Two-stage revision surgery for periprosthetic joint infection following total hip arthroplasty

Total hip arthroplasty (THA) is a common, highly successful surgical intervention for the treatment of symptomatic degenerative conditions of the hip, such as osteoarthritis (1). Periprosthetic joint infection (PJI) is an uncommon, but potentially devastating complication of THA, with a reported incidence of between 0.6% and 2.2% (2-4). PJI often necessitates invasive treatment strategies, such as revision surgery, and has a significant negative impact on patients’ quality of life (5,6). With more than 1 million THAs performed worldwide each year, the health and economic burdens of this infective complication are substantial (1,3). Furthermore, two large national registry studies have demonstrated that the risk of revision due to hip PJI is rising (7,8). In this context, an understanding of the most effective treatment options is of great importance.

The three principal treatment options for hip PJI include: surgical debridement with antibiotics and implant retention, with or without modular exchange (DAIR); one-stage revision; or two-stage revision. In contemporary healthcare settings, the additional options of excision, or amputation are considered a last resort. DAIR is commonly used in acute PJIs involving bacteria with known sensitivities, well-fixed prostheses and in patients unfit for major revision surgery. However, patients who undergo DAIR may require lifelong suppressive antibiotics and approximately half will subsequently require revision with implant exchange (9,10).

Revision for hip PJI involves removal of the existing prosthesis, debridement of affected tissues, administration of antibiotics and reimplantation of a new prosthesis. ‘One-stage’ revision refers to the completion of this protocol in a single operation under one anaesthetic, whereas a ‘two-stage’ approach refers to the delayed reimplantation of a definitive THA, following completion of a course of sensitivity-guided antimicrobial therapy. Two-stage protocols often utilize a temporary prosthesis, or antibiotic spacer prior to the definitive second stage.