arthroplasty•opsurg-609-revision-arthroplast-2

Two-Stage Revision for Periprosthetic Joint Infection - Hip

advanced Level

180 mins

Primary Indication

Chronic periprosthetic joint infection (PJI)

Danger Structures

Sciatic nerve - 15-30mm posterior to hip joint depending on approach and position, injury causes foot drop and sensory loss - EXAM KEY: identify and protect, keep hip flexed to relax nerve
Femoral neurovascular bundle - 30-50mm medial to anterior hip joint, injury catastrophic - EXAM KEY: stay on bone with anterior retractors
Superior gluteal neurovascular bundle - 30-50mm proximal to greater trochanter, injury causes abductor weakness - EXAM KEY: avoid proximal dissection, stay in safe zone
Lateral femoral cutaneous nerve - variable position 20-50mm from anterior incisions, injury causes meralgia paresthetica - EXAM KEY: protect when visible
Medial femoral circumflex artery - main blood supply to femoral head, at risk during capsulotomy - EXAM KEY: careful dissection around posterior femoral neck

Visual Atlas

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Step-by-Step Technique

Preoperative Diagnosis & Planning

MSIS CRITERIA: ≥2 of: (1) sinus tract, (2) elevated synovial WBC/PMN%, (3) elevated serum ESR/CRP, (4) positive culture (2+ samples), (5) histology >5 PMN/HPF. Hold antibiotics 2 weeks pre-op if possible. Obtain aspiration culture. Image bone stock (AP/lateral hip, CT if needed). Order antibiotic cement (vancomycin + tobramycin). Cell saver contraindicated.

Surgeon's Tip

EXAM KEY: '2-stage revision is GOLD STANDARD for chronic PJI (>4 weeks). Success rate 85-90%. MSIS criteria diagnose infection. MUST identify organism to guide antibiotics - aspiration pre-op or multiple intraop cultures. Antibiotic holiday 2 weeks pre-op improves culture yield.'

Danger Zone

Operating with unknown organism (reduces success)
Operating through active infection elsewhere

Positioning & Exposure (Stage 1)

LATERAL DECUBITUS position. Posterior approach most common (preserves abductors for revision). May need EXTENSILE EXPOSURE if scarred. Identify SCIATIC NERVE early - may be adherent in scar tissue. Wide draping for extensibility. Mark greater trochanter and plan for potential ETO.

Surgeon's Tip

EXAM KEY: 'Posterior approach standard - allows ETO if needed. SCIATIC NERVE at highest risk in revision - identify early, protect throughout. May be displaced by scar or implant subsidence. ETO gives excellent exposure for cement removal.'

Danger Zone

Sciatic nerve injury (2-5% risk in revision)
Abductor disruption (increases dislocation risk)

Tissue Sampling

Before debridement, obtain 5-6 TISSUE SAMPLES from different sites (capsule, interface membrane, bone). Avoid superficial contamination. Send for aerobic, anaerobic, fungal cultures. Hold tissue culture 14 days. Send 1 sample for histology. Document sample sites.

Surgeon's Tip

EXAM KEY: 'Multiple tissue samples CRUCIAL - single cultures unreliable. Need ≥2 positive cultures with same organism. Tissue culture more sensitive than fluid. Hold 14 days (slow-growing organisms like Cutibacterium). Histology >5 PMN/HPF supports infection.'

Danger Zone

Inadequate sampling (missed diagnosis)
Contamination from superficial tissues

Component Removal

Dislocate hip. Remove FEMORAL HEAD first. Use CURVED OSTEOTOMES around acetabular cup interface. For femoral stem: EXTENDED TROCHANTERIC OSTEOTOMY if cemented or well-fixed - mark 8-10cm length, 1/3 circumference, preserve vastus lateralis attachment. Oscillating saw, hinge open like a book. Remove stem and ALL CEMENT.

Surgeon's Tip

EXAM KEY: 'ETO essential for cement removal - attempting without ETO risks perforation. ETO: 8-10cm length, hinge open trochanter with abductors attached. Preserve vastus lateralis blood supply. Allows complete cement extraction. Repair with cables later.'

Danger Zone

Femoral perforation (without ETO)
Trochanteric fracture propagation
Incomplete cement removal (biofilm reservoir)

Radical Debridement

AGGRESSIVE SYNOVECTOMY - remove ALL synovium and interface membrane (biofilm harbor). Remove all cement fragments, beads, PMMA debris. Debride NON-VIABLE BONE (sclerotic, grey, avascular). Use high-speed burr for cement, curettes for membrane. Rongeurs for osteolytic bone. Aim for bleeding healthy bone bed.

Surgeon's Tip

EXAM KEY: 'Radical debridement is KEY to success. Remove EVERYTHING foreign - implants, cement, membrane, non-viable bone. Interface membrane is biofilm - must be completely excised. Healthy bleeding bone required for reimplantation to succeed.'

Danger Zone

Inadequate debridement (persistent biofilm)
Excessive bone loss (compromises reimplantation)
Femoral or acetabular perforation

Irrigation

COPIOUS PULSE LAVAGE with minimum 9L normal saline (some use 15L). High pressure initially, then low pressure. No added antibiotics or Betadine (cytotoxic to osteoblasts). Change gloves, gowns, instruments after lavage. Re-drape if possible. FRESH IMPLANT SETS for spacer.

Surgeon's Tip

EXAM KEY: 'Minimum 9L saline irrigation - mechanical removal of bacteria and debris. High-volume lavage more important than additives. CHANGE ALL before spacer - reduces bacterial load. Fresh instruments, gloves, drapes = 'new operation'.'

Danger Zone

Inadequate volume (bacterial load remains)
Cytotoxic additives damaging bone bed

Antibiotic Spacer Insertion

ARTICULATING SPACER preferred (maintains length, offset, ROM, easier Stage 2). Options: (1) PREFORMED (PROSTALAC), or (2) HAND-MADE using femoral head mold for acetabulum, +36/40mm head. Mix HIGH-DOSE ANTIBIOTIC CEMENT: 4g vancomycin + 2.4g tobramycin per 40g cement (3× normal). Organism-specific if known. Ensure spacer is STABLE but retrievable (avoid excess cement into canal).

Surgeon's Tip

EXAM KEY: 'ARTICULATING spacer benefits: maintains length/offset, prevents soft tissue contracture, allows mobilization, easier Stage 2. HIGH-DOSE antibiotics: 4g vancomycin + 2.4g tobramycin per 40g cement (Hanssen protocol). Organism-specific if cultured - daptomycin for VRE, etc.'

Danger Zone

Spacer dislocation (13-15% with articulating)
Spacer fracture (usually late)
Inadequate antibiotic dosing

ETO Repair & Closure

If ETO performed: reduce trochanter anatomically. Fix with minimum 3 CERCLAGE CABLES (18-gauge stainless or titanium). Ensure cables engage intact bone proximally and distally to osteotomy. May augment with vertical cable. Repair posterior structures (capsule, short external rotators). Close fascia, subcutaneous, skin. DRAINS optional (some avoid in infection).

Surgeon's Tip

EXAM KEY: 'ETO repair: ≥3 cerclage cables. Must achieve stable compression for union. Cable proximal to osteotomy, around intact femur distally. ETO union rate >90% if properly fixed. Protected WB until union (6-8 weeks).'

Danger Zone

ETO non-union (inadequate fixation, infection)
Trochanteric escape (cables cut out)

Stage 1 Postoperative Management

IV ANTIBIOTICS 6 weeks minimum (per ID). Organism-specific: MRSA (vancomycin), MSSA (flucloxacillin), Gram-negative (fluoroquinolone), polymicrobial (broad spectrum). Monitor weekly CRP/ESR. MOBILIZE with walker/crutches - articulating spacer allows WBAT if stable. Hip precautions (dislocation risk). ANTIBIOTIC HOLIDAY 2 weeks before Stage 2.

Surgeon's Tip

EXAM KEY: '6 weeks IV antibiotics standard. May extend to 12 weeks for difficult organisms or extensive debridement. Include RIFAMPICIN for Staph (biofilm penetration) once wound healed. Monitor CRP - should trend down. Antibiotic holiday 2 weeks pre-Stage 2 improves culture accuracy.'

Danger Zone

Inadequate antibiotic duration (recurrence)
Spacer complications (dislocation, fracture)

Interval Assessment & Timing Stage 2

CRITERIA for Stage 2: (1) Completed antibiotic course, (2) CRP/ESR normalized or trending down (CRP <10, ESR <30), (3) Well-healed wound, (4) Patient medically optimized. MINIMUM 6-8 weeks interval (some wait 12+ weeks). If CRP elevated or doubt: ASPIRATION after 2-week antibiotic holiday. If positive culture: consider repeat debridement or suppression.

Surgeon's Tip

EXAM KEY: 'Timing Stage 2: normalized inflammatory markers, minimum 6-8 weeks interval, healed wound. If doubt: aspirate after antibiotic holiday. Positive aspiration = either repeat debridement or chronic suppression. Success drops if reimplant with active infection.'

Danger Zone

Reimplanting with persistent infection (failure)
Inadequate interval time

Stage 2 - Exposure & Spacer Removal

Same POSTERIOR APPROACH through scar. Expect MORE DIFFICULT than Stage 1 - scarred planes. Protect sciatic nerve. Dislocate hip, remove spacer HEAD then ACETABULAR component. Use osteotomes to break spacer cement interface. Remove femoral spacer - may need HIGH-SPEED BURR if well-fixed. Remove ALL spacer cement. Debride any residual membrane.

Surgeon's Tip

EXAM KEY: 'Stage 2 exposure often more challenging than Stage 1 - scar tissue, distorted anatomy. Articulating spacer easier to remove than static. Remove ALL spacer cement - biofilm can form on retained cement. Fresh debridement essential.'

Danger Zone

Neurovascular injury in scarred field
Fracture during spacer removal
Retained cement (infection risk)

Tissue Sampling & Frozen Section

Obtain 5-6 FRESH CULTURES before reimplantation. Send for same culture protocol as Stage 1. FROZEN SECTION: send capsule/interface tissue - >5 PMN/HPF suggests persistent infection (consider aborting reimplantation). If frozen section positive or gross purulence: place new spacer, do not reimplant. If clear: proceed.

Surgeon's Tip

EXAM KEY: 'Frozen section at Stage 2: >5 PMN/HPF = abort reimplantation. Sensitivity ~80%, specificity ~95%. If positive or gross infection: new spacer, extended antibiotics, consider suppression. Cultures at Stage 2 detect persistent/recurrent infection (10-20% reinfection rate).'

Danger Zone

Reimplanting with persistent infection
False negative frozen section

Acetabular Reconstruction

Assess bone loss (PAPROSKY classification). Ream to bleeding bone. TYPE I/IIA: standard uncemented cup with screws. TYPE IIB/IIC/IIIA: may need AUGMENTS, jumbo cup, or trabecular metal. TYPE IIIB: cup-cage construct or custom triflange. Aim for 50% host bone contact. Multiple screws into intact columns. HIGHLY CROSS-LINKED POLYETHYLENE liner.

Surgeon's Tip

EXAM KEY: 'Bone loss common after 2-stage (debridement + spacer wear). Paprosky guides reconstruction. Need 50% host bone contact for ingrowth. May require augments, cages, or structural allograft. Consider DUAL MOBILITY liner (reduces dislocation - already high risk).'

Danger Zone

Cup migration (inadequate bone contact)
Instability (soft tissue damage from stages)

Femoral Reconstruction

Assess bone loss (PAPROSKY femoral classification). TYPE I: standard uncemented stem. TYPE II/IIIA: EXTENSIVELY POROUS COATED stem (distal fixation) or tapered modular stem. TYPE IIIB: modular taper, megaprosthesis, or APC. If ETO: leave open until stem inserted. Use antibiotic-loaded cement if cementing (controversial - some avoid cement, others use low-dose antibiotic cement).

Surgeon's Tip

EXAM KEY: 'Femoral bone loss from debridement, ETO, spacer subsidence. Type III defects common - need diaphyseal fixation (extensively coated or modular taper). Cemented vs uncemented debated - many prefer cementless (no biofilm substrate). If cement: use antibiotic-loaded (1g vancomycin per 40g).'

Danger Zone

Stem subsidence (inadequate fixation)
Fracture (weakened bone from debridement)
Cement as biofilm substrate (if cemented)

Stability Assessment & Adjuncts

Trial components: assess STABILITY (high dislocation risk post-2-stage). If UNSTABLE: consider (1) CONSTRAINED LINER (10° or lipped), (2) DUAL MOBILITY cup, (3) Larger head (36mm or 40mm). Adjust offset and leg length. Ensure no impingement. Repair posterior structures meticulously. May need ABDUCTOR ADVANCEMENT if deficient.

Surgeon's Tip

EXAM KEY: 'Dislocation rate 10-15% after 2-stage (soft tissue damage, multiple surgeries, abductor weakness). Strategies: dual mobility cup, constrained liner, larger head (36/40mm), meticulous soft tissue repair. Dual mobility preferred (lower revision rate than constrained).'

Danger Zone

Instability (soft tissue incompetence)
Impingement (liner-neck, bone-bone)

ETO Repair & Final Closure

If ETO: anatomic reduction, ≥3 cerclage cables, ensure stable fixation. May add vertical cable or claw plate if unstable. Repair posterior capsule, short external rotators, gluteus maximus. Ensure tension restored. Close fascia, subcutaneous tissue, skin. Drains optional (many use in revision). INTRAOP IV ANTIBIOTICS (typically vancomycin + cephalosporin).

Surgeon's Tip

EXAM KEY: 'ETO repair critical at Stage 2 - bone quality may be compromised from infection. ≥3 cables minimum, ensure compression. Non-union risk higher after infection. Protected WB 6-8 weeks. Abductor repair crucial for stability.'

Danger Zone

ETO non-union
Abductor failure (instability, Trendelenburg)

Stage 2 Postoperative Antibiotics

Controversial. Options: (1) NO additional antibiotics if cultures negative and frozen section negative, (2) 6 weeks organism-specific IV if cultures from Stage 1 were positive, (3) CHRONIC SUPPRESSION (oral antibiotics lifelong) - some centers advocate for all 2-stage patients. Consult ID. Monitor CRP/ESR for 2 years (recurrence).

Surgeon's Tip

EXAM KEY: 'Post-Stage 2 antibiotics debated. Most give at least 6 weeks organism-specific if Stage 1 cultures positive. Some advocate chronic suppression (e.g., doxycycline) indefinitely - reduces reinfection 10-20% to 5-10%. Monitor CRP lifelong - recurrence can occur years later.'

Danger Zone

Reinfection (10-20% at 2 years)
Antibiotic resistance with prolonged suppression

Rehabilitation & Surveillance

HIP PRECAUTIONS 6-12 weeks (high dislocation risk). WEIGHT-BEARING: if ETO performed, protect (toe-touch or partial WB) until union (6-8 weeks), then progress. If no ETO and stable fixation: WBAT. Physiotherapy: gentle ROM, strengthen abductors. SURVEILLANCE: X-rays at 6 weeks, 3 months, 6 months, 12 months, annually. CRP/ESR at each visit first 2 years.

Surgeon's Tip

EXAM KEY: 'Outcomes 2-stage revision: infection control 85-90%, but higher dislocation (10-15%), loosening (10-15% at 10y), satisfaction lower than primary. Reinfection 10-20%. Long-term surveillance essential - CRP/ESR, X-rays. Counsel patient realistic expectations.'

Danger Zone

Recurrent infection (late)
Dislocation (early and late)
Aseptic loosening