Two-stage Treatment Protocol for Isolated Septic Acetabular Cup Loosening

Abstract

The aim of this study was to evaluate the treatment of isolated septic acetabular cup loosening without involvement of the prosthesis stem by insertion of an antibiotic-loaded spacer head and stem retention. Between 1999 and 2008, 13 patients (5 men, 8 women, mean age 69 years) were treated according to this regimen. S. epidermidis and S. aureus were the two most commonly identified pathogens. In 12 cases the polymethylmethacrylate spacers were impregnated with 0.5 g gentamicin + 2 g vancomycin per 40 g bone cement, except in one patient with vancomycin allergy, in whom 0.5 g gentamicin + 0.4 g teicoplanin were used. The spacers acted as hemiarthroplasties. The mean spacer head implantation time was 88 (35-270) days. At a mean follow-up of 55 (12-83) months, infection eradication was achieved in 11 out of 12 cases (91.6%). Complications included a draining sinus, and one spacer and one definitive prosthesis dislocation. One patient died after reimplantation due to cardiopulmonary decompensation.

Can periprosthetic hip joint infections be successfully managed by debridement and prosthesis retention?

“…One study combined this procedure along with the use of the vacuum-assisted closure therapy [11] . Two studies reported on partial prosthesis retention [8,13] . In both studies, the infected acetabular cup was removed and an antibiotic-loaded spacer head was placed onto the retained femoral stem.…”

“…A total of 11 studies reporting on 292 cases could be identified ( Figure 1) [2][3][6][7][8][9][10][11][12][13][14] . Two studies were published before and nine after 2000.…”

“…[12] 89.6% (26/29) [8,13] 92.8% (26/28) [11] 70.4% (126/179) [2,3,6,7,9,14] ing factors identified no difference between methicillinsensitive and methicillin-resistant staphylococcus or head/liner exchange and no exchange [9] . These findings are contradictory to the general acceptance that prosthesis retention is feasible at the site of early infection with a short duration of symptoms.…”

“…Although single studies demonstrated high success rate exceeding 90%, the relative small number of patients treated as well as the low level of evidence does not allow for generalization of [7] 2013 19 All early 1 Ⅲ Anagnostakos et al [8] 2010…”

“…Additional subgroup analysis to identify other possible contribut- Aboltins et al [6] Debridement, lavage, 1/13 aseptic prosthesis loosening 92.30% Change of PE-liner [Median = 1 (1-4)] Aboltins et al [7] Debridement, lavage, N.c.d. 89.50% Change of PE-liner [Median = 3 (3-6)] Anagnostakos et al [8] Acetabular cup removal + 2/12 draining sinus 91.60% Spacer head onto retained stem After spacer head implantation; Mean implantation period 88 (35-270) d 1/12 spacer dislocation; 3/12 prosthesis dislocation Choi et al [9] 19/28 debridement, irrigation, 5/28 staged revision, 50% Change of PE-liner 6/28 repeated debridement, 9/28 debridement, irrigation, 4/28 resection arthroplasty No change of PE-liner Crockarell et al [10] Debridement 1/42 prosthesis dislocation, 21% 1 1/42 periprosthetic femoral fracture, 1/42 exitus due to sepsis Kelm et al [11] Debridement, pulsatile lavage, None 92.80% Change of PE-liner, Vacuum-assisted closure Klouche et al [12] Debridement, irrigation n.r. 75% Change of PE-liner and femoral head Lee et al [13] Acetabular cup removal + n.r.…”