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Treatment of Infection Associated with Segmental Bone Loss in the Proximal Part of the Femur in Two Stages with Use of an Antibiotic-Loaded Interval Prosthesis*

ALASTAIR S. E. YOUNGER, F.R.C.S.(C), CLIVE P. DUNCAN, F.R.C.S.(C) and BASSAM A. MASRI, F.R.C.S.(C), VANCOUVER, BRITISH COLUMBIA, CANADA

Investigation performed at the Department of Orthopaedics, University of British Columbia, Vancouver

	Abstract

Top Abstract Introduction Materials and Methods Results Discussion References

 
Treatment of an infection at the site of a total hip replacement associated with extensive loss of the proximal part of the femur is a challenging problem. In the present preliminary report, we describe the results after use of a prosthesis of antibiotic-loaded acrylic cement (PROSTALAC) in thirty such hips. The purpose of the prosthesis, which acts as an internal splint, is to maintain the length of the femur as well as the range of motion of the joint and the mobility of the patient between stages. A local level of antibiotics is maintained by the antibiotic-coated surface. A PROSTALAC with a cement-on-cement articulation was used in the first fifteen hips (Group I) in the study, and a custom metal-on-polyethylene articulating PROSTALAC was inserted in the subsequent fifteen hips (Group II). One patient who had a recurrent infection was managed with a second two-stage exchange and was included in both groups. Between stages, the average limb-length discrepancy was twenty-five millimeters despite a loss of more than 25 per cent of the femur in nineteen limbs. Sixteen patients were discharged home and seven, to a community hospital between stages. Six patients in Group I and only one in Group II were hospitalized for the entire course of treatment. The total duration of hospitalization for both stages averaged thirty-eight days. Twenty-eight patients were mobile even though they did not bear weight on the involved limb between stages: three patients used a cane, fifteen used crutches, and ten used a walker. Twenty-six patients reported no, slight, or moderate pain in the thigh, groin, or buttock between stages. The average Harris hip score before the first stage of the operation was 23 points (range, 0 to 63 points), which improved to 74 points (range, 40 to 91 points) at an average of forty-seven months (range, twenty-four to 114 months) postoperatively. Two patients died of unrelated causes before two years (the minimum follow-up period) had elapsed and were excluded from the final analysis; they had no evidence of recurrent infection. Of the remaining twenty-eight hips, twenty-seven (96 per cent) had no evidence of infection at the most recent follow-up examination.

	Introduction

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Infection has been reported after less than 1 to 2 per cent of primary total hip replacements and after 3 to 4 per cent of revisions^{5,8,11,23,24,28,30} in series ranging from slightly less than 200 to more than 4000 operations. Lidwell²³ reported that sixty-three (1.5 per cent) of 4133 primary hip replacements performed in conventional operating rooms were followed by infection, as were twenty-three (0.6 per cent) of 3922 procedures performed in ultra-clean-air enclosures. Schutzer and Harris³⁰ reported a rate of infection of 0.3 per cent (one of 376 procedures) after standard primary hip replacements and a rate of 3 per cent (two of sixty-six procedures) after revisions with bone-grafting. Charnley⁵ reported that the rate of infection after primary joint replacement decreased from 9 per cent for the first 190 procedures to 1.3 per cent for 708 procedures performed after the introduction of ultra-clean-air enclosures. A similar rate of 0.2 per cent (one of 499 primary arthroplasties) was reported by Eftekhar and Tzitzikalakis⁸. However, they reported that infection developed after five (2.5 per cent) of 197 revision procedures.

As additional revision procedures are performed on a hip, the risk of infection increases and the bone stock decreases. Therefore, infection may coexist with a major loss of bone, which poses a difficult operative problem. We address the management of a group of patients who had loss of bone stock and an infection after a total hip replacement.

There is little doubt that an infection at the site of a total hip replacement should be treated with thorough débridement and removal of foreign material as many organisms are able to adhere to the surface of the implant. This enables them to isolate themselves from endogenous defenses such as complement fixation and from exogenous therapy such as antibiotics^15,26. After débridement, the immediate placement of the final prosthesis (a single-stage exchange) is recommended by some authors^3,9,29,32 and a delayed two-stage exchange is advocated by others^6,12,19,25. Single-stage exchange may be contraindicated for patients who have segmental loss of femoral bone as a large segment of metal or allograft would be placed into a contaminated wound during the reconstruction. The patient may be managed in the interval between the stages of a two-stage exchange by an interval resection arthroplasty with or without the placement of a spacer within the joint^20,27. The use of antibiotic-loaded cement as an adjuvant allows the so-called dead space, which is not usually accessible to systemic antibiotic therapy, to be bathed in high concentrations of antibiotics^2,4. A period of six weeks to three months should separate the stages of a two-stage exchange^10,27.

When a spacer is not used during the interval between stages, the limb shortens, particularly if there is loss of bone stock in the proximal part of the femur¹⁰. The shortening makes the subsequent procedure technically more complex and may result in a large limb-length discrepancy¹⁴. Soft-tissue planes are often difficult to identify at the second stage if a resection arthroplasty alone was performed at the first stage.

In an attempt to improve the management of patients who have infection and loss of bone stock from the proximal part of the femur, an interval prosthesis was developed for use between the two stages of the exchange^7,22. Initially, the prosthesis included a facsimile of the proximal part of the femur made of antibiotic-loaded acrylic cement on a metal endoskeleton. The corresponding acetabular component was composed of antibiotic-loaded cement as well, so there was a cement-on-cement articulation. Because of the early success of this spacer, the design was developed further into a system that had a metal-on-polyethylene bearing. The use of an articulating surface was believed to be preferable to a hemiarthroplasty design, as a cement-on-bone articulation could cause pain and loss of acetabular bone. Because the prosthesis is coated with antibiotic-loaded cement, the acronym PROSTALAC (Prosthesis of Antibiotic-Loaded Acrylic Cement) was used to describe it.

A PROSTALAC was used in twenty-nine patients (thirty hips) who had infection with segmental loss of femoral bone, and they were followed for at least two years. The results for two of these patients, who died less than two years postoperatively (the minimum duration of follow-up), were excluded from the final analysis. The purpose of the present study was to report the outcome of the final reconstruction of the hip with respect to control of infection, relief of pain, maintenance of limb length, and short-term complications.

	Materials and Methods

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Twenty-nine patients (thirty procedures) who had infection with major loss of bone from the proximal part of the femur after a total hip replacement were managed consecutively at our center and followed prospectively. There were twenty-one women and eight men in the study group. The average age at the time of the most recent follow-up was seventy-one years (range, fifty-one to eighty-eight years). The average duration of follow-up was forty-seven months (range, twenty-four to 114 months).

Eight of the twenty-nine patients were first seen because of an infection after a primary hip arthroplasty and nineteen, because of an infection after a revision hip arthroplasty. One patient had a recurrent infection and therefore was included in the series twice. One patient had a failure of fusion with loss of bone stock after multiple attempts at arthrodesis of the hip. Another patient had an infection at the site of an intertrochanteric fracture with devascularization of the proximal part of the femur.

The infection of the joint was associated with a bulk allograft in three hips and with a metal proximal femoral replacement prosthesis in two hips. Five patients had a periprosthetic fracture. One patient had an infection after an excision arthroplasty with removal of a total hip replacement from an infected joint associated with major loss of femoral bone stock. Two patients were seen because of persistent infection after a two-stage revision procedure performed elsewhere. Twenty-seven patients had a hip replacement in situ at the time of presentation. One patient had a long-standing resection arthroplasty, with loss of bone stock from the proximal part of the femur and osteomyelitis. Two patients had internal fixation with plates, which was used to attempt an arthrodesis in one and to treat a fracture in the other. Both patients had an infection at the site of a non-union.

Of the thirty hips, fourteen had pain and a positive culture of fluid aspirated from the hip on presentation. Seven patients had a history of a sinus tract in the hips; five, a periprosthetic fracture of the femur with a deep infection; two, a failed débridement for an infection at the site of a proximal femoral non-union after attempted osteosynthesis; one, an infection at the site of a non-union after multiple attempts to achieve a fusion of the hip; and one, a hematogenous infection of the proximal part of the femur with osteomyelitis.

The infection in twenty-nine hips was proved by cultures of biopsy specimens obtained at the time of the initial procedure. The remaining patient had a negative culture of the synovial biopsy specimen, but antibiotics had been administered elsewhere before the first stage of the procedure. The clinical history, laboratory investigation, histological analysis, and finding of an abscess in the hip at the first stage suggested that the patient had an infection. One patient had diabetes; one, ankylosing spondylitis; and two, rheumatoid arthritis.

The series was divided into two groups on the basis of the type of interval prosthesis that was used (Table I). Group I had a cement-on-cement articulation. The femoral prosthesis consisted of a bent intramedullary rod, coated with antibiotic-loaded cement, and a head made of cement shaped by the excised acetabular component. The acetabular component was made from a bolus of cement shaped into a cup by the head of the excised femoral component. The fifteen procedures in Group I were performed between 1985 and 1990.

View larger version (69K): [in this window] [in a new window]   Figs. 1-A through 1-D: A seventy-seven-year-old woman in Group II who had had multiple revisions of a left hip replacement. During the last revision before the index procedure, an intraoperative periprosthetic fracture occurred and was treated with wide exposure of the femur and placement of cerclage plastic bands. Four months after that revision, she had a painful hip and Staphylococcus epidermidis grew on culture of aspirate. Fig. 1-A: Radiograph made at presentation, showing a dislocation of the hip replacement, which was complicated by deep infection with segmental loss of bone affecting the proximal part of the femur and devascularization of a large segment of the remaining femur.

View larger version (123K): [in this window] [in a new window]   Fig. 1-B Photograph made during the first stage of the operative procedure, which included removal of the devascularized segment and insertion of the PROSTALAC (prosthesis of antibiotic-loaded acrylic cement). The prosthesis consisted of a metal endoskeleton with a metal-on-polyethylene articulation and an antibiotic-loaded coat of acrylic cement to the level of the prosthetic head (Group II).

Simplex-P cement (Howmedica, Rutherford, New Jersey) was used in the construction of the twenty-two earlier prostheses, and Palacos-R cement (Smith and Nephew Richards, Memphis, Tennessee) was used for the eight most recent implants. The antibiotics placed in the cement were chosen according to the sensitivities of the organisms identified on culture of the preoperative aspirate. Tobramycin (Nebcin) and vancomycin (Vancocin) were used in twenty-three procedures, vancomycin alone was used in three procedures, tobramycin and penicillin were used in three procedures, and streptomycin was mixed into the cement for the patient who had a mycobacterial infection. This patient also received systemic antituberculous chemotherapy.

The first-stage procedure consisted of removal of all foreign material (Table II) and placement of the PROSTALAC. Preoperative hematological studies included determination of the erythrocyte sedimentation rate and a white blood-cell count. An anteroposterior radiograph of the pelvis, a cross-table lateral radiograph of the involved hip, and two orthogonal radiographs of the entire length of the femur that allowed identification of cement in the distal aspect of the femoral canal were made. Judet radiographs of the pelvis were used to assess acetabular bone stock and to locate acetabular fragments of bone cement in selected hips. All patients had preoperative aspiration of fluid from the joint and a biopsy of synovial tissue, with use of a Westcott needle (Becton Dickinson, Franklin Lakes, New Jersey) under fluoroscopic guidance and with aseptic techniques. Two samples of synovial fluid and one biopsy specimen of synovial tissue—a total of three specimens—were sent to the laboratory for culture and sensitivity tests.

After thorough débridement and irrigation, the acetabular component was inserted. The acetabular bone stock was carefully assessed, and the findings were recorded in the operative report to assist in the second-stage procedure. In Group I, the head of the excised femoral component was used as a tool for molding an appropriate hemispherical defect within the cement bolus on the pelvic side of the joint to simulate an acetabular component. In both groups, the acetabular cement was inserted at a late stage of polymerization to allow minimum interdigitation of the cement without deep intrusion into the acetabular bone. This technique makes it possible to remove the component easily at the time of the second-stage procedure.

After débridement and adequate excision of non-viable bone on the femoral side, the amount of the deficit varied among the hips. It was more than 25 per cent of the length of the femur in nineteen patients (26 to 50 per cent in fifteen [six in Group I and nine in Group II] and 51 to 75 per cent in four [three in Group I and one in Group II]). The deficit was 25 per cent of the femur or less in eleven patients (six in Group I and five in Group II). After construction of the PROSTALAC femoral component on a separate table, a collar of cement was applied around the component to allow it to be seated at the appropriate depth in the medullary canal of the femur and to ensure that the correct limb length was reestablished (Figs. 1-A, 1-B, and 1-C). The remaining abductor muscles and the greater trochanter were reattached to the proximal end of the femur with cerclage wire. After reduction of the joint, the wound was closed without drains so that the antibiotic-rich periprosthetic fluid was not removed.

View larger version (47K): [in this window] [in a new window]   Fig. 1-C: Radiograph made between stages. The cement spacer was loaded with 2.4 grams of tobramycin and one gram of vancomycin per forty grams of cement powder. The length of the limb was maintained (the limb lengths were equal between stages), and the patient was able to walk with partial weight-bearing with the aid of crutches. She was discharged home three weeks after the procedure.

The second-stage procedure was performed if the culture of the aspirate obtained after two to four weeks without antibiotic coverage was negative and if there was no visible evidence of infection at the time of the operation. Tissue samples were obtained for repeat cultures, and antibiotics were administered intraoperatively. Histological examination of a frozen section of synovial tissue was not performed routinely. The acetabular cement mantle was removed by fragmentation of the cement bolus with use of standard osteotomes. The acetabulum was reconstructed with use of appropriate techniques depending on the amount of bone loss.

The femoral bone stock was assessed, and appropriate reconstruction was performed (Fig. 1-D). After the procedure, antibiotics were administered intravenously for five days, until the results of the final cultures were obtained. The rehabilitation program thereafter was prescribed on the basis of the stability of the reconstruction and the specific needs of the patient.

View larger version (101K): [in this window] [in a new window]   Fig. 1-D: Radiograph made after the second stage of the procedure, which was performed ninety-six days after the first stage. A metal proximal femoral replacement was used with a cup inserted without cement. Morselized allograft was placed in the acetabulum. The total duration of hospitalization was thirty-three days: twenty-four days for the first stage and for intravenous administration of antibiotics and nine days for the second stage. At the latest follow-up examination, the patient had little pain and was able to walk two miles (3.2 kilometers) with use of a cane. She was satisfied with the outcome.

Study Protocol
The patients were followed prospectively since the time of presentation of the infection. The initial evaluation included a history and physical examination as well as radiographs of the pelvis, a lateral radiograph of the hip, and orthogonal radiographs of the femur. Aspiration of the hip was repeated in any patient who had continuing pain. The functional outcome was assessed with use of the Harris hip score¹⁸.

At the time of the first-stage procedure, the appearance of the hip after the components were removed, the type of bone cement, and the type of antibiotics used in the bone cement were documented. The time-interval between the stages, the amount of pain, the degree of function, the limb-length discrepancy, and the destination of the patient on discharge were recorded as well. Information documented at the time of the second-stage procedure included the appearance of the joint, the prosthesis used, the amount of bone loss, and the results of cultures of specimens obtained during the second-stage procedure.

The radiographic outcome was assessed with use of the criteria of Johnston et al.²¹. The hips were classified according to the amount of subsidence or the presence of radiolucent lines surrounding both components.

	Results

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Clinical and Radiographic Outcome
The average Harris hip score¹⁸ at the initial presentation was 23 points (range, 0 to 63 points), and it improved to an average of 74 points (range, 40 to 91 points) at the most recent follow-up examination. The relatively low Harris hip score at the follow-up examination reflected the comorbid conditions in these patients. Two patients died, from causes unrelated to the infection at the site of the total hip replacement, after less than two years (the minimum duration of follow-up). Although there was no evidence of recurrent infection at the time of death, they were excluded from the final analysis. Three of the remaining twenty-seven patients (twenty-eight procedures) did not have an improvement of more than 40 points in the Harris hip score. One patient who had only a minor improvement (of 5 points) in the score had a cauda equina syndrome secondary to an unrelated fracture. He needed two canes to walk and used a considerable amount of analgesics. The hip remained pain-free at the most recent follow-up examination, and he was satisfied with the outcome of the procedure. Another patient had an improvement in the score from 63 to 88 points. Despite avascular necrosis of the proximal part of the femur with an infection at the site of an ununited periprosthetic fracture, the patient had little pain at the time of the initial presentation. After a two-stage reconstruction, the patient had an excellent outcome and was able to play eighteen holes of golf without walking aids.

The only patient who was not satisfied with the outcome of the procedure had an improvement in the Harris hip score from 15.5 to 47.5 points. She had limitation of mobility and pain because of advanced degeneration of the ipsilateral knee with instability. She had complete relief of the pain in the hip.

Radiographs showed no evidence of subsidence of the femoral component or of non-union at the junction of the proximal femoral allograft and the host in the seven hips reconstructed with such a graft. One patient had migration, into the ilium, of a saddle prosthesis (a modular prosthesis manufactured by Link America, Denville, New Jersey, and used for reconstruction of missing femoral and acetabular bone primarily after resection of a tumor). Two patients had migration of a bipolar hemiprosthesis.

Microbiological Results
Most infections were caused by gram-positive organisms, as determined by examination of tissue obtained at the operation (Table III). One patient in Group II had no growth on culture of tissue obtained at the first stage. However, this patient had had débridement followed by management with antibiotics elsewhere. At the time of the first-stage procedure at our center, pus was found in the periprosthetic space and a two-stage revision was performed on the basis of this evidence of infection. There was also substantial loss of femoral bone. One patient had infection with Mycobacterium tuberculosis, which was treated with streptomycin placed within the bone cement.

Operative Results
The overall loss of blood in the first stage averaged 2161 milliliters, and an average of 3.3 units of blood was transfused. The duration of the first-stage operation averaged three hours and fifteen minutes (range, one hour and twenty minutes to five hours and thirty-nine minutes). The loss of blood in the second stage averaged 1722 milliliters, and an average of 2.7 units of blood was transfused. The duration of the second-stage operation was three hours (range, two hours to five hours and twenty minutes) (Table IV).

Control of Infection
At the second stage, there was no visible evidence of infection in any of the thirty hips. The cultures of the fluid obtained from aspiration before the second-stage treatment were all negative. After the débridement performed at the first stage, foreign material remained in three hips. The retained material included a non-absorbable mass of suture used previously to repair the trochanter, a fragment of cement, and a metal-backed acetabular cup. The suture and the fragment of cement were discovered at the time of the second stage and were removed. The acetabular shell, which had been inserted without cement, had been retained intentionally at the first stage as it was solidly fixed in a patient who had major loss of bone. The PROSTALAC had been inserted with cement into this component, and it was exchanged at the second stage. None of the three patients who had had retention of foreign material at the first stage had evidence of recurrent infection at the most recent follow-up examination.

Usually, there was a total of five routine cultures of tissue obtained at the second stage. These cultures were negative for twenty-five of the thirty patients. One of the five cultures was positive for four patients. Two of the five cultures were positive for one patient. In only one case did the organism grown in one of the five cultures correspond to the organism grown on culture of tissue taken from the site of a recurrent infection. This finding indicated that the rest of these positive cultures were probably due to contaminants.

One patient in this series had a recurrent infection. At the time of presentation of the initial infection, Enterobacter cloacae was grown on culture. Despite a two-stage exchange, the patient was seen with another infection twelve months after the second-stage procedure. At the time of the new presentation, Staphylococcus epidermidis was grown on culture of fluid aspirated from the hip joint. The patient was managed with repeat débridement and another two-stage revision with the PROSTALAC followed by placement of a saddle prosthesis because of severe loss of bone. (As a result, the patient was included in both Group 1 and Group 2.) As the patient had some pain and difficulty with walking associated with the saddle prosthesis, an aspiration of the joint with the prosthesis was performed at the most recent follow-up examination. However, there was no growth on culture of the fluid.

Complications
After the first stage, three patients in Group I and two in Group II had dislocation of the prosthesis. This was the most common complication between the stages, and it usually led to an earlier second-stage procedure. None of the four patients in Group II who had a snap-fit cup had a dislocation. Three temporary nerve palsies (one femoral, one sciatic, and one radial) occurred after the first-stage procedure; there were no long-term sequelae. No clinically apparent deep-vein thrombosis or pulmonary embolus occurred. In Group II, one patient had removal of a cerclage band that had been missed at the time of the first procedure. One patient had a major hemorrhage of five liters of blood because of injury of the iliac vessels. The hemorrhage was controlled with the assistance of a vascular surgeon.

Early complications after the second-stage procedure included hematoma in two patients and delayed wound-healing in one. One patient had extrusion of cement into the knee, necessitating an arthrotomy of the knee to remove the cement. One patient had two second-stage procedures because fluid aspirated after the first second-stage procedure was positive on culture at a community hospital. All cultures performed at the time of the second second-stage procedure were negative, suggesting that the previous aspirate had been contaminated. No clinically important thromboembolic event occurred after the second stage.

Late complications included one recurrent infection as already described. Two patients had late dislocation, and one of them had three dislocations; none had needed a revision operation at the time of writing. Two allografts did not unite, necessitating additional procedures, but at the latest follow-up examination all allografts had united with the host bone. A loose Lord ring cup (Howmedica, Rutherford, New Jersey) was revised in one hip. Other complications included migration of a hemiprosthesis into the ilium in two patients and migration of a saddle prosthesis into the ilium in one patient. None of these three components were revised. At the time of the most recent follow-up, which was an average of forty-seven months postoperatively, four of the twenty-nine patients had had a repeat operative procedure.

	Discussion

Top Abstract Introduction Materials and Methods Results Discussion References

 
In the present series, we showed that a patient who has infection with loss of bone from the proximal part of the femur after a total hip arthroplasty can be managed with an interval prosthesis without decreasing the likelihood that the infection will be eradicated. Of the twenty-eight hips that were followed for a minimum of two years, only one became reinfected; thus, the presumed rate of successful treatment of infection was 96 per cent. However, the duration of follow-up was relatively short and additional infections may appear with time. Therefore, these results should be considered preliminary, but they are encouraging. We were initially concerned that the interval spacer would maintain function between stages at the cost of a higher rate of reinfection. This has not been the case in the present series.

Alternatives for the treatment of infection after a total hip arthroplasty include a single-stage exchange arthroplasty^3,9,29,32, conversion to a permanent excision arthroplasty^14,16, treatment with suppressant antibiotics¹³, and a two-stage exchange with a resection arthroplasty between stages^6,12,19,25. All have distinct disadvantages in patients who have severe loss of bone. As far as we know, single-stage exchange previously was the only method for treating this problem without loss of limb length. However, a single-stage exchange in a hip with severe loss of bone, with the implantation of segmental bone graft or a metal replacement prosthesis, would likely increase the rate of recurrent infection and would create a more difficult exchange problem, particularly as fixation of the new implant is extended more distally into the intact femoral bone stock^10,26. For this reason, single-stage exchange may be contraindicated. If a gram-negative infection is present, or if there is abscess formation within the tissues, a single-stage exchange may not be adequate for the eradication of infection¹⁰.

A patient who has an infection with loss of bone stock after a total hip arthroplasty is a particularly poor candidate for excision arthroplasty because the functional result of excision arthroplasty deteriorates as the amount of bone loss increases¹⁴. Weight-bearing would be difficult, and problems with transfer could be expected. However, the rate of eradication of infection may be improved with use of antibiotic beads to improve the antibiotic concentration in the dead space²⁸.

Another option for the treatment of segmental loss of bone with infection includes the use of skeletal traction and a resection arthroplasty with the intramedullary placement of antibiotic beads to augment parenteral antibiotic therapy. At present, the cost to manage a patient who has an infection after a total hip replacement is high and most health-care systems cannot afford the additional expense of skeletal traction in the hospital^17,31. The complications of bed rest are well known. If the limb length is not maintained during the interval period, it may not be regained at the time of the second-stage procedure, which compromises the final outcome.

Use of the PROSTALAC (prosthesis of antibiotic-loaded acrylic cement) allowed our group of patients to regain adequate function. Most needed to stay in the hospital only for as long as the antibiotic treatment was continued, and there is now a program for intravenous administration of antibiotics at home. Although full mobility was not possible between stages, most patients had an acceptable level of pain and enough function to return to their homes with use of crutches and toe-touch weight-bearing on the involved extremity. The continued mobilization of the extremity provided by the prosthesis allowed soft-tissue planes to be maintained, making the second-stage dissection easier to perform.

The number of hip arthroplasties being performed is growing, and the number of patients who have complications has placed an increasing burden on the health-care system¹. It is important to find ways to reduce the cost of managing these complications while maintaining or improving the quality of care³¹. The interval PROSTALAC allows the patient to be mobilized quickly and discharged to home early, reducing the cost of care while successfully eradicating infection and providing an appropriate soft-tissue environment for a relatively straightforward second-stage procedure. The cost of managing a patient who has an infection at the site of a hip replacement has been decreased further by the development of programs for intravenous administration of antibiotics at home. This can reduce the duration of hospitalization to four or five days after each stage.

	Footnotes

 
*Although none of the authors has received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article, benefits have been or will be received but are directed solely to a research fund, foundation, educational institution, or other non-profit organization with which one or more of the authors is associated. No funds were received in support of this study.

Division of Reconstructive Orthopaedics, Department of Orthopaedics, University of British Columbia, 3rd Floor, Room 3415, 910 West 10th Avenue, Vancouver, British Columbia V5Z 4E3, Canada. E-mail address for Mr. Duncan: cduncan@unixg.ubc.ca. E-mail address for Mr. Masri: masri@unixg.ubc.ca.

	References

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