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. 2016 Oct 10;16:553. doi: 10.1186/s12879-016-1869-4

Does cemented or cementless single-stage exchange arthroplasty of chronic periprosthetic hip infections provide similar infection rates to a two-stage? A systematic review

D A George 1,, N Logoluso 2, G Castellini 3,4, S Gianola 4,5, S Scarponi 2, F S Haddad 1, L Drago 4,6, C L Romano 2
PMCID: PMC5057405  PMID: 27724919

Abstract

Background

The best surgical modality for treating chronic periprosthetic hip infections remains controversial, with a lack of randomised controlled studies. The aim of this systematic review is to compare the infection recurrence rate after a single-stage versus a two-stage exchange arthroplasty, and the rate of cemented versus cementless single-stage exchange arthroplasty for chronic periprosthetic hip infections.

Methods

We searched for eligible studies published up to December 2015. Full text or abstract in English were reviewed. We included studies reporting the infection recurrence rate as the outcome of interest following single- or two-stage exchange arthroplasty, or both, with a minimum follow-up of 12 months. Two reviewers independently abstracted data and appraised quality assessment.

Results

After study selection, 90 observational studies were included. The majority of studies were focused on a two-stage hip exchange arthroplasty (65 %), 18 % on a single-stage exchange, and only a 17 % were comparative studies. There was no statistically significant difference between a single-stage versus a two-stage exchange in terms of recurrence of infection in controlled studies (pooled odds ratio of 1.37 [95 % CI = 0.68-2.74, I2 = 45.5 %]).

Similarly, the recurrence infection rate in cementless versus cemented single-stage hip exchanges failed to demonstrate a significant difference, due to the substantial heterogeneity among the studies.

Conclusion

Despite the methodological limitations and the heterogeneity between single cohorts studies, if we considered only the available controlled studies no superiority was demonstrated between a single- and two-stage exchange at a minimum of 12 months follow-up. The overalapping of confidence intervals related to single-stage cementless and cemented hip exchanges, showed no superiority of either technique.

Keywords: Infection, Periprosthetic hip infections, Exchange arthroplasty, Single-stage, Two-stage, Cemented, Cementless

Background

There remains an ongoing discrepancy in the literature between the infection recurrence rates after a single-stage exchange arthroplasty compared to a two-stage exchange for chronic periprosthetic hip infections. Infection has been reported as the third reason for revision after total hip arthroplasty in the USA [1], complicating 0.5 to 2 % of primary arthroplasties [24].

The operative approach is determined by a combination of surgeon, patient, joint, and infection factors. Literature regarding the optimal inclusion and exclusion criteria for each modality is varied, but there is a general consensus that a two-stage exchange should be undertaken in patients with unknown pathogens or those of high-virulence [57].

Previous attempts at addressing this issue have been undertaken by various prospective [810] and retrospective cohort studies [1113] comparing the modalities used, or systematic reviews [14, 15], but due to various limitations, such as determining the ‘ideal candidate’ for each treatment, a definitive conclusion has not been shown.

In the lack of large prospective, randomised controlled comparative trials, this comprehensive systematic review and meta-analysis of observational studies was undertaken to investigate the relative efficacy, in terms of recurrence of the infection, in a single- compared to two-stage exchange arthroplasty for chronic periprosthetic hip infection. A similar review has been recently reported for periprosthetic knee and shoulder infections [16, 17]. In addition, we aim to further analyse the infection rates after cemented and cementless single-stage exchanges, which have not been previously undertaken.

Methods

Search startegy

We searched for studies published up to December 2015 on the following databases: EMBASE; PubMed/Medline; Medline Daily Update; Medline In-Process and other non-indexed citations; Google Scholar; SCOPUS; CINAHL; Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews; NHS Health Technology Assessment; http://www.google.com; and http://www.yahoo.com. The search was executed using MeSH and text keywords [see Appendix 1] and adapted for each database in order to achieve more sensitivity. Original study reports as well as review articles were retrieved, and the reference lists from all reviewed articles were assessed to complete the literature search. No language restrictions were applied.

Eligibility criteria

We included studies that fuflilled the following inclusion criteria: (a) sample of at least 4 patients with prosthetic hip infection that underwent a surgical revision; (b) single-stage or two-stage exchange arthroplasty as surgical treatment; (c) a minimum follow-up of 12 months; (d) study reporting results relating to delayed or chronic infection (6 weeks or later) stages of disease; (e) recurrent infection after treatment as outcome; (f) study design classifiable as comparative study, prospective or retrospective study with no compared group.

Study selection

Two investigators independently searched and reviewed the literature and classified the references in terms of whether they should be included on the basis of the title and abstract. In order to include all studies, if full text was not avaiable, abstracts with enough information to be qualitative and quantitative assessed were included. If more than one paper by the same author(s) was retrieved and their follow-ups were found to overlap, only the most recent reference with the longest follow-up and largest patient series was included. Discrepancies were solved by consusus.

Data extraction

Data collection was performed by four reviewers. The following data were extracted: name of author, year of publication, type of study design, minimum, maximum and mean period of follow up, number of patients included and number of recurrent infections (in case of comparative studies number of patients per group).

Outcome

Our primary outcome was the recurrent infection rate. We chose to extract data only of patients who completed the single-stage or the two-stage revision. We did not include patients that had received a supplemental revision for a new infection following the prior septic revision, nor those who did not receive the complete reimplantation process, or died for cause unrelated to infection recurrence.

Quality assessment

In order to reflect the information expected to be present in each included study, as a measure of quality we selected and evaluated the following two bias: (1) retrospective or prospective analysis and source of data (record bias); (2) relevance and definition of measured outcome for infection (reporting bias). Two independent reviewers performed the quality assessment; disagreements were resolved by consensus.

Statistical analysis

Infection recurrence rates were treated as dichotomous variables using the odds ratio (OR) for meta-analysis of controlled studies (single-stage versus two-stage) and the ratio between number of infection and total number of patients for proportional meta-analysis of cohort studies reporting only one treatment group, along with 95 % confidential intervals (CI).

The analysis was performed using extracted patient data from the individual studies. Because of the differences among the included studies and several uncontrolled variables, we used a random-effect model [18]. The results from individual trials were combined when possible, but otherwise single forest plots will be reported without the overall duration of follow-up.

In single forest plot, each horizontal line on the graph represents a case series included in the meta-analysis. The estimated effect is marked with a solid black square, and the size of the square represents the weight of the corresponding study plotted in the meta-analysis. The combined total estimate is marked with an unfilled diamond at the bottom of the forest plot. Statistical heterogeneity was assessed using the I2 statistic and assume influential when the I2 was greater than 50 % and p < 0.05 as statistically significant for the calculation of heterogeneity; I2 illustrates the percentage of the variability in effect estimates resulting from clinical and/or methodological heterogeneity rather than sampling error [19, 20].

Forest plots were presented for the following interventions: single-stage, two-stage, single-stage cemented, and single-stage cementless hip arthroplasties. The presence of an overlap of the confidence intervals from the two interventions, for example between single-stage and two stage exchanges, suggests similar effect of the interventions on the outcome. Alternatively, non-overlapping CIs suggest different effects from the interventions studied [21].

We used the following software: StatsDirect [StatsDirect Ltd, Cheshire, UK] for the proportional meta-analyses and Review Manager [RevMan version 5.2, The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen 2012] for meta-analyses in controlled studies.

Results

Selection and characteristics of studies

The results of the study selection are shown in Fig. 1. We found 90 original observational studies. Sixteen studies reported the results only after a single-stage exchange, 59 reported only a two-stage hip exchange and 15 reported the comparison of a single-stage versus a two-stage. Overall, 31 original studies reported data about single-stage hip exchange arthroplasty (number of patients, n = 1608), which included 27 full text and 4 abstracts. Seventyfive studies reported on two-stage exchanges (n = 3679), of which 68 were full texts and 7 abstracts. Characteristics of the included studies are summarized in Table 1.

Fig. 1.

Fig. 1

Flow diagram of study selection process

Table 1.

General characteristics, record bias and reporting bias of included studies

Study First Author Ref. Year Patients (n) Stage Investigated Follow Up (months) Design Record Bias Reporting Bias (Outcome Measure)
Min Max Mean
Babiak [28] 2012 9 Two 36 180 84 NA Yes NA
Babis [29] 2015 31 Two 20 48 30 Retrospective Yes Symptoms, Imaging, Laboratory
Berend [30] 2013 186 Two 24 180 53 Retrospective NR Culture
Biring [31] 2009 48 Two 120 180 144 Retrospective Yes Culture
Bori [32] 2014 24 Single 25 94 45 Retrospective Yes Culture
Buchholz [33] 1981 583 Single 24 132 Prospective Yes Culture
Buttaro [34] 2005 29 Two 24 60 32.4 Retrospective Yes Symptoms, Imaging, Laboratory
Cabrita [8] 2007 38 Two 24 102 48 Prospective Yes Culture
Callaghan [35] 1999 12 Single 12 168 109.2 Retrospective Yes Imaging
Camurcu [36] 2015 41 Two 24 96 54 Retrospective Yes Culture
Carlsson [37] 1985 72 Both 12 72 Prospective Yes Symptoms, Imaging, Culture
Chen [38] 2015 155 Two 36 180 116.4 Retrospective NR Culture
Choi [12] 2013 61 Both 12 132 61 Retrospective Yes Culture
Colyer [10] 1994 37 Two 12 88 36 Unclear Yes Culture
Cordero-Ampuero [39] 2009 36 Two 12 144 52.8 Prospective Yes Culture
D'Angelo [40] 2011 28 Two 18 106 53 Retrospective Yes Symptoms, Imaging, Laboratory
Darley [41] 2009 19 Two 24 36 26 Prospective Yes Symptoms, Culture
De Man [42] 2011 72 Both 17 204 60 Retrospective Yes Culture
Degen [43] 2012 30 Two 24 70 43 Retrospective Yes Symptoms, Culture
Ekpo [44] 2014 19 Two 24 132 48 Retrospective Yes Laboratory, Culture
Evans [45] 2004 23 Two 24 108 48 Prospective NR Symptoms, Culture
Fehring [46] 1999 25 Two 24 98 41 Prospective Yes Symptoms, Laboratory
Fink [47] 2009 36 Two 24 60 35 Prospective Yes Culture
Fitzgerald [48] 1985 131 Two 24 108 49 Retrospective Yes Symptoms
Gao [49] 2008 15 Both 12 37 19 NA NA Culture
Garvin [50] 1994 40 Both 24 120 60 NA NA Culture
Haddad [51] 2000 50 Two 24 104 69.6 Retrospective Yes Symptoms
Hofmann [52] 2005 27 Two 28 148 76 Retrospective Yes Symptoms, Imaging, Laboratory
Hope [53] 1989 80 Both 2 121 Retrospective Yes Culture
Hsieh [55] 2004 128 Two 24 96 58.8 Retrospective Yes Symptoms, Laboratory
Hsieh [11] 2009 99 Two 24 60 43 Retrospective Yes Symptoms, Culture
Hsieh [54] 2013 28 Two 48 120 86 Retrospective Yes Symptoms,Culture, Laboratory
Hughes [24] 1979 26 Both 32 83 51 Retrospective Yes Symptoms, Imaging, Laboratory, Culture
Ibrahim [56] 2014 125 Two 60 75 103.2 Retrospective Yes Symptoms, Laboratory, Culture
Ilchmann [57] 2015 38 Single 24 181.2 79.2 Retrospective Yes Symptoms, Culture
Jenny [58] 2014 63 Single 36 72 Retrospective Yes Symptoms, Culture
Johnson [59] 2013 66 Two 24 105 45 Retrospective Yes Symptoms, Laboratory, Culture
Karpas [60] 2003 18 Two 24 120 42 Retrospective Yes NR
Kent [61] 2010 12 Two 26 60 38 Retrospective NR NR
Ketterl [13] 1988 161 Two 24 168 32 NA NA NA
Kim [63] 2011 130 Two 60 168 124.8 Retrospective Yes Laboratory, Culture
Klouche [22] 2012 84 Both 24 68 35 Prospective Yes Culture
Koo [62] 2001 22 Two 24 78 41 Prospective Yes Symptoms, Imaging, Laboratory
Lai [64] 1996 39 Two 30 84 48 Prospective Yes Symptoms, Laboratory
Lee [65] 2013 17 Two 24 96 48 Retrospective Yes Symptoms, Laboratory, Culture
Leung [66] 2011 38 Two 24 123 58 Retrospective Yes Symptoms,Laboratory
Li [67] 2015 10 Both 78 187.2 103.2 Retrospective Yes Symptoms, Laboratory, Culture
Lieberman [68] 1994 32 Two 24 74 40 Retrospective NR NR
Macheras [69] 2012 35 Two 84 168 139.2 Retrospective Yes NR
Magnan [70] 2001 8 Two 24 48 35 Retrospective NR NR
Masri [71] 2007 29 Two 24 88 47 Retrospective Yes Symptoms, Laboratory
McDonald [72] 1989 81 Two 24 163.2 66 Prospective Yes Culture
McKenna [73] 2009 30 Two 24 60 35 Retrospective Yes Laboratory
Miley [74] 1982 46 Single 32 48.5 Prospective NR Unclear
Morales [75] 1999 37 Two 36 156 57.6 NA NA NA
Morscher [76] 1994 74 Both 12 132 84 NA Yes Symptoms, Imaging, Laboratory
Mulcahy [77] 1996 15 Single 24 84 53 Retrospective Yes Symptoms, Imaging, Laboratory, Culture
Nestor [78] 1994 34 Two 24 72 47 Retrospective Yes Culture
Neumann [79] 2011 44 Two 36 120 67 Retrospective Yes Laboratory
Nusem [80] 2006 18 Two 60 168 108 Retrospective Yes Unclear
Oussedik [9] 2010 50 Both 66 105.7 81.6 Prospective Yes Imaging, Laboratory
Pignatti [81] 2010 41 Two 60 120 63.6 Retrospective Yes Symptoms, Imaging, Laboratory
Raut [82] 1995 57 Single 24 151 88 Prospective Yes Symptoms, Laboratory
Romanò [83] 2012 183 Two 24 104 56 Retrospective Yes Laboratory, Culture
Rudelli [84] 2008 32 Single 24 96 52.8 Unclear Yes Imaging, Laboratory, Culture
Sabry [85] 2013 78 Two 24.3 135.3 58 Retrospective Yes Symptoms, Laboratory
Sanchez [86] 2009 168 Two 24 192 84 Retrospective Yes Symptoms, Culture
Sanzen [87] 1988 102 Both 24 108 Prospective Yes Culture
Schneider [88] 1989 26 Single 12 108 NA Yes NA
Schwarzkopf [89] 2014 56 Two 12 32.4 Retrospective Yes Laboratory, Culture
Seung-Jae [90] 2009 34 Two 24 120 52.8 Retrospective Yes Symptoms, Culture
Stockley [91] 2008 114 Two 24 175 74 Prospective Yes Symptoms, Laboratory, Culture
Sudo [25] 2008 7 Two 27.6 73.2 60 Retrospective Yes Symptoms, Imaging, Laboratory
Takigami [92] 2010 8 Two 24 81 49 Retrospective Yes Symptoms, Laboratory
Thabe [93] 2007 16 Two 72 120 75.6 Prospective Yes NR
Toulson [94] 2009 82 Two 24 203 64.8 Retrospective Yes Unclear
Ure [95] 1998 20 Single 42 205.2 118.8 Prospective Yes Symptoms, Imaging, Laboratory, Culture
van Diemen [96] 2013 136 Two 24 180 72 Retrospective Yes Symptoms, Imaging, Laboratory, Culture
Wang [97] 2011 12 Two 36 96 64.8 NA Yes NR
Weber [98] 1986 33 Both 60 96 72 Retrospective NR Laboratory
Whittaker [99] 2009 41 Two 25 83 49 Retrospective Yes Culture, Laboratory
Wilson [100] 1974 19 Single 24 Prospective Culture
Wilson [24] 1989 22 Both 36 120 60.2 Prospective Yes Symptoms, Imaging, Laboratory
Winkler [27] 2008 37 Single 63 183 103 Prospective Yes Symptoms, Imaging, Laboratory
Wolf [101] 2014 92 Both 24 Retrospective Yes Symptoms, Laboratory, Culture
Wroblewski [23] 1986 101 Single 38.8 Prospective NR NR
Yamamoto [102] 2003 17 Two 14 62 38 Retrospective Yes Laboratory
Yoo [103] 2009 12 Single 39.6 135.6 86.4 Prospective Yes Laboratory, Culture
Younger [104] 1997 48 Two 24 63 43 Prospective Yes Culture
Zeller [105] 2014 99 Single 24 41.6 Prospective Yes NA

The number of patients undergoing a single-stage exchange ranged from 12 to 583, with a follow-up of 12 to 183 months. Considering a single-stage exchange performed with cementless implants (with or without antibiotic-loaded bone grafts) we found a total of 148 patients (mean follow-up: 78.1 months) whereas for single-stage exchange performed with cemented implant involved 1271 patients (mean follow-up: 78.1 months). The number of cases for only two-stage exchange studies ranged from 7 to 186, with a follow-up of 12 to 203 months.

Quality assessment

The quality of included studies is shown in Table 1. Overall, 62 % of included studies were retrospective, 29 % prospective and 8 % were not definable because the full text was unavailable. Observational studies can produce high quality information but, given the nature of these study design, the lack of a control group and the likely confounding variables, the methodological quality was limited leading to difficult generalisation of results. The outcome was specified in the majority of the studies (84 %), selecting infection recurrence as the elective outcome to reflect the success of the two types of interventions. In the half of the included studies, the infection recurrence was diagnosed with more than two measurements (i.e. positive culture, clinical symptoms, imaging etc.). Nevertheless, a unique and universal definition of ‘hip periprosthetic infection’ was not adopted and among studies.

Concerning data reporting, only 57.3 % of the studies gave a description of their criteria for selecting either a single- or two-stage exchange arthroplasty. Other relevant variables such as the indication for primary hip arthroplasty or host type were poorly reported (49.0 % and 36.5 % respectively). Other variables, such as age (90.7 %), gender (86.4 %), isolated pathogen (91.6 %), duration of interim period between stages (88.6 %), implant type used at exchange arthroplasty (72 %), length of antibiotic therapy (76.3 %), number of patients lost to follow-up (73.8 %) were more often reported.

Recurrent infection

Single-stage vs two-stage

We have analysed the data using a random-effects model to incorporate the wide range of variables.

The mean pooled proportion of recurrent infection was 12 % (95 % CI = 8 %-17 %) in single-stage hip exchange (1608 cases, n = 31 studies) and demonstrated high clinical and methodological inconsistency between the studies included (I2 value = 80.3 %, p < 0.0001) (Fig. 2).

Fig. 2.

Fig. 2

Proportional meta-analysis regarding infection recurrence after single-stage hip arthroplasty

The mean pooled proportion of recurrence of infection was 9 % (95 % CI = 8 %-11 %) in two-stage hip exchange (3679 cases, n = 74 studies) and demonstrated moderate clinical and methodological inconsistency between the studies included (I2 value = 50.3 %, p < 0.0001) (Fig. 3).

Fig. 3.

Fig. 3

Proportional meta-analysis regarding infection recurrence after two-stage hip arthroplasty

The combined overlapped CIs from single- and two-stage exchanges suggests similar effect between the interventions, as represented in Fig. 4. This estimate was confirmed by the comparisons of the available controlled studies (n = 15): no statistically significant difference between people undertaking a single- versus a two-stage exchange in terms of recurrence of infection with a pooled odds ratio of 1.37 (95 % CI = 0.68-2.74, I2 = 45.5 %, p = 0.03) (Fig. 5).

Fig. 4.

Fig. 4

Combined overlapped CIs from single- and two-stage exchange proportional meta-analyses

Fig. 5.

Fig. 5

Meta-analysis regarding infection recurrence after single-stage versus two-stage–exchange

Single-stage cementless vs single-stage cemented

The mean pooled proportion of infection recurrence in a single-stage hip cementless exchange (148 cases, n = 6 studies) was 14 % (95 % CI 4 %-28 %), whereas in a cemented exchange (1271 cases, n = 19 studies) it was 12 % (95 % CI 7 %-17 %). In both analyses a high clinical and methodological inconsistency was shown between the included studies (I2 value = 77.4 % for cementless and I2 value = 83.3 % for cemented; p < 0.0001).

Figures 6 and 7 present the pooled proportion for cementless and cemented hip exchanges. The combined overlapped 95 % CIs from cementless and cemented single-stage exchanges suggests similar effect between the interventions studied, as represented in Fig. 8.

Fig. 6.

Fig. 6

Proportional meta-analysis regarding infection recurrence after cementless single-stage exchange

Fig. 7.

Fig. 7

Proportional meta-analysis regarding infection recurrence after cemented single-stage exchange

Fig. 8.

Fig. 8

Combined overlapped CIs from cementless and cemented single-stage exchange

Discussion

This systematic review analyses the current published literature regarding a single- and two-staged exchange for hip periprosthetic infections, where the number of reported two-stage exchange arthroplasty studies largely exceeds that of a single-stage ones.

This study includes a much higher number of studies and patients compared to previous systematic reviews comparing both treatment options in a more limited population [14, 15] and is also, to our knowledge, the first attempt to investigate separately cemented and cementless one-stage revision procedures.

Our results failed to demonstrate a statistical difference between a single- and two-stage exchange arthroplasty, when applying a random effect model. Lange et al. [14] identified only a limited superiority of two-stage exchange arthroplasty in infection eradication, highlighting the low quality of available material, while Beswisk et al. [15] could not demonstrate any difference in eradication rates following a systematic review of studies with a minimum of 24 months of follow-up.

In line with these findings, when considering comparative studies only, the available material did not allow us to prove the superiority of single- or two-stage exchange arthroplasty, while a high heterogeneity of results was observed. As an example, Klouche and co-workers [22], recently reported no infection recurrence after single-stage exchange arthroplasty, even without using antibiotic-loaded cement, while Wolf et al. [23] demonstrated a 43 % infection recurrence rate after single-stage exchange, compared to only 4 % after two-stage revision. Further analysing their data, these authors provided evidence that the difference between the two treatments could be due to the better results obtained with a two-stage approach in more compromised hosts, while either seem to perform equally well, when normal hosts and early infections are involved [23].

Based upon the random-effects model used in our study, the rate of infection recurrence following a single-stage cementless exchange arthroplasty is not significantly different from single-stage cemented exchange. Once again, the limited number of studies and heterogeneity between both types, cemented and cementless, are worth considering.

More generally, the following limitations of the present study do apply. Patient selection and the eligibility for a single- or two-stage exchange arthroplasty may differ across centers; pathogen and host’s type, implant model and degree of bone loss, type of hip spacer, use and dose of local antibiotics, time interval between stages, post-operative systemic antibiotic treatment, definition of infection, diagnosis and surveillance protocols are all important variables [5, 11, 2427] that were not reported uniformly across studies and were not considered in the present analysis.

A further limitation of this review concerns the study end-point, that we restricted to reporting infection recurrence, which limits the ability to catch differences in functional outcome, quality of life, or economical impact related to a given surgical option. In addition, we paid attention to the definition of measurements for recurrence of infection in order to investigate the “outcome reporting bias” but we were unable to distinguish between recurrent and new infections, as such a distinction was not made in the majority of the studies. The conventional definition of a ‘new’ infection is the isolation of a new microorganism, as opposed to the detection of the same pathogen in ‘recurrent’ infections, however we feel such a differentiation is unreliable. The microbiological results following periprosthetic samples are too unpredictable, especially after previous antibiotic treatment. The criteria for differentiating between recurrent and new infections is weakly supported in the literature, and somewhat artificial [16].

Classifing the design of included studies in order to judge their quality and internal validity was difficult. In fact, for an important part of studies the design assigned was unclear, and considering the inclusion of a paper or abstract published only in English we had an additional limit.

We found a substantial presence of the “record bias” for the majority of studies. Out of the 90 studies included, only 15 studies had a controlled group. The lack of a control group, and the prospective collection of data according to a protocol established before the beginning of the study, can affect the methodological quality limiting the external validity of findings.

We call for the need of large, multi-center randomised controlled trials with higher quality assessment in order to establish the superiority of one type of surgical treatment over another. However, certain circumstantial limitations such as the low incidence of the disease, relatively small patient cohorts, need for long-term follow-up, and variations in microorganisms and patients’ co-morbidities, would also make a large controlled prospective study in this field extremely challenging.

Conclusion

No superiority was seen for a two-stage exchange arthroplasty over that of a single-stage for chronic periprosthetic hip infections, nor a statistical difference between cemented and cementless single-stage exchanges. This may reflect the shear complexity of this patient cohort and the difficulty in finding the true answer, and further reiterates that the ultimate choice of treatment modality depends on a variety of parameters not addressed in this review. This should include the patient’s preoperative clinical status, potential benefits in function and quality of life to be gained from treatment, its economical implications, and complication rates.

Acknowledgements

None.

Funding

The authors declare that there was no funding associated with the manuscript.

Availability of data and materials

All the data supporting our findings are contained within the manuscript.

Authors’ contributions

DG: participated in the conception and design of the study, acquisition of data, interpreted the data, drafted the manuscript. NL: involved in the acquisition and interpretation of the data. GC and SG: participated in the acquisition of data, critically appraised and analysed the data, drafted the manuscript. SS and LD: involved in the acquisition and interpretation of the data. FSH: jointly conceived the study, participated in its design and interpreted the data. CLR: conceived the study, participated in its design, involved in the acquisition and interpreted of the data, drafted the manuscript and was overall coordinator. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Not applicable.

Ethics approval and consent to participate

No ethical approval was sought as it was deemed unneccesary for this meta-analysis.

Abbreviations

CI

Confidential intervals

n

number of patients

OR

Odds ratio

Appendix 1

Keywords entered either alone or in a variety of combinations during the systematic review process.

Hip

Infection

Arthroplasty

Prosthesis

Total hip replacement

THR

Prosthetic hip infection

Periprosthetic hip infection

Exchange arthroplasty

One-stage

Single-stage

Two-stagerevision

Contributor Information

D. A. George, Phone: (+44) 20 3456 7890, Email: davidgeorge@doctors.org.uk

N. Logoluso, Email: nicola.logoluso@gmail.com

G. Castellini, Email: greta.castellini@unimi.it

S. Gianola, Email: silvia.gianola@grupposandonato.it

S. Scarponi, Email: scarponi1981@libero.it

F. S. Haddad, Email: fsh@fareshaddad.net

L. Drago, Email: lorenzo.drago@unimi.it

C. L. Romano, Email: carlo.romano@grupposandonato.it

References

  • 1.Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am. 2009;91(1):128–33. doi: 10.2106/JBJS.H.00155. [DOI] [PubMed] [Google Scholar]
  • 2.Phillips JE, Crane TP, Noy M, Elliott TSJ, Grimer RJ. The incidence of deep prosthetic infections in a specialist orthopaedic hospital, a 15-year prospective survey. J Bone Joint Surg (Br) 2006;88(7):943–948. doi: 10.1302/0301-620X.88B7.17150. [DOI] [PubMed] [Google Scholar]
  • 3.Berbari EF, Hanssen AD, Duffy MC, et al. Risk factors for prosthetic joint infection: case–control study. Clin Infect Dis. 1998;27:1247–1254. doi: 10.1086/514991. [DOI] [PubMed] [Google Scholar]
  • 4.Willis-Owen CA, Konyves A, Martin DK. Factors affecting the incidence of infection in hip and knee replacement. An analysis of 5277 cases. J Bone Joint Surg (Br) 2010;92(8):1128–1133. doi: 10.1302/0301-620X.92B8.24333. [DOI] [PubMed] [Google Scholar]
  • 5.Hart WJ, Jones RS. Two-stage revision of infected total knee replacements using articulating cement spacers and short-term antibiotic therapy. J Bone Joint Surg (Br) 2006;88(8):1011–1015. doi: 10.1302/0301-620X.88B8.17445. [DOI] [PubMed] [Google Scholar]
  • 6.Kurd MF, Ghanem E, Steinbrecher J, Parvizi J. Two-stage exchange knee arthroplasty: does resistance of the infecting organism influence the outcome? Clin Orthop Relat Res. 2010;468(8):2060–2066. doi: 10.1007/s11999-010-1296-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Parvizi J, Adeli B, Zmistowski B, Restrepo C, Greenwald AS. Management of periprosthetic joint infection: the current knowledge: AAOS exhibit selection. J Bone Joint Surg Am. 2012;94(14):e104. doi: 10.2106/JBJS.K.01417. [DOI] [PubMed] [Google Scholar]
  • 8.Cabrita HB, Croci AT, Camargo OP, Lima AL. Prospective study of the treatment of infected hip arthroplasties with or without the use of an antibiotic-loaded cement spacer. Clinics. 2007;62(2):99–108. doi: 10.1590/S1807-59322007000200002. [DOI] [PubMed] [Google Scholar]
  • 9.Oussedik SI, Dodd MB, Haddad FS. Outcomes of revision total hip replacement for infection after grading according to a standard protocol. J Bone Joint Surg. 2010;92-B(9):1222–1226. doi: 10.1302/0301-620X.92B9.23663. [DOI] [PubMed] [Google Scholar]
  • 10.Colyer RA, Capello WN. Surgical treatment of the infected hip implant. Two-stage reimplantation with a one-month interval. Clin Orthop Relat Res. 1994;298:75–79. [PubMed] [Google Scholar]
  • 11.Hsieh PH, Huang KC, Lee PC, Lee MS. Two-stage revision of infected hip arthroplasty using an antibiotic-loaded spacer: retrospective comparison between short-term and prolonged antibiotic therapy. J Antimicrob Chemother. 2009;64(2):392–7. doi: 10.1093/jac/dkp177. [DOI] [PubMed] [Google Scholar]
  • 12.Choi HR, Kwon YM, Freiberg AA, Malchau H. Comparison of one-stage revision with antibiotic cement versus two-stage revision results for infected total hip arthroplasty. J Arthroplasty. 2013;28(8 Suppl):66–70. doi: 10.1016/j.arth.2013.02.037. [DOI] [PubMed] [Google Scholar]
  • 13.Ketterl R, Henly MB, Stübinger B, Beckurts T, Claudi B. Analysis of three operative techniques for infected total hip replacements. Orthop Trans. 1988;12:715. [Google Scholar]
  • 14.Lange J, Troelsen A, Thomsen RW, Søballe K. Chronic infections in hip arthroplasties: comparing risk of reinfection following one-stage and two-stage revision: a systematic review and meta-analysis. Clin Epidemiol. 2012;4(4):57–73. doi: 10.2147/CLEP.S29025. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Beswick AD, Elvers KT, Smith AJ, Gooberman-Hill R, Lovering A, Blom AW. What is the evidence base to guide surgical treatment of infected hip prostheses? Systematic review of longitudinal studies in unselected patients. BMC Med. 2012;10:18. doi: 10.1186/1741-7015-10-18. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Romanò CL, Gala L, Logoluso N, Romanò D, Drago L. Two-stage revision of septic knee prosthesis with articulating knee spacers yields better infection eradication rate than one-stage or two-stage revision with static spacers. Knee Surg Sports Traumatol Arthrosc. 2012;20:2445–2453. doi: 10.1007/s00167-012-1885-x. [DOI] [PubMed] [Google Scholar]
  • 17.George DA, Volpin A, Scarponi, Haddad FS, Romano CL. Does Revision Surgery Of Infected Shoulder Prosthesis Provide Better Eradication Rate And Better Functional Outcome, Compared To a Permanent Spacer or Resection Arthroplasty? A Systematic Review. BMC Musculoskelet Disord. 2016;17:52. doi: 10.1186/s12891-016-0901-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Der Simonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7:177–188. doi: 10.1016/0197-2456(86)90046-2. [DOI] [PubMed] [Google Scholar]
  • 19.Barretti P, Doles JV, Pinotti DG, El Dib R. Efficacy of antibiotic therapy for peritoneal dialysis-associated peritonitis: a proportional meta-analysis. BMC Infect Dis. 2014;14(1):445. doi: 10.1186/1471-2334-14-445. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.El Dib R, Nascimento Junior P, Kapoor A. An alternative approach to deal with the absence of clinical trials: a proportional meta-analysis of case series studies. Acta Cir Bras. 2013;28(12):870–6. doi: 10.1590/S0102-86502013001200010. [DOI] [PubMed] [Google Scholar]
  • 21.Gurgel SJT, El Dib R, do Nascimento Jr P. Enhanced Recovery after Elective Open Surgical Repair of Abdominal Aortic Aneurysm: A Complementary Overview through a Pooled Analysis of Proportions from Case Series Studies. PLoS One. 2014;9(6):e98006. doi: 10.1371/journal.pone.0098006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Klouche S, Leonard P, Zeller V, et al. Infected total hip arthroplasty revision: one- or two-stage procedure? Orthop Traumatol Surg Res. 2012;98(2):144–150. doi: 10.1016/j.otsr.2011.08.018. [DOI] [PubMed] [Google Scholar]
  • 23.Wroblewski BM. One-stage revision of infected cemented total hip arthroplasty. Clin Orthop Relat Res. 1986;211:103–7. [PubMed] [Google Scholar]
  • 24.Hughes PW, Salvati EA, Wilson PD, Blumenfeld EL. Treatment of Subacute Sepsis of the Hip by Antibiotics and Joint Replacement Criteria For Diagnosis With Evaluation of Twenty-Six Cases. Clin Orthop Relat Res. 1979;141:143–157. [PubMed] [Google Scholar]
  • 25.Sudo A, Hasegawa M, Fukuda A, Uchida A. Treatment of infected hip arthroplasty with antibiotic-impregnated calcium hydroxyapatite. J Arthroplasty. 2008;23(1):145–150. doi: 10.1016/j.arth.2006.09.009. [DOI] [PubMed] [Google Scholar]
  • 26.Wilson MG, Dorr LD. Reimplantation of infected total hip arthroplasties in the absence of antibiotic cement. J Arthroplasty. 1989;4(3):263–269. doi: 10.1016/S0883-5403(89)80023-3. [DOI] [PubMed] [Google Scholar]
  • 27.Winkler H, Stoiber A, Kaudela K, Winter F, Menschik F. One stage uncemented revision of infected total hip replacement using cancellous allograft bone impregnated with antibiotics. J Bone Joint Surg (Br) 2008;90(12):1580–4. doi: 10.1302/0301-620X.90B12.20742. [DOI] [PubMed] [Google Scholar]
  • 28.Babiak I. Application of individually performed acrylic cement spacers containing 5 % of antibiotic in two-stage revision of hip and knee prosthesis due to infection. Pol Orthop Traumatol. 2012;77:29–37. [PubMed] [Google Scholar]
  • 29.Babis GC, Sakellariou VI, Pantos PG, Sasalos GG, Stavropoulos NA. Two-Stage Revision Protocol in Multidrug Resistant Periprosthetic Infection Following Total Hip Arthroplasty Using a Long Interval Between Stages. J Arthroplasty. 2015;30:1602–1606. doi: 10.1016/j.arth.2015.04.004. [DOI] [PubMed] [Google Scholar]
  • 30.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;471:510–518. doi: 10.1007/s11999-012-2595-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Biring GS, Kostamo T, Garbuz DS, Masri BA, Duncan CP. Two-stage revision arthroplasty of the hip for infection using an interim articulated Prostalac hip spacer: a 10- to 15-year follow-up study. J Bone Joint Surg (Br) 2009;91(11):1431–7. doi: 10.1302/0301-620X.91B11.22026. [DOI] [PubMed] [Google Scholar]
  • 32.Bori G, Muñoz-Mahamud E, Cuñé J, Gallart X, Fuster D, Soriano A. One-Stage Revision Arthroplasty Using Cementless Hip Arthroplasties. J Arthroplasty. 2014;29:1076–1081. doi: 10.1016/j.arth.2013.11.005. [DOI] [PubMed] [Google Scholar]
  • 33.Buchholz H, Elson R, Engelbrecht E, Lodenkamper H, Rottger J, Siegel A. Management of deep infection of total hip replacement. J Bone Joint Surg. 1981;63-B(3):342–353. doi: 10.1302/0301-620X.63B3.7021561. [DOI] [PubMed] [Google Scholar]
  • 34.Buttaro MA, Pusso R, Piccaluga F. Vancomycin-supplemented impacted bone allografts in infected hip arthroplasty. Two-stage revision results. J Bone Joint Surg (Br) 2005;87:314–319. doi: 10.1302/0301-620X.87B3.14788. [DOI] [PubMed] [Google Scholar]
  • 35.Callaghan JJ, Katz RP, Johnston RC. One-stage revision surgery of the infected hip. A minimum 10-year followup study. Clin Orthop Relat Res. 1999;369:139–43. doi: 10.1097/00003086-199912000-00014. [DOI] [PubMed] [Google Scholar]
  • 36.Camurcu Y, Sofu H, Buyuk AF, Gursu S, Kaygusuz MA, Sahin V. Two-Stage Cementless Revision Total Hip Arthroplasty for Infected Primary Hip Arthroplasties. J Arthroplasty. 2015;30:1597–1601. doi: 10.1016/j.arth.2015.03.040. [DOI] [PubMed] [Google Scholar]
  • 37.Carlsson AS, Egund N, Gentz CF, Hussenius A, Josefsson G, Lindberg L. Radiographic loosening after revision with gentamicin-containing cement for deep infection in total hip arthroplasties. Clin Orthop Relat Res. 1985;194:271–9. [PubMed] [Google Scholar]
  • 38.Chen SY, Hu CC, Chen CC, Chang YH, Hsieh PH. Two-Stage Revision Arthroplasty for Periprosthetic Hip Infection: Mean Follow-Up of Ten Years. Biomed Res Int. 2015;2015:345475. doi: 10.1155/2015/345475. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.Cordero-Ampuero J, Esteban J, Garcia-Cimbrelo E. Oral antibiotics are effective for highly resistant hip arthroplasty infections. Clin Orthop Relat Res. 2009;467(9):2335–2342. doi: 10.1007/s11999-009-0808-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 40.D'Angelo F, Negri L, Binda T, Zatti G, Cherubino P. The use of a preformed spacer in two-stage revision of infected hip arthroplasties. Musculoskelet Surg. 2011;95(2):115–20. doi: 10.1007/s12306-011-0128-5. [DOI] [PubMed] [Google Scholar]
  • 41.Darley E, Bannister G, Blom A, MacGowan AP, Jacobson S, Alfouzan W. Early intravenous to oral antibiotic switch therapy is effective in the treatment of infected total hip replacement. Clin Microbiol Infect. 2009;15(Suppl S4):S139. [Google Scholar]
  • 42.De Man FH, Sendi P, Zimmerli W, Maurer TB, Ochsner PE, Ilchmann T. Infectiological, functional, and radiographic outcome after revision for prosthetic hip infection according to a strict algorithm. Acta Orthop. 2011;82(1):27–34. doi: 10.3109/17453674.2010.548025. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Degen RM, Davey JR, Davey JR, Howard JL, McCalden RW, Naudie DD. Does a prefabricated gentamicin-impregnated, load-bearing spacer control periprosthetic hip infection? Clin Orthop Relat Res. 2012;470(10):2724–9. doi: 10.1007/s11999-012-2350-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.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. doi: 10.1007/s11999-013-3168-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Evans RP. Successful treatment of total hip and knee infection with articulating antibiotic components: a modified treatment method. Clin Orthop Relat Res. 2004;427:37–46. doi: 10.1097/01.blo.0000143739.07632.7c. [DOI] [PubMed] [Google Scholar]
  • 46.Fehring TK, Calton TF, Griffin WL. Cementless fixation in 2-stage reimplantation for periprosthetic sepsis. J Arthroplasty. 1999;14(2):175–181. doi: 10.1016/S0883-5403(99)90122-5. [DOI] [PubMed] [Google Scholar]
  • 47.Fink B, Grossmann A, Fuerst M, Schäfer P, Frommelt L. Two-stage cementless revision of infected hip endoprostheses. Clin Orthop Relat Res. 2009;467(7):1848–58. doi: 10.1007/s11999-008-0611-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 48.Fitzgerald RH, Jones DR. Hip implant infection: Treatment with resection arthroplasty and late total hip arthroplasty. Am J Med. 1985;78(6):225–228. doi: 10.1016/0002-9343(85)90389-4. [DOI] [PubMed] [Google Scholar]
  • 49.Gao H, Lv H. One-stage revision operations for infection after hip arthroplasty. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2008;22(1):5–8. [PubMed] [Google Scholar]
  • 50.Garvin KL, Evans BG, Salvati EA, Brause BD. Palacos gentamicin for the treatment of deep periprosthetic hip infections. Clin Orthop Relat Res. 1994;298:97–105. [PubMed] [Google Scholar]
  • 51.Haddad FS, Muirhead-Allwood SK, Manktelow AR, Bacarese-Hamilton I. Two-stage uncemented revision hip arthroplasty for infection. J Bone Joint Surg (Br) 2000;82(5):689–94. doi: 10.1302/0301-620X.82B5.9668. [DOI] [PubMed] [Google Scholar]
  • 52.Hofmann AA, Goldberg TD, Tanner AM, Cook TM. Ten-year experience using an articulating antibiotic cement hip spacer for the treatment of chronically infected total hip. J Arthroplasty. 2005;20:874–879. doi: 10.1016/j.arth.2004.12.055. [DOI] [PubMed] [Google Scholar]
  • 53.Hope PG, Kristinsson KG, Norman P, Elson RA. Deep infection of cemented total hip arthroplasties caused by coagulase-negative staphylococci. J Bone Joint Surg (Br) 1989;71(5):851–5. doi: 10.1302/0301-620X.71B5.2584258. [DOI] [PubMed] [Google Scholar]
  • 54.Hsieh PH, Huang KC, Shih HN. Prosthetic joint infection in patients with rheumatoid arthritis: an outcome analysis compared with controls. PLoS One. 2013;8(8):e71666. doi: 10.1371/journal.pone.0071666. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 55.Hsieh PH, Shih CH, Chang YH, Lee MS, Shih HN, Yang WE. Two-stage revision hip arthroplasty for infection: comparison between the interim use of antibiotic-loaded cement beads and a spacer prosthesis. J Bone Joint Surg Am. 2004;86-A(9):1989–97. [PubMed]
  • 56.Ibrahim MS, Raja S, Khan MA, Haddad FS. A multidisciplinary team approach to two-stage revision for the infected hip replacement: a minimum five-year follow-up study. Bone Joint J. 2014;96-B:1312–1318. doi: 10.1302/0301-620X.96B10.32875. [DOI] [PubMed] [Google Scholar]
  • 57.Ilchmann T, Zimmerli W, Ochsner PE, Kessler B, Zwicky L, Graber P, Clauss M. One-stage revision of infected hip arthroplasty: outcome of 39 consecutive hips. Int Orthop. 2016;40(5):913-8. [DOI] [PubMed]
  • 58.Jenny JY, Lengert R, Diesinger Y, Gaudias J, Boeri C, Kempf JF. Routine one-stage exchange for chronic infection after total hip replacement. Int Orthop. 2014;38(12):2477–81. doi: 10.1007/s00264-014-2466-z. [DOI] [PubMed] [Google Scholar]
  • 59.Johnson AJ, Zywiel MG, Jones LC, Delanois RE, Stroh DA, Mont MA. Reduced re-infection rates with postoperative oral antibiotics after two-stage revision hip arthroplasty. BMC Musculoskelet Disord. 2013;14(1):123. doi: 10.1186/1471-2474-14-123. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 60.Karpas K, Sponer P. Management of the infected hip arthroplasty by two-stage reimplantation. Acta Med (Hradec Kralove) 2003;46(3):113–5. [PubMed] [Google Scholar]
  • 61.Kent M, Rachha R, Sood M. A technique for the fabrication of a reinforced moulded articulating cement spacer in two-stage revision total hip arthroplasty. Int Orthop. 2010;34:949–953. doi: 10.1007/s00264-009-0847-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 62.Koo KH, Yang JW, Cho SH, et al. Impregnation of vancomycin, gentamicin, and cefotaxime in a cement spacer for two-stage cementless reconstruction in infected total hip arthroplasty. J Arthroplasty. 2001;16:882–92. [DOI] [PubMed]
  • 63.Kim YH, Kim JS, Park JW, Joo JH. Cementless revision for infected total hip replacements. J Bone Joint Surg (Br). 2011;93(1):19–26. [DOI] [PubMed]
  • 64.Lai KA, Shen WJ, Yang CY, Lin RM, Lin CJ, Jou IM. Two-stage cementless revision THR after infection. 5 recurrences in 40 cases followed 2.5-7 years. Acta Orthop Scand. 1996;67(4):325–8. doi: 10.3109/17453679609002324. [DOI] [PubMed] [Google Scholar]
  • 65.Lee YK, Lee KH, Nho JH, Ha YC, Koo KH. Retaining well-fixed cementless stem in the treatment of infected hip arthroplasty. Acta Orthop. 2013;84(3):260–4. doi: 10.3109/17453674.2013.795830. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 66.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):1009–15. doi: 10.1007/s11999-010-1725-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 67.Li P, Hou M, Zhu ZQ, Shi ZJ. Cementless Revision for Infected Hip Arthroplasty: an 8.6 Years Follow-up. Orthop Surg. 2015;7(1):37–42. doi: 10.1111/os.12159. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 68.Lieberman JR, Callaway GH, Salvati EA, Pellicci PM, Brause BD. Treatment of the infected total hip arthroplasty with a two-stage reimplantation protocol. Clin Orthop Relat Res. 1994;301:205–212. [PubMed] [Google Scholar]
  • 69.Macheras GA, Koutsostathis SD, Kateros K, Papadakis S, Anastasopoulos P. A two stage re-implantation protocol for the treatment of deep periprosthetic hip infection. Mid to long-term results. Hip Int. 2012;22 Suppl 8:S54–61. doi: 10.5301/HIP.2012.9571. [DOI] [PubMed] [Google Scholar]
  • 70.Magnan B, Regis D, Biscaglia R, Bartolozzi P. Preformed acrylic bone cement spacer loaded with antibiotics: use of two-stage procedure in 10 patients because of infected hips after total replacement. Acta Orthop Scand. 2001;72(6):591–4. doi: 10.1080/000164701317269003. [DOI] [PubMed] [Google Scholar]
  • 71.Masri BA, Panagiotopoulos KP, Greidanus NV, Garbuz DS, Duncan CP. Cementless two-stage exchange arthroplasty for infection after total hip arthroplasty. J Arthroplasty. 2007;22(1):72–8. doi: 10.1016/j.arth.2006.02.156. [DOI] [PubMed] [Google Scholar]
  • 72.McDonald DJ, Fitzgerald RH, Ilstrup DM. Two-stage reconstruction of a total hip arthroplasty because of infection. J Bone Joint Surg. 1989;71-A(6):828–834. [PubMed] [Google Scholar]
  • 73.McKenna PB, O'Shea K, Masterson EL. Two-stage revision of infected hip arthroplasty using a shortened post-operative course of antibiotics. Arch Orthop Trauma Surg. 2009;129(4):489–94. doi: 10.1007/s00402-008-0683-x. [DOI] [PubMed] [Google Scholar]
  • 74.Miley GB, Scheller AD, Turner RH. Medical and surgical treatment of the septic hip with one-stage revision arthroplasty. Clin Orthop Relat Res 1982;170(76–82). [PubMed]
  • 75.Morales FL, González JF, Ortiz FB, Martínez JM, Araujo CG. Treatment of infected hip arthroplasty. Retrospective study. Revista de Ortopedia y Traumatologia. 1999;43(2):84–92. [Google Scholar]
  • 76.Morscher E, Herzog R, Bapst R. Hip revision surgery in septic loosening. Chir Organi Mov. 1994;79(4):335–40. [PubMed] [Google Scholar]
  • 77.Mulcahy DM, O'Byrne JM, Fenelon GE. One stage surgical management of deep infection of total hip arthroplasty. Ir J Med Sci. 1996;165(1):17–9. doi: 10.1007/BF02942793. [DOI] [PubMed] [Google Scholar]
  • 78.Nestor BJ, Hanssen AD, Ferrer-Gonzalez R, Fitzgerald RH. The use of porous prostheses in delayed reconstruction of total hip replacements that have failed because of infection. J Bone Joint Surg Am. 1994;76:349–359. doi: 10.2106/00004623-199403000-00005. [DOI] [PubMed] [Google Scholar]
  • 79.Neumann DR, Hofstaedter T, List C, Dorn U. Two-Stage Cementless Revision of Late Total Hip Arthroplasty Infection Using a Premanufactured Spacer. J Arthroplasty. 2012;27(7):1397–401. doi: 10.1016/j.arth.2011.10.022. [DOI] [PubMed] [Google Scholar]
  • 80.Nusem I, Morgan DA. Structural allografts for bone stock reconstruction in two- stage revision for infected total hip arthroplasty: good outcome in 16 of 18 patients followed for 5–14 years. Acta Orthop. 2006;77:92–97. doi: 10.1080/17453670610045740. [DOI] [PubMed] [Google Scholar]
  • 81.Pignatti G, Nitta S, Rani N, et al. Two stage hip revision in periprosthetic infection: results of 41 cases. Open Orthop J. 2010;4:193–200. doi: 10.2174/1874325001004010193. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 82.Raut VV, Siney PD, Wroblewski BM. One-stage revision of infected total hip replacements with discharging sinuses. J Bone Joint Surg (Br) 1994;76(5):721–4. [PubMed] [Google Scholar]
  • 83.Romanò CL, Romanò D, Albisetti A, Meani E. Preformed antibiotic-loaded cement spacers for two-stage revision of infected total hip arthroplasty. Long-term results. Hip Int. 2012;22 Suppl 8:S46–53. doi: 10.5301/HIP.2012.9570. [DOI] [PubMed] [Google Scholar]
  • 84.Rudelli S, Uip D, Honda E, Lima AL. One-stage revision of infected total hip arthroplasty with bone graft. J Arthroplasty. 2008;23(8):1165–77. doi: 10.1016/j.arth.2007.08.010. [DOI] [PubMed] [Google Scholar]
  • 85.Sabry FY, Szubski CR, Stefancin JJ, Klika AK, Higuera CA, Barsoum WK. Comparison of complications associated with commercially available and custom-made articulating spacers in two-stage total hip arthroplasty revision. Curr Orthop Pract. 2013;24(4):406–413. doi: 10.1097/BCO.0b013e318297c3fb. [DOI] [Google Scholar]
  • 86.Sanchez-Sotelo J, Berry DJ, Hanssen AD, Cabanela ME. Midterm to long-term followup of staged reimplantation for infected hip arthroplasty. Clin Orthop Relat Res. 2009;467:219–224. doi: 10.1007/s11999-008-0480-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 87.Sanzen L, Carlsson A, Josefsson G, Lindberg LT. Revision operations on infected total hip arthroplasties. Clin Orthop Relat Res. 1988;229:165–172. [PubMed] [Google Scholar]
  • 88.Schneider R. The infected total prosthesis. Orthopade. 1989;18(6):527–532. [PubMed] [Google Scholar]
  • 89.Schwarzkopf R, Mikhael B, Wright E, Estok DM, Katz JN. Treatment Failure Among Infected Periprosthetic Total Hip Arthroplasty Patients. Open Orthop J. 2014;8:118–124. doi: 10.2174/1874325020140515002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 90.Lim S-J. Treatment of Periprosthetic Hip Infection Caused by Resistant Microorganisms Using 2-Stage Reimplantation Protocol. J Arthroplasty. 2009;24(8):1264–1269. doi: 10.1016/j.arth.2009.05.012. [DOI] [PubMed] [Google Scholar]
  • 91.Stockley I, Mockford BJ, Hoad-Reddick A, Norman P. The use of two-stage exchange arthroplasty with depot antibiotics in the absence of long-term antibiotic therapy in infected total hip replacement. J Bone Joint Surg (Br) 2008;90:145–148. doi: 10.1302/0301-620X.90B2.19855. [DOI] [PubMed] [Google Scholar]
  • 92.Takigami I, Ito Y, Ishimaru D, et al. Two-stage revision surgery for hip prosthesis infection using antibiotic-loaded porous hydroxyapatite blocks. Arch Orthop Trauma Surg. 2010;130(10):1221–6. doi: 10.1007/s00402-009-0991-9. [DOI] [PubMed] [Google Scholar]
  • 93.Thabe H, Schill S. Two-stage reimplantation with an application spacer and combined with delivery of antibiotics in the management of prosthetic joint infection. Oper Orthop Traumatol. 2007;19(1):78–100. doi: 10.1007/s00064-007-1196-4. [DOI] [PubMed] [Google Scholar]
  • 94.Toulson C, Walcott-Sapp S, Hur J, et al. Treatment of infected total hip arthroplasty with a 2-stage reimplantation protocol: update on "our institution's" experience from 1989 to 2003. J Arthroplasty. 2009;24(7):1051–1060. doi: 10.1016/j.arth.2008.07.004. [DOI] [PubMed] [Google Scholar]
  • 95.Ure KJ, Amstutz HC, Nasser S, Schmalzried TP. Direct-exchange arthroplasty for the treatment of infection after total hip replacement. An average ten-year follow-up. J Bone Joint Surg Am. 1998;80:961–968. doi: 10.2106/00004623-199807000-00004. [DOI] [PubMed] [Google Scholar]
  • 96.van Diemen MP, Colen S, Dalemans AA, Stuyck J, Mulier M. Two-stage revision of an infected total hip arthroplasty: a follow-up of 136 patients. Hip Int. 2013;23(5):445–50. doi: 10.5301/hipint.5000049. [DOI] [PubMed] [Google Scholar]
  • 97.Wang L, Hu Y, Dai Z, Zhou J, Li M, Li K. Mid-term effectiveness of two-stage hip prosthesis revision in treatment of infection after hip arthroplasty. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2011;25(6):646–9. [PubMed] [Google Scholar]
  • 98.Weber FA, Lautenbach EEG. Revision of infected total hip arthroplasty. Clin Orthop Relat Res. 1986;211:108–115. [PubMed] [Google Scholar]
  • 99.Whittaker JP, Warren RE, Jones RS, Gregson PA. Is prolonged systemic antibiotic treatment essential in two-stage revision hip replacement for chronic Gram-positive infection? J Bone Joint Surg (Br) 2009;91(1):44–51. doi: 10.1302/0301-620X.91B1.20930. [DOI] [PubMed] [Google Scholar]
  • 100.Wilson PD, Aglietti P, Salvati EA. Subacute sepsis of the hip treated by antibiotics and cemented prosthesis. J Bone Joint Surg. 1974;56-A(5):879–898. [PubMed] [Google Scholar]
  • 101.Wolf M, Clar H, Friesenbichler J, et al. Prosthetic joint infection following total hip replacement: results of one-stage versus two-stage exchange. Int Orthop. 2014;38(7):1363–1368. doi: 10.1007/s00264-014-2309-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 102.Yamamoto K, Miyagawa N, Masaoka T, Katori Y, Shishido T, Imakiire A. Clinical effectiveness of antibiotic-impregnated cement spacers for the treatment of infected implants of the hip joint. J Orthop Sci. 2003;8(6):823–828. doi: 10.1007/s00776-003-0722-y. [DOI] [PubMed] [Google Scholar]
  • 103.Yoo JJ, Kwon YS, Koo KH, Yoon KS, Kim YM, Kim HJ. One-stage cementless revision arthroplasty for infected hip replacements. Int Orthop. 2009;33(5):1195–1201. doi: 10.1007/s00264-008-0640-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 104.Younger AS, Duncan CP, Masri BA, McGraw RW. The outcome of two-stage arthroplasty using a custom-made interval spacer to treat the infected hip. J Arthroplasty. 1997;12(6):615–23. doi: 10.1016/S0883-5403(97)90133-9. [DOI] [PubMed] [Google Scholar]
  • 105.Zeller V, Lhotellier L, Marmor S, et al. One-stage exchange arthroplasty for chronic periprosthetic hip infection: results of a large prospective cohort study. J Bone Joint Surg Am. 2014;96(1):e1. doi: 10.2106/JBJS.L.01451. [DOI] [PubMed] [Google Scholar]

Associated Data

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Data Availability Statement

All the data supporting our findings are contained within the manuscript.


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