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Infected THR – 2 Stage Revision

- Discussion:
          - outcome studies:
          - references:
                  - Two-stage reconstruction of a total hip arthroplasty because of infection.
                  - Surgical treatment of the infected hip implant. Two-stage reimplantation with a one-month interval.
                  - Treatment of the infected total hip arthroplasty with a two-stage reimplantation protocol.
                  - The Use of Bone Allografts in Two-Stage Reconstruction after Failure of Hip Replacements Due to Infection.
                  - Persistent infection associated with residual cement after resection arthroplasty of the hip.
                  - Two-stage revision HA for infection with a custom-made, antibiotic-loaded, cement prosthesis as an interim spacer.
                  - Individual bone cement spacers (IBCS) for septic hip revision-preliminary report. 
                  - Two-stage revision for prosthetic joint infection: predictors of outcome and the role of reimplantation microbiology
                  - Two-stage Total Hip Arthroplasty: How Often Does It Control Methicillin-resistant Infection
                  - Surgical procedures in the treatment of 784 infected THAs reported to the Norwegian Arthroplasty Register
                          Best survival with 2-stage exchange revision, but also good results with debridement and retention of the fixed implant
         - timing:
                  - high recurrence rate occurs w/ virulent organisms that were not treated with intravenous antibiotics more than 28 days;
                  - there is no difference in success with low virulent organisms w/ regimen of IV antibiotics for more than 28 days;
                  - gram-negative infections and enterococcus;
                          - have dreadfully poor prognosis for successful reimplantation;
                  - when causal organism is gram-negative bacillus or enteroccus, reconstruction should be delayed for 12 months;
                  - successful reconstruction can be done earlier (three months) with the less virulent microorganisms;
                          - however, the finding of acute inflammatory cells at surgery is worrisome and probably indicates the presence of an
                                  active infection; 
                  - references:
                          - Is prolonged systemic antibiotic treatment essential in two-stage revision hip replacement for chronic Gram-positive infection? 
                          - Oral Antibiotics Reduce Reinfection After Two-Stage Exchange: A Multicenter, Randomized Controlled Trial.

          - revision technique:
                  - removal of femoral component
                          - references:
                                 - Preservation of the original femoral cement mantle during the management of infected cemented total hip replacement by two-stage revision.
                  - removal of acetabular component
          - need for tissue biopsy cultures from the component membrane interface
                  - remember that in the case of biofilm, there may be minimal infection in joint fluid and capsule, and the main area of
                             infection will be over the component /bone-membrane interface;
                  - ref: A comprehensive microbiological evaluation of 54 patients undergoing revision surgery due to prosthetic joint loosening.

          - antibiotic spacer: 
                  - addition of antibiotics to cement
                           - properties of vancomycin in cement;
                           - gentamicin and tobramycin properties in cement
                                   - ref: Does a Prefabricated Gentamicin-impregnated, Load-bearing Spacer Control Periprosthetic Hip Infection? 

                  - provides high level of the drugs locally w/o generating excessive levels systemically;
                  - antibiotic-laden cement is usually used in conjunction w/ conventional doses of antibiotic agents given systemically;
                  - once the cement has hardened, the component can be placed into the medullary canal and into the acetabulum;
                  - the spacer will deliver high concentrations of ATB and will help prevent shortening;
                  - consider coating a small inexpensive femoral component w/ antibioitic laden cement;
                  - postoperatively, these patients need to be touch down wt bearing only;
                  - outcomes:
                        - in the study by Koo et al., 21 of 22 patients were sucessfully treated w/ staged revision using 2 g each of vanc, gent,
                                and cefotaxime per 40 g of cement;
                  - references: 
                         - Treatment of infection with bone loss in the proximal part of femur in 2 stages with antibiotic loaded interval prosthesis
                         - Two-stage revision hip arthroplasty for infection: comparison between the interim use of antibiotic-loaded cement beads and a spacer prosthesis.
                         - Impregnation of vancomycin, gentamicin, and cefotaxime in a cement spacer for two-stage cementless reconstruction in infected total hip arthroplasty. 
                         - The use of two-stage exchange arthroplasty with depot antibiotics in the absence of long-term antibiotic therapy in infected total hip replacement.
                         - The "glove" technique: a modified method for femoral fixation of antibiotic-loaded hip spacers.

Partial Two-stage Exchange for Infected Total Hip Arthroplasty: A Preliminary Report
Retaining well-fixed cementless stem in the treatment of infected hip arthroplasty Good results in 19 patients followed for mean 4 years