title: Two-stage treatment of hip periprosthetic joint infection is associated with a high rate of infection control but high mortality.
abstract: BACKGROUND
  Periprosthetic infection after total hip arthroplasty (THA) is a devastating complication. Reported rates of infection control range from 80% to 95% but mortality rates associated with treatment of infected THA are also substantial and we suspect underreported.
  
  
  OBJECTIVE
  For patients selected for two-stage treatment of infected THA we therefore determined (1) mortality; (2) rate of reimplantation; and (3) rate of reinfection.
  
  
  METHODS
  We identified 202 patients (205 hips) with infected primary or revision THA treated with a two-stage protocol between 1996 and 2009 in our prospectively collected practice registry. Patients underwent two-stage treatment for infection, including removal of all implants and foreign material with implantation of an antibiotic-laden cement spacer in the first stage followed by intravenous culture-specific antibiotics for a minimum of 6 weeks. Second-stage reimplantation was performed if erythrocyte sedimentation rate and C-reactive protein were trending toward normal and the wound was well healed. Thirteen patients (13 hips) were lost to followup before 24 months. The minimum followup in surviving patients was 24 months or failure (average, 53 months; range, 24-180 months).
  
  
  RESULTS
  Fourteen patients (7%; 14 hips) died before reimplantation and two were not candidates because of medical comorbidities. The 90-day mortality rate after the first-stage débridement was 4% (eight patients). Of the 186 patients (189 hips) who underwent reimplantation, 157 (83%) achieved control of the infection. Including all patients who underwent the first stage, survival and infection control after two-stage reimplantation was 76%.
  
  
  CONCLUSIONS
  Two-stage treatment of deep infection in primary and revision THA is associated with substantial mortality and a substantial failure rate from both reinfection and inability to perform the second stage.
  
  
  METHODS
  Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
authors.affiliation: Joint Implant Surgeons, Inc, 7277 Smith's Mill Road, Suite 200, New Albany, OH 43054, USA. berendkr@joint-surgeons.com
authors.forename: Keith R
authors.initials: KR
authors.lastname: Berend
authors.forename: Adolph V
authors.initials: AV
authors.lastname: Lombardi
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Morris
authors.forename: Adam G
authors.initials: AG
authors.lastname: Bergeson
authors.forename: Joanne B
authors.initials: JB
authors.lastname: Adams
authors.forename: Michael A
authors.initials: MA
authors.lastname: Sneller
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects*; D001843:Bone Cements / Q000627:therapeutic use; D003646:Debridement; D005260:Female; D006621:Hip Joint / Q000601:surgery; D006622:Hip Prosthesis / Q000009:adverse effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D016459:Prosthesis-Related Infections / Q000188:drug therapy / Q000401:mortality* / Q000601:surgery / Q000628:therapy*; D012086:Reoperation; D013203:Staphylococcal Infections / Q000188:drug therapy / Q000401:mortality* / Q000601:surgery / Q000628:therapy*; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents; D001843:Bone Cements