Managing periprosthetic joint infection through the direct anterior approach: Partial two-stage exchange with femoral stem retention
- 1Yale School of Medicine, Department of Orthopaedics & Rehabilitation, New Haven, CT, USA
- 2Hannover Medical School, Department of Orthopaedics, Hannover, Germany
- 3Torkieh J: Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
Abstract
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.
Related
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- Extensor Mechanism Reconstruction Following Periprosthetic Joint Infection After Total Knee Arthroplasty: A Systematic Review
- Antibiotic-Loaded Hydrogel, Calcium Bead, and Cement in Periprosthetic Joint Infection Following Hip-Knee Arthroplasty: A Systematic Review and Meta-Analysis of Commercially Available Products
- Retrospective analysis of LAG3, TIGIT, TIM3 and VISTA immune checkpoints expression in hip and knee periprosthetic joint infection
BibTeX
@article{rublev2026managing,
title = {{Managing periprosthetic joint infection through the direct anterior approach: Partial two-stage exchange with femoral stem retention}},
author = {George A. Rublev and Nils Becker and Joseph Torkieh and Thomas R. Hickernell and Lee E. Rubin},
journal = {Journal of Clinical Orthopaedics and Trauma},
year = {2026},
month = oct,
doi = {10.1016/j.jcot.2026.103646},
url = {https://doi.org/10.1016/j.jcot.2026.103646},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Managing periprosthetic joint infection through the direct anterior approach: Partial two-stage exchange with femoral stem retention
AU - George A. Rublev
AU - Nils Becker
AU - Joseph Torkieh
AU - Thomas R. Hickernell
AU - Lee E. Rubin
PY - 2026
DA - 2026/10/23
JO - Journal of Clinical Orthopaedics and Trauma
DO - 10.1016/j.jcot.2026.103646
UR - https://doi.org/10.1016/j.jcot.2026.103646
AB - 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.
SN - 0976-5662
SN - 2213-3445
ER -