Cemented versus uncemented fixation of femoral components in 2-stage hip revision arthroplasty to treat periprosthetic joint infection: a cohort study on 94 patients comparing the risks for relapse and reoperation
DOI:
https://doi.org/10.2340/17453674.2025.44923Keywords:
Arthroplasty, Cement, Hip, Implants, InfectionAbstract
Background and purpose: Both cemented and uncemented stem fixation is used in 2-stage hip revision arthroplasty addressing periprosthetic joint infection (PJI). We aimed to compare the risk of infection relapse and the risk of reoperation for any reason between uncemented and cemented stem fixation.
Methods: Patients who underwent 2-stage hip revision arthroplasty for PJI between 2005 and 2020 were included. Data on baseline demographics, implant type, and microbiological and antibiotic treatment data was obtained from a local registry and medical records. Kaplan–Meier analysis compared relapse-free survival and reoperation-free survival between uncemented (n = 60) and cemented (n = 34) stems. Cox regression models were fitted to assess adjusted hazard ratios (aHR) for the risk of relapse or reoperation with 95% confidence intervals (CIs).
Results: 94 patients underwent 2-stage revision hip arthroplasty for PJI. Unadjusted 2-year relapse-free survival rates were 95% (CI 89–100) for patients with uncemented stem fixation and 97% (CI 90–100) for those with cemented fixation. Reoperation-free survival at 10 years was 82% (CI 70–95) for patients with uncemented fixation and 61% (CI 43–85) for those with cemented fixation. Using cemented fixation as the reference, the aHR for infection relapse was 2.0 (CI 0.2–20.1, P = 0.6) for uncemented fixation, whereas the aHR for reoperation was 0.3 (CI 0.1–0.9, P = 0.03).
Conclusion: We showed no statistical difference in the risk of infection relapse, but uncemented stem fixation in 2-stage revision arthroplasty for PJI was associated with a reduced risk of reoperation for any reason. Uncemented stems may thus be a suitable choice in 2-stage revisions for PJI when this concept is believed to provide better fixation.
Downloads
References
Cooper H J, Della Valle C J. The two-stage standard in revision total hip replacement. Bone Joint J 2013; 95-B: 84-7. doi: 10.1302/0301-620X.95B11.32906. DOI: https://doi.org/10.1302/0301-620X.95B11.32906
Zahar A, Gehrke T A. One-stage revision for infected total hip arthroplasty. Orthop Clin North Am 2016; 47: 11-18. doi: 10.1016/j.ocl.2015.08.004. DOI: https://doi.org/10.1016/j.ocl.2015.08.004
Russo A, Camacho Uribe A, Abuljadail S, Bokhari A, Gehrke T, Citak M. Excellent survival rate of cemented modular stems in one-stage revision for periprosthetic hip infections with massive femoral bone loss: a retrospective single-center analysis of 150 cases. J Arthroplasty 2024; 39: 1577-82. doi: 10.1016/j.arth.2023.12.006. DOI: https://doi.org/10.1016/j.arth.2023.12.006
Pellegrini A V, Suardi V. Antibiotics and cement: what I need to know? Hip Int 2020; 30: 48-53. doi: 10.1177/1120700020915463. DOI: https://doi.org/10.1177/1120700020915463
Leonard H A C, Liddle A D, Burke O, Murray D W, Pandit H. Single- or two-stage revision for infected total hip arthroplasty? A systematic review of the literature. Clin Orthop Relat Res 2014; 472: 1036-42. doi: 10.1007/s11999-013-3294-y. DOI: https://doi.org/10.1007/s11999-013-3294-y
Led och skelettinfektioner 2023 n.d. Available from: https://infektion.net/kunskap/vardprogram-for-led-och-skelettinfektioner/
Sebastian S, Liu Y, Christensen R, Raina D B, Tägil M, Lidgren L. Antibiotic containing bone cement in prevention of hip and knee prosthetic joint infections: a systematic review and meta-analysis. J Orthop Translat 2020; 23: 53-60. doi: 10.1016/j.jot.2020.04.005. DOI: https://doi.org/10.1016/j.jot.2020.04.005
Duncan C P, Masri B A. The role of antibiotic-loaded cement in the treatment of an infection after a hip replacement. Instr Course Lect 1995; 44: 305-13.
Blom A W, Lenguerrand E, Strange S, Noble S M, Beswick A D, Burston A, et al. Clinical and cost effectiveness of single stage compared with two stage revision for hip prosthetic joint infection (INFORM): pragmatic, parallel group, open label, randomised controlled trial. BMJ 2022; 379: e071281. doi: 10.1136/bmj-2022-071281. DOI: https://doi.org/10.1136/bmj-2022-071281
McNally M, Sousa R, Wouthuyzen-Bakker M, Chen A F, Soriano A, Vogely H C, et al. The EBJIS definition of periprosthetic joint infection. Bone Joint J 2021; 103-B: 18-25. doi: 10.1302/0301-620X.103B1.BJJ-2020-1381.R1. DOI: https://doi.org/10.1302/0301-620X.103B1.BJJ-2020-1381.R1
Wimmer M D, Hischebeth G T R, Randau T M, Gathen M, Schildberg F A, Fröschen F S, et al. Difficult-to-treat pathogens significantly reduce infection resolution in periprosthetic joint infections. Diagn Microbiol Infect Dis 2020; 98: 115114. doi: 10.1016/j.diagmicrobio.2020.115114. DOI: https://doi.org/10.1016/j.diagmicrobio.2020.115114
Sanchez-Sotelo J, Berry D J, Hanssen A D, Cabanela M E. Midterm to long-term followup of staged reimplantation for infected hip arthroplasty. Clin Orthop Relat Res 2009; 467: 219-24. doi: 10.1007/s11999-008-0480-4. DOI: https://doi.org/10.1007/s11999-008-0480-4
Gramlich Y, Hagebusch P, Faul P, Klug A, Walter G, Hoffmann R. Two-stage hip revision arthroplasty for periprosthetic joint infection without the use of spacer or cemented implants. Int Orthop 2019; 43: 2457-66. doi: 10.1007/s00264-019-04297-y. DOI: https://doi.org/10.1007/s00264-019-04297-y
Hipfl C, Leopold V, Becker L, Pumberger M, Perka C, Hardt S. Two-stage revision for periprosthetic joint infection in cemented total hip arthroplasty: an increased risk for failure? Arch Orthop Trauma Surg 2023; 143: 4481-90. doi: 10.1007/s00402-022-04671-3. DOI: https://doi.org/10.1007/s00402-022-04671-3
Kildow B J, Springer B D, Brown T S, Lyden E, Fehring T K, Garvin K L. Long term results of two-stage revision for chronic periprosthetic hip infection: a multicenter study. J Clin Med 2022; 11: 1657. doi: 10.3390/jcm11061657. DOI: https://doi.org/10.3390/jcm11061657
Haddad F S, Muirhead-Allwood S K, Manktelow A R, Bacarese-Hamilton I. Two-stage uncemented revision hip arthroplasty for infection. J Bone Joint Surg Br 2000; 82: 689-94. doi: 10.1302/0301-620x.82b5.9668. DOI: https://doi.org/10.1302/0301-620X.82B5.0820689
Kraay M J, Goldberg V M, Fitzgerald S J, Salata M J. Cementless two-staged total hip arthroplasty for deep periprosthetic infection. Clin Orthop Relat Res 2005; 441: 243-9. doi: 10.1097/01.blo.0000194312.97098.0a. DOI: https://doi.org/10.1097/01.blo.0000194312.97098.0a
Masri B A, Panagiotopoulos K P, Greidanus N V, Garbuz D S, Duncan C P. Cementless two-stage exchange arthroplasty for infection after total hip arthroplasty. J Arthroplasty 2007; 22: 72-8. doi: 10.1016/j.arth.2006.02.156. DOI: https://doi.org/10.1016/j.arth.2006.02.156
Tyson Y, Hillman C, Majenburg N, Sköldenberg O, Rolfson O, Kärrholm J, et al. Uncemented or cemented stems in first-time revision total hip replacement? An observational study of 867 patients including assessment of femoral bone defect size. Acta Orthop 2021; 92: 143-50. doi: 10.1080/17453674.2020.1846956. DOI: https://doi.org/10.1080/17453674.2020.1846956
Espíndola R, Vella V, Benito N, Mur I, Tedeschi S, Zamparini E, et al. Incidence, associated disease burden and healthcare utilization due to Staphylococcus aureus prosthetic joint infection in European hospitals: the COMBACTE-NET ARTHR-IS multi-centre study. J Hosp Infect 2023; 142: 9-17. doi: 10.1016/j.jhin.2023.09.012. DOI: https://doi.org/10.1016/j.jhin.2023.09.012
Flurin L, Greenwood-Quaintance K E, Patel R. Microbiology of polymicrobial prosthetic joint infection. Diagn Microbiol Infect Dis 2019; 94: 255-9. doi: 10.1016/j.diagmicrobio.2019.01.006. DOI: https://doi.org/10.1016/j.diagmicrobio.2019.01.006
Tai D B G, Patel R, Abdel M P, Berbari E F, Tande A J. Microbiology of hip and knee periprosthetic joint infections: a database study. Clin Microbiol Infect 2022; 28: 255-9. doi: 10.1016/j.cmi.2021.06.006. DOI: https://doi.org/10.1016/j.cmi.2021.06.006
Rava A, Bruzzone M, Cottino U, Enrietti E, Rossi R. Hip spacers in two-stage revision for periprosthetic joint infection: a review of literature. Joints 2019; 7: 56-63. doi: 10.1055/s-0039-1697608. DOI: https://doi.org/10.1055/s-0039-1697608
Molstad S, Cars O, Struwe J. Strama: a Swedish working model for containment of antibiotic resistance. Euro Surveill 2008; 13: 19041. DOI: https://doi.org/10.2807/ese.13.46.19041-en
Gonzalez M R, Bedi A D S, Karczewski D, Lozano-Calderon S A. Treatment and outcomes of fungal prosthetic joint infections: a systematic review of 225 cases. J Arthroplasty 2023; 38: 2464-71.e1. doi: 10.1016/j.arth.2023.05.003. DOI: https://doi.org/10.1016/j.arth.2023.05.003
Sambri A, Zunarelli R, Fiore M, Bortoli M, Paolucci A, Filippini M, et al. Epidemiology of fungal periprosthetic joint infection: a systematic review of the literature. Microorganisms 2022; 11: 84. doi: 10.3390/microorganisms11010084. DOI: https://doi.org/10.3390/microorganisms11010084
Weiss R J, Stark A, Kärrholm J. A modular cementless stem vs. cemented long-stem prostheses in revision surgery of the hip: a population-based study from the Swedish Hip Arthroplasty Register. Acta Orthop 2011; 82: 136-42. doi: 10.3109/17453674.2011.566145. DOI: https://doi.org/10.3109/17453674.2011.566145
Carroll F E, Gooberman-Hill R, Strange S, Blom A W, Moore A J. What are patients’ preferences for revision surgery after periprosthetic joint infection? A discrete choice experiment. BMJ Open 2020; 10: e031645. doi: 10.1136/bmjopen-2019-031645. DOI: https://doi.org/10.1136/bmjopen-2019-031645
Additional Files
Published
How to Cite
License
Copyright (c) 2025 Georgios Palechoros, Anders Brüggemann, Nils P Hailer
This work is licensed under a Creative Commons Attribution 4.0 International License.
PlumX (by Elsevier) is an altmetrics platform that tracks and visualizes the online attention, usage, captures, citations, and social media engagement.
