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    Partial Radical Debridement: Heresy, or Cautiously Optimistic?

    At ICJR’s Pan Pacific Orthopaedic Congress, Dr. Adolph Lombardi discussed an alternative to removing a well-fixed femoral stem in periprosthetic joint infection of the hip. Following is the abstract of his presentation.

    By Adolph V. Lombardi Jr., MD, FACS

    Eradication of periprosthetic joint infection after total hip arthroplasty (THA) is an ongoing challenge.

    The common, recommended treatment for an infected THA is two-stage exchange, including removal of all components. However, removal of well-fixed femoral stems can result in bone damage and compromised fixation.

    We recently reported on an alternative treatment of partial two-stage exchange used in selected cases, in which the well-fixed femoral stem was left in place and only the acetabular component was removed. The joint space was débrided thoroughly, and an antibiotic-laden polymethylmethacrylate spacer was molded using a bulb-type syringe and placed in the acetabulum. Delayed reimplantation was performed, with intravenous antibiotics administered during the interval.

    In 19 patients treated with this technique from 2000 to January 2011, 89% were free of infection at a mean follow-up of 4 years. During the study period, this represented 7% (19 of 262) of the patients whom we treated for a chronically infected THA.

    Two patients (11%), both with prior failure of two-stage treatment of infection, failed secondary to recurrence of infection at an average of 3.3 years. There were no patient deaths within 90 days. Postoperative Harris hip score averaged 68 (range, 31-100).

    Since then, disposable silicone molds (Stage One Select Hip Spacer Molds; Biomet, Inc., Warsaw, Indiana) have become available to fabricate the spacers in separate femoral and head units. The head spacer mold, which can incorporate various taper adapter options, greatly facilitates the technique of partial two-stage exchange.

    We are currently reporting our early experience using disposable silicone head spacer molds for partial two-stage exchange in 7 patients with infected THA. Follow-up after reimplantation averaged 1.5 years (range, 4 months to 3 years). One patient expired 2 years after reimplantation with no recurrence of infection. No patients were lost to follow-up.

    One patient evaluated at 4 months postoperative was noted to have a 7-cm fluid collection in the hip and redness at the incision. Her serum ESR was 87 mm/hour (normal, 0-30 mm/hour) and CRP was 57.2 mg/L (normal, 0.0-9.9 mg/L). Radical débridement was recommended; however, the patient has declined to schedule. There have been no other complications or further surgical procedures.

    Eradication of infection has been successful in 6 of 7 patients (86%). The mean postoperative Harris hip score at most recent evaluation was 71.8 (range, 44-90).

    As 89% and 86% of patients in these two series were clinically free of infection at follow-up, we believe partial two-stage exchange may represent an acceptable option for patients with infected THA when femoral component removal would result in significant bone loss and compromise of reconstruction. Further study is required on this approach.

    Dr. Lombardi’s presentation can be found here.

    References

    1. Ekpo TE, Berend KR, Morris MJ, Adams JB, Lombardi AV Jr. Partial two-stage exchange for infected total hip arthroplasty: A preliminary report. Clin Orthop Relat Res 2014;472(2):437-48.
    2. Lombardi AV Jr, Berend KR, Adams JB. Partial two-stage exchange of the infected total hip arthroplasty using disposable spacer molds. Bone Joint J, 2014;96-B(Supple A):66-69