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Paper text:
although periprosthetic joint infection ( pji ) is rare , its treatment is quite difficult .
two - stage revision surgeries are recommended , especially in late term and chronic infections.1 however , removing all the implants makes surgery harder and causes serious bone defects . especially in patients who have previous serious bone defect due to recurrent revision or tumor
, it can cause the total loss of the existing bone.2 we presented a case that was treated by leaving the well - fixed components and covering them with cement which included antibiotics to minimize these kind of complications .
a 59-year - old female patient was admitted to our clinic for pji after surgeries at different centers including hemiarthroplasty , total hip arthroplasty [ figure 1a ] , and finally total hip revision arthroplasty [ figure 1b ] due to femoral neck fracture . on admission , direct graph [ figure 1b ] and
blood examinations were assessed ( hemoglobin : 13.6 , white blood cell count : 12.92 , erythrocyte sedimentation rate [ esr ] : 48 , and c - reactive protein [ crp ] : 282 ) and a two - stage revision was planned .
soft tissues were sent from neighboring implant areas for microbiological culture analysis . since acetabular cup was well fixed and it had a thin cortical continuity around , only screws and polietilen insert were removed not to cause additional bone defect . since the femoral stem was too long and seemed well fixed to the bone , the femoral stem was not removed by the surgeon .
all the implants left were covered with cement ( 40 g implantcast ) mixed with antibiotics ( teicoplanin 400 mg sanofi - aventis ) [ figure 2a and b ] . in tissue culture analysis
, there was no reproduction ; however , due to high infection markers and intraoperative apses appearance , infectious diseases specialist started teicoplanin 800 mg / day ( targocid 400 mg sanofi - aventis ) .
the second stage of revision was performed after esr , and c - rp controls were seen to become normal at the end of 8 weeks [ figure 2c ] .
( a ) total arthroplasty ( b ) infected revision arthroplast ( a ) bone cement covered in intraoperative view ( b ) early postoperative x - ray covered bone cement ( c ) after treatment of infection on revision arthroplasty
nearly , 0.53% pji is observed after primary hip arthroplasty whereas 315% pji is observed after revision hip arthroplasty.3 when micro - organisms reach the surgical area , they reproduce fast and form a biofilm layer by adhering to the open surfaces of implants . in early period of infections ,
pressure washing and debridement are partly successful . however , in late and chronic infections , the microorganism is protected from both host defense mechanisms and local or systemic antibiotic treatment since it expresses biofilm layer .
the accepted approach in late - term pij is two - stage revision surgery.4 two - stage revision surgery includes removing all implants and revising with new implants through soft tissue debridement and antibiotic spacer after the infection has been removed .
however , removing both well - fixed implants makes the surgery more complicated and may cause serious bone defects.5 the spacer applied can be prepared in intraoperative bone cement or it can be readily provided . while fixing spacers well to the bone , they will increase their functionality and will cause additional bone losses while removing them .
spacers to be used and implants to be used in the second phase of revision are quite expensive , and they will increase surgical expenses.67 since our case was a middle - aged woman with a long - life expectancy , we tried to show maximum attention to protect the existing bone stock .
although extensive apses were observed , we saw that both acetabular and femoral component was well fixed to the bone . predicting that removing implants after radical soft tissue and necrotic bone debridement would increase bone defect , we preferred to remove only the mobile parts .
we covered the remaining implants with bone cement that we prepared by adding antibiotics on it .
in the course of freezing , bone cement gives off 7090 of heat and adheres tight to the implant .
we think that these properties of cement can influence the micro - organisms on the implant . by covering the implant with cement and with the help of soft tissue debridement ,
bone cement separates the implant surface from the environment and also maintains the local antibiotic amount in a high dose with the help of the antibiotic it includes . in the controls of our case
, we decreased the surgery time , loss of blood volume , and bone defects .
since the existing implants were not removed , a stabile spacer was used during the treatment . since
only the mobile components were removed in the second stage of the revision , the treatment cost was less .
no re - infection or comorbid complication was seen in the 1 postoperative year . in a similar partial two - stage revision hip arthroplasty study conducted by ekpo et al .
, they reported success in 17 ( 89% ) of 19 patients.8 more extensive in vitro studies showing which mechanisms take infection under control by covering implants in periprosthetic infection and higher numbers of long - term follow - up studies are needed .
this process can be preferred in removing periprosthetic infections in which implants are well fixed .
periprosthetic joint infection ( pji ) is a challenging complication with a frequency of 0.53% . the patient 's age , recurrent surgeries , and comorbid systemic diseases increase the risk of infection . 
 although the current approach in the treatment of pji is a two - stage revision ; sometimes , removing all the implants can lead to more serious complications . 
 pji 's complications are increase in the time of surgery , loss of blood volume , and increase in the amount of bone loss . infected soft tissue and dead bone tissue debridement 
 must be made in all cases . 
 one of our cases had bone defects due to recurrent hip arthroplasty revisions . 
 our case that was given pji treatment by covering the well - fixed components with bone cement and removing only the mobile parts was discussed in line with the literature .