):1227–1232PubMedGoogle Scholar
  32. 32.
    Nguyen S, Robineau O, Titecat M, Blondiaux N, Valette M, Loiez C, Beltrand E, Migaud H, Senneville E (2015) Influence of daily dosage and frequency of administration of rifampicin–levofloxacin therapy on tolerance and effectiveness in 154 patients treated for prosthetic joint infections. Eur J Clin Microbiol Infect Dis 34(8):1675–1682PubMedGoogle Scholar
  33. 33.
    Valour F, Karsenty J, Bouaziz A, Ader F, Tod M, Lustig S, Laurent F, Ecochard R, Chidiac C, Ferry T (2014) Antimicrobial-related severe adverse events during treatment of bone and joint infection due to methicillin-susceptible Staphylococcus aureus. Antimicrob Agents Chemother 58(2):746–755PubMedPubMedCentralGoogle Scholar
  34. 34.
    Mabry TM, Hanssen AD (2007) Articulating antibiotic spacers: a matter of personal preference. Orthopedics 30(9):783–785PubMedGoogle Scholar
  35. 35.
    Bloomfield MR, Klika AK, Barsoum WK (2010) Antibiotic-coated spacers for total hip arthroplasty infection. Orthopedics 33(9):649.
  36. 36.
    Ferguson JY, Dudareva M, Riley ND, Stubbs D, Atkins BL, McNally MA (2014) The use of a biodegradable antibiotic-loaded calcium sulphate carrier containing tobramycin for the treatment of chronic osteomyelitis: a series of 195 cases. Bone Joint J 96-B(6):829–836. CrossRefPubMedGoogle Scholar
  37. 37.
    Turner TM, Urban RM, Hall DJ, Chye PC, Segreti J, Gitelis S (2005) Local and systemic levels of tobramycin delivered from calcium sulfate bone graft substitute pellets. Clin Orthop Relat Res 437(1976–2007):97–104Google Scholar
  38. 38.
    Chang W, Colangeli M, Colangeli S, Di Bella C, Gozzi E, Donati D (2007) Adult osteomyelitis: debridement versus debridement plus Osteoset T pellets. Acta Orthop Belg 73(2):238–243PubMedGoogle Scholar
  39. 39.
    Gramlich Y, Walter G, Gils J, Hoffmann R (2017) Early results of adjuvant topical treatment of recurrent osteomyelitis with absorbable antibiotic carriers. Z Orthop Unfall 155(1):35–44PubMedGoogle Scholar
  40. 40.
    Marczak D, Synder M, Sibiński M, Polguj M, Dudka J, Kowalczewski J (2017) Two stage revision hip arthroplasty in periprosthetic joint infection. Comparison study: with or without the use of a spacer. Int Orthop 41(11):2253–2258PubMedGoogle Scholar
  41. 41.
    Tikhilov R, Bozhkova S, Denisov A, Labutin D, Shubnyakov I, Razorenov V, Artyukh V, Klitsenko O (2016) Risk factors and a prognostic model of hip periprosthetic infection recurrence after surgical treatment using articulating and non-articulating spacers. Int Orthop 40(7):1381–1387PubMedGoogle Scholar
  42. 42.
    Cabrita HB, Croci AT, Camargo OP, Lima AL (2007) Prospective study of the treatment of infected hip arthroplasties with or without the use of an antibiotic-loaded cement spacer. Clinics 62(2):99–108PubMedGoogle Scholar
  43. 43.
    Du YQ, Zhou YG, Hao LB, Wu WM, Ma HY, Zheng C, Piao S, Gao ZS, Sun JY, Wang S (2017) Mechanical complications with self-made, antibiotic-loaded cement articulating spacers in the treatment of the infected hip replacement. Zhongguo Gu Shang 30(5):436–440PubMedGoogle Scholar
  44. 44.
    Gomez MM, Tan TL, Manrique J, Deirmengian GK, Parvizi J (2015) The fate of spacers in the treatment of periprosthetic joint infection. J Bone Joint Surg Am 97(18):1495–1502PubMedGoogle Scholar
  45. 45.
    Kahlenberg CA, Hernandez-Soria A, Cross MB (2017) Poor prognosis of patients treated for Periprosthetic joint infection. HSS J 13(1):96–99PubMedGoogle Scholar
  46. 46.
    Bordini B, Stea S, Castagnini F, Busanelli L, Giardina F, Toni A (2018) The influence of bearing surfaces on periprosthetic hip infections: analysis of thirty nine thousand, two hundred and six cementless total hip arthroplasties. Int Orthop 11(10):018–4097Google Scholar
  47. 47.
    Wirtz D, Niethard F (1997) Etiology, diagnosis and therapy of aseptic hip prosthesis loosening--a status assessment. Z Orthop Grenzgeb 135(4):270–280Google Scholar
  48. 48.
    Masri BA, Panagiotopoulos KP, Greidanus NV, Garbuz DS, Duncan CP (2007) Cementless two-stage exchange arthroplasty for infection after total hip arthroplasty. J Arthroplast 22(1):72–78Google Scholar

Copyright information

© SICOT aisbl 2019

Authors and Affiliations

  1. 1.Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am MainFrankfurt am MainGermany

Personalised recommendations