Archives of Orthopaedic and Trauma Surgery

, Volume 139, Issue 8, pp 1051–1056 | Cite as

High incidence of early periprosthetic joint infection following total hip arthroplasty with concomitant or previous hardware removal

  • Ruben Scholten
  • Wout Füssenich
  • Matthijs P. Somford
  • Job L. C. van SusanteEmail author
Orthopaedic Surgery



Hardware removal preceding total hip arthroplasty may increase the risk of prosthetic joint infection (PJI). Whether hardware removal and total hip arthroplasty (THA) should be performed in a single- or two-stage procedure remains controversial. In this comparative retrospective study, the incidence of PJI following either single- or two-stage THA with hardware removal was assessed in a consecutive series.

Patients and methods

All patients that underwent THA preceded by hardware removal from January 2006 until March 2018 were retrospectively reviewed and checked for the occurrence of early PJI. Recognized risk factors for PJI at the time of surgery were evaluated and the incidence of early PJI was compared between one- and two-stage THA regarding hardware removal.


145 patients underwent THA and hardware removal (52 two-stage surgery and 93 single-stage surgery). There were no significant differences between both groups regarding pre-operative hemoglobulin levels, time interval between internal fixation and THA, antibiotic-loaded-cement use, BMI and ASA classification. Overall the incidence of early PJI was 6.9%. The incidence of PJI was 8.6% in the single-stage group versus 3.8% in the two-stage group (P = 0.234).


Irrespective of single- or two-stage procedures, a high incidence of PJI was encountered. Despite non-significance, a trend towards a higher proportion of patients developing PJI after single-stage surgery was encountered. We recommend a two-stage surgical procedure regarding hardware removal and THA in patients that are expected to tolerate this surgical strategy. When considering a one-stage procedure, it should be preceded by a thorough pre-operative workup including joint aspiration and serum determination of inflammatory parameters. Multiple tissue samples should be obtained during hardware removal in either one- or two-stage procedures since the risk for development of PJI is relevant.


Hardware removal Internal fixation Osteosynthesis Total hip arthroplasty Periprosthetic joint infection 



All authors, their immediate families, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article. Consequently, there is no funding source.

Compliance with ethical standards

Ethical approval

This study received approval of the local Committee for Research Involving Human Subjects that granted a waiver of informed consent due to its retrospective nature.


  1. 1.
    Gullberg B, Johnell O, Kanis JA (1997) World-wide projections for hip fracture. Osteoporos Int 7 (5):407–413CrossRefGoogle Scholar
  2. 2.
    Bhandari M, Swiontkowski M (2017) Management of Acute Hip Fracture. N Engl J Med 377(21):2053–2062. CrossRefGoogle Scholar
  3. 3.
    Mahmoud SS, Pearse EO, Smith TO, Hing CB (2016) Outcomes of total hip arthroplasty, as a salvage procedure, following failed internal fixation of intracapsular fractures of the femoral neck: a systematic review and meta-analysis. Bone Jt J 98-b(4):452–460. CrossRefGoogle Scholar
  4. 4.
    Mortazavi SM, Bican MRG, Kane O, Parvizi P, Hozack J WJ (2012) Total hip arthroplasty after prior surgical treatment of hip fracture is it always challenging? J Arthroplasty 27(1):31–36. CrossRefGoogle Scholar
  5. 5.
    Haidukewych GJ, Berry DJ (2003) Hip arthroplasty for salvage of failed treatment of intertrochanteric hip fractures. J Bone Jt Surg Am 85-a(5):899–904CrossRefGoogle Scholar
  6. 6.
    Tetsunaga T, Fujiwara K, Endo H, Noda T, Tetsunaga T, Sato T, Shiota N, Ozaki T (2017) Total hip arthroplasty after failed treatment of proximal femur fracture. Arch Orthop Trauma Surg 137(3):417–424. CrossRefGoogle Scholar
  7. 7.
    Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ (2009) The epidemiology of revision total hip arthroplasty in the United States. J Bone Jt Surg Am 91(1):128–133. CrossRefGoogle Scholar
  8. 8.
    Phillips JE, Crane TP, Noy M, Elliott TS, Grimer RJ (2006) The incidence of deep prosthetic infections in a specialist orthopaedic hospital: a 15-year prospective survey. J Bone Jt Surg Br 88(7):943–948. CrossRefGoogle Scholar
  9. 9.
    Hernandez NM, Chalmers BP, Perry KI, Berry DJ, Yuan BJ, Abdel MP (2018) Total hip arthroplasty after in situ fixation of minimally displaced femoral neck fractures in elderly patients. J Arthroplasty 33(1):144–148. CrossRefGoogle Scholar
  10. 10.
    Klatte TO, Meinicke R, O’Loughlin P, Rueger JM, Gehrke T, Kendoff D (2013) Incidence of bacterial contamination in primary THA and combined hardware removal: analysis of preoperative aspiration and intraoperative biopsies. J Arthroplasty 28(9):1677–1680. CrossRefGoogle Scholar
  11. 11.
    Moussa FW, Anglen JO, Gehrke JC, Christensen G, Simpson WA (1997) The significance of positive cultures from orthopedic fixation devices in the absence of clinical infection. Am J Orthop (Belle Mead NJ) 26(9):617–620Google Scholar
  12. 12.
    Enocson A, Mattisson L, Ottosson C, Lapidus LJ (2012) Hip arthroplasty after failed fixation of trochanteric and subtrochanteric fractures: a cohort study with 5–11 year follow-up of 88 consecutive patients. Acta Orthop 83(5):493–498. CrossRefGoogle Scholar
  13. 13.
    McKinley JC, Robinson CM (2002) Treatment of displaced intracapsular hip fractures with total hip arthroplasty: comparison of primary arthroplasty with early salvage arthroplasty after failed internal fixation. J Bone Jt Surg Am 84-a(11):2010–2015CrossRefGoogle Scholar
  14. 14.
    Dapunt U, Spranger O, Gantz S, Burckhardt I, Zimmermann S, Schmidmaier G, Moghaddam A (2015) Are atrophic long-bone nonunions associated with low-grade infections? Ther Clin Risk Manag 11:1843–1852. CrossRefGoogle Scholar
  15. 15.
    Banerjee A, Chitnis UB, Jadhav SL, Bhawalkar JS, Chaudhury S (2009) Hypothesis testing, type I and type II errors. Ind Psychiatry J 18(2):127–131. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of OrthopaedicsRijnstate ZiekenhuisArnhemThe Netherlands

Personalised recommendations