Managing Extensive Femoral Bone Loss in 2-Stage Revision THA for Infection
A 57-year-old male with a history of multiple revision surgeries on his right hip presents with recurrent chronic periprosthetic joint infection. What is the best option to manage this patient at explantation and reconstruction?
Jessica L. Phillips, MD; Andrew Battenberg, MD; and P. Maxwell Courtney, MD
Periprosthetic joint infection (PJI) is a challenging complication following total hip arthroplasty (THA), with a reported incidence of 1% to 2%.  As demand for THA rises with population growth, and as risk factors for PJI (including obesity and diabetes) continue to increase in prevalence, the management of patients with PJI will remain a critical area for surgeons. [1-4]
Two-stage revision THA is the standard of care for chronic PJI, with a failure rate of less than 10%. [3,5,6] Nonetheless, recurrent PJI following 2-stage revision represents a devastating problem for both patients and surgeons.
Given the relative rarity of patients who fail 2-stage revision THA for PJI, there are few reports to provide guidance on management. [7-10] In a study by Kheir et al,  the success rate of irrigation and debridement alone was found to be as low as 43%. Additional studies have found that surgical management of failed 2-stage revision is associated with overall failure rates as high as 25%, with significantly increased mortality. [8-10]
Massive femoral bone loss in the repeatedly revised THA poses an added challenge to obtaining a functional reconstruction. Limitations associated with allografts and resection arthroplasty have led to an increase in the utilization of proximal femoral replacement for non-oncologic purposes. [11,12] However, a clear treatment algorithm is still lacking, and the management of recurrent PJI following 2-stage revision remains controversial.
In this article, we present a case of a patient with a chronic periprosthetic hip infection following multiple revision surgeries.
A 57-year-old male patient presented with right groin and thigh pain that had worsened over the past 2 years. He had undergone bilateral THA in 2003 for avascular necrosis, with 3 subsequent revision surgeries on his right hip. His most recent surgery, in 2010, involved a 2-stage exchange for infection with a modular tapered stem requiring an extended trochanteric osteotomy (ETO).
He has walked with a limp on the right side since his last surgery, and he reports that the pain is worse with ambulation. He has also noted drainage from his hip incision over the last 6 months, for which his primary care physician prescribed antibiotics.
His past medical history is significant for hypertension, asthma, and hyperlipidemia.
- Height: 6 feet; weight: 250 pounds; BMI: 34 kg/m2
- Multiple posterior and lateral incisions on the right hip
- 3-cm draining sinus on the right hip
- Antalgic gait; cane used for ambulation
- Right hip range of motion to 90 degrees of flexion, 20 of external rotation, and 10 of internal rotation
- Clinically equivalent leg lengths
- Normal distal motor and sensory exam
- Palpable pedal pulses
- Erythrocyte sedimentation rate: 54 mm/hour
- C-reactive protein: 28.2 mg/L
- Hip aspiration: 38,000 white blood cells, with 95% neutrophils
- Cultures: No growth at 3 days (the patient has been taking oral trimethoprim and sulfamethoxazole [Bactrim])
- Alpha-defensin: Positive
Figure 1. Radiographs on presentation show a modular tapered revision femoral stem with malunion of a prior extended trochanteric osteotomy and periosteal reaction concerning for osteomyelitis of his right proximal femur.
Figure 2. Three-phase bone scan from an outside facility demonstrates increased uptake in the right proximal femur.
- Chronic PJI and malunion of prior ETO following revision THA
We had several issues to consider in the management of this patient:
- Should we offer an irrigation and debridement with a ball head and liner exchange due to the morbidity of removing these revision components?
- If proceeding with explantation of the prosthesis and 2-stage revision arthroplasty, how can we best remove the distally fixed modular tapered stem?
- Can we preserve any of the proximal bone from the prior ETO for later reconstruction?
- What is the best option for a spacer in this patient: static or articulating?
- After appropriate treatment for the infection, what are the best options for femoral and acetabular reconstruction at the time of reimplantation?
After carefully discussing the risks and benefits of surgical treatment with this patient, and considering his young age and desire for the greatest chance for success in eradicating the infection, we decided to proceed with a 2-stage revision arthroplasty.
- Using a posterior approach to the hip, we excised the sinus tract and encountered purulence on opening the capsule.
- We carefully removed all infected proximal bone surrounding the prosthesis until healthy femoral bone was encountered distally.
- Using a pencil-tip burr, we circumferentially freed the distal portion of the modular tapered stem and removed the prosthesis.
- We then used the explant osteotomes to remove the acetabular cup and thoroughly debrided the wound.
- To preserve some function for the patient, we decided to use a cephalomedullary nail as an antibiotic spacer.
- We coated the nail with a total of 3 batches of high-viscosity cement mixed with 2 grams of vancomycin and 2.4 grams of tobramycin per batch.
- Using the head of the bulb syringe, we packed cement and placed it on the cephalomedullary screw to act as a femoral head (Figure 3).
- We had stopped antibiotics preoperatively to obtain adequate cultures. Intraoperative cultures grew methicillin-resistant Staphyloccocus aureus, and the patient was placed on 6 weeks of intravenous vancomycin therapy following surgery.
- Following a 2-week antibiotic holiday, inflammatory markers trended downward and the patient was scheduled for the second stage of his revision arthroplasty
- For the acetabulum, a porous metal augment was used to provide primary stability and restore the anatomic hip center.
- We also used a dual mobility bearing articulation to minimize the risk of dislocation.
- We then cemented a proximal femoral replacement to manage the extensive femoral bone loss.
Figure 3. Postoperative radiographs demonstrating the use of a cephalomedullary nail as an antibiotic spacer following resection of the proximal femur.
The patient was made toe-touch weight-bearing for 6 weeks to allow osseous integration of the acetabular component. Intraoperative frozen section and cultures were negative for infection. At 2 months after surgery, the patient was doing well and had advanced to full weight-bearing (Figure 4). He will remain on oral antibiotic suppression for a minimum of 3 months.
Figure 4. Radiographs at 2 months following the second stage reimplantation with a proximal femoral replacement and a multihole acetabular shell with a porous metal augment for primary stability.
- Despite the technical difficulty, removal of all implants and potentially infected bone is necessary to maximize the chance of eradicating the infection in multiply revised patients.
- A cephalomedullary nail is a reasonable option for an antibiotic spacer in patients with extensive femoral bone loss.
- Use of porous metal acetabular augments can help downsize the acetabular component to restore the anatomic hip center and maximize coverage.
Jessica L. Phillips, MD, is an orthopaedic resident at Thomas Jefferson University Department of Orthopaedic Surgery, Philadelphia, Pennsylvania. Andrew Battenberg, MD, is an adult reconstruction fellow with The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania. P. Maxwell Courtney, MD, is an Assistant Professor of Orthopaedic Surgery at Thomas Jefferson University Hospital and attending surgeon at The Rothman Institute, Philadelphia, Pennsylvania.
Adult Reconstruction Section Editor, Rothman Institute Grand Rounds
The authors have no disclosures relevant to this article.
- O’Toole P, Maltenfort MG, Chen AF, Parvizi J. Projected increase in periprosthetic joint infections secondary to rise in diabetes and obesity. J Arthroplasty. 2016;31(1):7-10.
- Dale H, Fenstad AM, Hallan G, et al. Increasing risk of prosthetic joint infection after total hip arthroplasty. Acta Orthop. 2012;83(5):449-458.
- Ibrahim MS, Twaij H, Haddad FS. Two-stage revision for the culture-negative infected total hip arthroplasty: a comparative study. Bone Joint J. 2018;100-B(1 Supple A):3-8.
- Brochin RL, Phan K, Poeran J, Zubizarreta N, Galatz LM, Moucha CS. Trends in periprosthetic hip infection and associated costs: a population-based study assessing the impact of hospital factors using national data. J Arthroplasty. 2018.
- Puhto AP, Puhto TM, Niinimäki TT, Leppilahti JI, Syrjälä HP. Two-stage revision for prosthetic joint infection: outcome and role of reimplantation microbiology in 107 cases. J Arthroplasty. 2014;29(6):1101-1104.
- Cooper HJ, Della Valle CJ. The two-stage standard in revision total hip replacement. Bone Joint J. 2013;95-B(11 Suppl A):84-87.
- Mortazavi SM, O’Neil JT, Zmistowski B, Parvizi J, Purtill JJ. Repeat 2-stage exchange for infected total hip arthroplasty: a viable option? J Arthroplasty. 2012;27(6):923-926.e921.
- Kheir MM, Tan TL, Gomez MM, Chen AF, Parvizi J. Patients with failed prior two-stage exchange have poor outcomes after further surgical intervention. J Arthroplasty. 2017;32(4):1262-1265.
- Leung F, Richards CJ, Garbuz DS, Masri BA, Duncan CP. Two-stage total hip arthroplasty: how often does it control methicillin-resistant infection? Clin Orthop Relat Res. 2011;469(4):1009-1015.
- Berend KR, Lombardi AV, Morris MJ, Bergeson AG, Adams JB, Sneller MA. Two-stage treatment of hip periprosthetic joint infection is associated with a high rate of infection control but high mortality. Clin Orthop Relat Res. 2013;471(2):510-518.
- Grammatopoulos G, Alvand A, Martin H, Whitwell D, Taylor A, Gibbons CL. Five-year outcome of proximal femoral endoprosthetic arthroplasty for non-tumour indications. Bone Joint J. 2016;98-B(11):1463-1470.
- Viste A, Perry KI, Taunton MJ, Hanssen AD, Abdel MP. Proximal femoral replacement in contemporary revision total hip arthroplasty for severe femoral bone loss: a review of outcomes. Bone Joint J. 2017;99-B(3):325-329.