Managing periprosthetic joint infection through the direct anterior approach: Partial two-stage exchange with femoral stem retention.

Periprosthetic joint infection (PJI) remains a devastating complication of total hip arthroplasty (THA), and chronic PJI in the presence of a well-fixed femoral stem is particularly challenging because removal of an osseointegrated stem carries substantial morbidity. Partial two-stage exchange (P2-SE) with femoral stem retention, in which the acetabular components are removed and replaced with an antibiotic-cement functional spacer while the well-fixed stem is retained and debrided, has emerged as an alternative to complete one-stage or two-stage exchange. The direct anterior approach (DAA), although widely adopted for primary THA, has rarely been described for the management of PJI. This article reports three cases of chronic PJI managed by P2-SE performed entirely through the original anterior interval, together with a comprehensive review of the published outcomes of P2-SE. Two of the three patients achieved infection control and were pain-free and ambulatory at final follow-up with an antibiotic-loaded cemented acetabular construct (a polyethylene liner with a modular ceramic head in one, a dual-mobility construct in the other), and did not require second-stage reimplantation, while the third patient developed a recurrent infection after cessation of oral suppression and was subsequently converted to a formal two-stage exchange. The accompanying literature review demonstrates infection eradication rates of approximately 81 to 100% across predominantly Level IV series, with reported outcomes comparable to those of complete two-stage exchange. P2-SE through the DAA appears to be a reasonable option in carefully selected patients with a well-fixed femoral stem, although further prospective comparative investigation is warranted.

Keywords

Anti-bacterial agents, Arthroplasty, Bone cements, Direct anterior approach, Dual mobility, Femoral stem retention, Hip, Hip prosthesis, Partial two-stage exchange, Prosthesis-related infections, Reoperation, Replacement

Conflict of interest statement

Lee E. Rubin, MD reports the following disclosures: Arthroplasty Today: Editorial or governing board. DePuy, A Johnson & Johnson Company: Paid consultant. Innovative Medical Products, Inc.: Paid consultant. Johns Hopkins University Press: Publishing royalties, financial or material support Journal of Arthroplasty: Editorial or governing board. Reconstructive Review: Editorial or governing board. Taylor & Francis: Publishing royalties, financial or material support Thompson Surgical Instruments, Inc.: Paid consultant. Wolters Kluwer: Publishing royalties, financial or material support Thomas R. Hickernell, MD reports the following disclosures: DePuy, A Johnson & Johnson Company: Paid consultant. George A. Rublev, MD: No conflicts of interest to declare. Nils Becker, MD: No conflicts of interest to declare. Joseph Torkieh, BS: No conflicts of interest to declare. Hickernell TR is a consultant with Depuy Synthes Rubin LE is a consultant with DePuy Synthes, Innovative Medical Products, Thompson Surgical Instruments, Receives royalties from Talyor & Francis, Johns Hopkins University Press, and Wolters Kluwer, and serves as an unpaid Editorial board member with Arthroplasty Today and Journal of Arthroplasty.