One and a half-stage Total Hip Arthroplasty with Custom-Made Articulating Spacers (CUMARS) for Management of Bilateral Destructive Hip Septic Arthritis – A Case Report

One and a half-stage Total Hip Arthroplasty with Custom-Made Articulating Spacers (CUMARS) for Management of Bilateral Destructive Hip Septic Arthritis – A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report One and a half-stage Total Hip Arthroplasty with Custom-Made Articulating Spacers (CUMARS) for Management of Bilateral Destructive Hip Septic Arthritis – A Case Report Angela Lim Hui-Shan, Andy Yeo Kuei Siong, Raghavan Raghuraman, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3992730/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Septic arthritis (SA) is a rare but potentially debilitating condition that can have quality-of-life impacting consequences. Prompt diagnosis and management is pivotal for early infection eradication and prevention of severe joint destruction. However, in a severely destructed joint, surgical options include resection arthroplasty or total hip arthroplasty (THA). Two-stage THA has been described in native hip SA with joint destruction while 1.5-stage THA has only been described in infected THA. This led to the consideration of 1.5-stage THA for management of chronic destructive hip SA. We report a 67-year-old patient with functional decline over eight months. Work-up revealed raised inflammatory markers and bilateral destructive hip SA. He underwent bilateral 1.5-stage THA with antibiotic-loaded Custom-Made Articulating Spacers (CUMARS). Post-operatively, he remains infection free is progressing well with rehabilitation. Management of SA varies largely depending on infection duration, activity level and extent of joint destruction. In primary destructive hip SA, a 1.5-stage THA with CUMARS can be considered due to the benefits of effective infection eradication, cost-effectiveness with reduced physical and psychological burden in avoiding a second operation, yet not precluding the possibility of a two-stage exchange THA if required. Infection Septic arthritis Hip Custom-made articulating spacer (CUMARS) Antibiotic cement Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Introduction Primary septic arthritis (SA) of the hip joint in an adult is relatively rare, but a potentially devastating condition that can cause accelerated joint degeneration, osteonecrosis, functional disability with estimated mortality rates of 11% [ 1 ]. Prompt diagnosis and management is pivotal for early source control of the infection and prevention of quality-of-life consequences. However, its heterogenous etiology and multifactorial pattern of clinical presentation pose a challenge for both diagnosis and treatment. Hence, there is no consensus on the treatment algorithm for these group of patients. The management of acute SA of the hip with preserved anatomic structures include open or arthroscopic joint washout and debridement, followed by systemic antibiotics. However, the treatment of destructive and recalcitrant septic hip arthritis can be complicated and remains controversial. In these cases, there is osteomyelitis of the acetabulum and proximal femur resulting in destruction of articular cartilage and underlying bone with significant joint deformity. Traditionally, hip SA was treated with resection arthroplasty as described by GR Girdlestone [ 2 ]. While this procedure successfully controlled infection, patients often have chronic joint pain, limb length discrepancy, inability to weight bear on the affected limb and significantly poor functional results [ 3 ]. Total hip arthroplasty (THA) has been introduced in the last decades as a new therapeutic surgical treatment for patients with hips destroyed secondary to chronic SA. However, an existing infection is a contraindication to joint arthroplasty [ 4 ] due to the risk of periprosthetic joint infection [ 5 , 6 ] and can be associated with high morbidity and mortality. An ideal surgery for this group of patients is one that can eradicate infection while preserving hip function. It is well documented that 1.5-stage and 2-stage exchange arthroplasty is an established form of management for infected THA that controls infection and improves pain and function [ 7 ]. However, in the context of primary hip SA, study on the use of 2-stage exchange arthroplasty is limited and few. 2-stage exchange THA has been has been reported in a two case series’ by Fleck et al. and Younger et al. of with a subset of fourteen and sixty-one patients respectively [ 8 , 9 ]. Both case series by Fleck et al. and Younger et al. used primary Prosthesis with Antibiotic-Loaded Acrylic Cement (PROSTALAC) articulating spacer with 14.2% and 3% of patients electing to not proceed with 2-stage exchange respectively as their spacer provided adequate function. Infection was controlled in majority of these patients, except a single case reported by Fleck et al. [ 8 ] and three cases reported by Younger et al. [ 9 ]. To our knowledge, 1.5-stage THA has only been described in infected THA but not in the context of native hip SA. In infected THA, Tsung et al. described a 1.5-stage THA using Custom-Made Articulating Spacers (CUMARS) where 44.7% of patients kept a spacer that was functional [ 10 ]. Comparing PROSTALAC and CUMARS, several factors are taken into consideration. Firstly, CUMARS was designed for the possibility of a 1.5-stage THA which is defined as a single stage THA that remains permanent, whist allowing for a second-stage exchange THA if required [ 11 , 12 ]. However, PROSTALAC was designed to remain in-situ short term thereafter requiring a second surgery for implantation of a permanent THA prosthesis [ 13 ]. Secondly, PROSTALAC is a semi-constraint implant that has the benefit of stability but risk of increased stress on the prosthesis and bone interface unlike CUMARS which is a THA without constraints. Lastly, PROSTALAC has limited sizes unlike CUMARS which is also more common and readily available. Accounting for the small percentage of patients electively choosing not to proceed with 2-stage exchange arthroplasty due to adequate functionality in the two case series, it led us to consider antibiotic-loaded CUMARS in a 1.5-stage operation as a viable option in the context of native hip SA with the benefit of infection eradication, functional weight bearing, whilst not precluding the possibility of a 2-stage revision arthroplasty with ease. We describe a novel technique using antibiotic-loaded CUMARS in a 1.5-stage THA in the management of a case of chronic destructive SA in bilateral hip joints. Case History A 67-year-old male was admitted three times under various specialties over a span of eight months. He was pre-morbidly independent in Activities of Daily Living (ADL) and community ambulant without aids. Significant past medical history includes diabetes mellitus, hypertension, hyperlipidaemia and ischemic heart disease with heart failure with reduced ejection fracture. Others include prostate cancer status post cystoscopy, insertion of ureter guidewires and robot-assisted radical prostatectomy, and he remains in remission till date. He was first admitted under General Medicine for a 4-month-history of unintentional loss of weight, borderline blood pressure, high white blood cell counts and functional decline since his prostate cancer resection surgery. Laboratory tests revealed serum white blood cell count of 21.39× 10 9 /L, C-reactive protein level of 122.7 mg/L and procalcitonin level of 0.58 ug/L. A Computed Tomography scan of the Thorax, Abdomen and Pelvis (CT TAP) (Fig. 1) was done to find the source of infection which incidentally revealed a mild non-specific right hip effusion and a rheumatology review was obtained. X-rays appeared normal (Fig. 2). In view of no inflammatory symptoms, he was diagnosed to have right hip osteoarthritis and was discharged after two weeks hospitalization. At this time, no additional assessment or Orthopaedic referral was done to rule out the possibility of SA. Over five months, he continued to functionally decline, being unable to tolerate prolong sitting and was mostly bedbound. He was re-admitted under Geriatric Medicine due to a fall secondary to lower limb weakness, right worse than left. Physical examination revealed right lower limb shortening, limited hip ranging with mild tenderness. X-rays revealed right hip destruction of the superior acetabulum with superior subluxation and left hip degenerative changes (Fig. 3). In view of significant progression of his condition, an Orthopaedic review was requested and Magnetic Resonance Imaging (MRI) of the pelvis and right hip showed evidence of moderate to severe bilateral hip effusion, worst on the right, with moderate joint effusion partially decompressing into periarticular soft tissues (Fig. 4). In addition, there was acute osteomyelitis of the right acetabulum and femoral head with bony destruction and subluxation and blood cultures grew pseudomonas aeruginosa. Ultrasound-guided right hip joint aspiration and core biopsy had no bacterial yield despite not having antibiotics started. Intravenous (IV) tazocin was started for pseudomonas bacteraemia coverage. To ensure proper source control, the patient underwent bilateral arthrotomy, debridement, synovectomy and washout via an ABMS approach. Intra-operative cultures yielded pseudomonas aeruginosa and he received organism-specific IV ciprofloxacin daily for two weeks post-surgery, followed by oral ciprofloxacin for 6 more weeks. Post-operatively, his hip pain improved significantly but functionally, he remained bedbound requiring assistance for transfers. Follow-up MRI 2 months post-operation revealed interval progression of SA worse over the left hip (Fig. 5). Inflammatory markers remained raised with serum white blood cell count of 15.7× 10 9 /L and C-reactive protein level of 28.6 mg/L. Interval X-rays showed left hip progressive destruction while the right hip remained grossly stable since last discharge (Fig. 6). He was re-admitted for repeat bilateral hip joint washout, synovectomy debridement and a 1.5-stage antibiotic-loaded THA with CUMARS via ABMS approach, with both operations done in a single setting. An anterior-based approach was chosen to preserve soft tissue, muscle and reduce the risk of dislocation after THA. The surgery was performed under general anaesthesia in lateral decubitus position. The hip joint was fully exposed. Intra-operative right hip findings include recalcitrant SA and osteomyelitis with synovitis and no purulent fluid, false acetabulum with Paprosky 3A bone loss and subluxation more than 3cm. Meanwhile, intra-operative left hip findings include SA with synovitis with no purulent fluid, deformed and unhealthy femoral head, superolateral acetabular wall contained bone loss with superior wall intact. The damaged femoral head and neck were excised. Meticulous and radical debridement were performed to remove remnant infective tissues. The acetabulum was debrided using an acetabular reamer. Five tissues from each side were taken and sent for culture. The surgical site was then washed with iodine and saline. Prior to reconstruction, a surgical site was re-draped and surgical team re-gowned. A new set of surgical instruments was used for the reconstruction. The articulating spacers for the right hip were prepared using a Stryker Rimfit cup 50mm OD 32mm ID, Stryker LFIT V40 femoral head 32mm OD, + 4 offset and Exeter V40 cemented hip stem 35.5 offset stem length 125mm stem length. The articulating spacers for the left hip were prepared using a Stryker Rimfit cup 52mm OD 36mm ID, Stryker LFIT V40 femoral head 36mm OD, 0 offset and Exeter V40 cemented hip stem 35.5 offset stem length 125mm stem length (Stryker NY). The Palacos cement was loaded with 8g of ceftazidime total per hip. Due to the significant amount of acetabulum bone loss for the right hip, additional 2x3.5cm cancellous screw was inserted to the superior acetabular wall defect. At the end of each section of the surgery, first being wound debridement and joint washout with subsequent 1.5-stage THA, the hip was irrigated with copious amounts of normal saline, chlorhexidine subsequently soaked in 9mls of 10% iodine mixed with 250mls of normal saline. Post-operatively, intra-operative cultures came back negative for bacterial growth, he completed 2 more weeks of oral ciprofloxacin and was allowed to full weight bear immediately. However, his rehabilitation recovery was slow requiring moderate to maximum assistance for ADLs due to sarcopenia from prolonged functional decline and bedrest. Post-operative X-rays done on day 0, 1-month and 1-year review revealed On one-month review, he is able to ambulate with walking frame with minimum assistance. There was no clinical or biochemical evidence of recurrent infection with serum white blood cell count of 9.1 × 10 9 /L, C-reactive protein level of 0.9 mg/L. On one-year review, he was he is able to ambulate with walking frame independently (Fig. 7) and there is no clinical evidence of infection recurrence. Overall, post-operative X-rays done on day 0, 1-month and 1-year review revealed stable bilateral hip replacement prostheses with no evidence of periprosthetic fractures or loosening (Fig. 8). Discussion Septic hip arthritis is a rare condition that commonly occurs secondary to haematogenic spread of bacteraemia from other locations and typically occurs unilaterally, rarely involving bilateral hips [ 14 ]. Optimal treatment of patients with a degenerative joint disease secondary to SA of the hip is unclear. Several papers have described that the ideal treatment choice largely depends on duration of symptoms and the type of infection – active vs quiescent [ 15 , 16 ]. In early onset native hip SA, it can be managed arthroscopically or via open debridement as described by Cargnelli et al. [ 17 ]. Traditionally, hip SA with significant joint destruction was managed with resection hip arthroplasty for infection eradication. However, this resulted in poor functional outcomes [ 18 ]. To allow for satisfactory clinical and functional outcomes whilst ensuring infection eradication, two-stage THA is currently considered the treatment of choice [ 19 ]. In a two-stage THA, the first step can be resection arthroplasty or the implantation of an antibiotic-loaded hip spacer with the former having significantly poorer outcomes. However, patients with chronic destructive SA tend to have multiple comorbidities, are deconditioned and may be unfit or unwilling to undergo a second surgery. Hipfl et al. reported the result of largest series of two-stage THA after resection arthroplasty for destructive hip SA [ 20 ] of which 33% have treatment failure with a considerable number of patients who failed to undergo definitive THA. Additionally, resection hip arthroplasty in the first stage can lead to muscle contractures, pain, further deconditioning, poor functional result and hamper reimplantation surgery at the second stage. In contrast, multiple papers studying two-stage THA using antibiotic-loaded hip spacer as first stage has been proven to be effective in infection eradication with success rates ranging from 92 to 100 percent while providing excellent functional outcomes [ 19 , 21 ]. Antibiotic-loaded spacers offers the advantage of distributing highly concentrated antibiotics to a localized area while maintaining the joint space and soft tissue tension for future component reimplantation [ 22 ]. However, high rates of cement spacer-related complications have been reported, including spacer migration, dislocation and spacer fracture [ 23 ]. Hence, the strength of the spacer is important and must be able to resist stress and shear force. The ideal operation for this group of patients is one that can achieve high infection eradication rates while preserving hip function and potentially avoiding a second operation. In avoiding a second operation with a 1.5-stage THA, it is more cost effective, provides satisfactory functional outcomes and eliminates the physical and psychological burden of a repeat operation [ 24 ]. This is an important consideration, especially in frail patients with multiple comorbidities. However, in the unfortunate context of spacer-related complications or infection recurrence, it is ideal to have the option of a second stage exchange THA. PROSTALAC and CUMARS are both possible antibiotic-loaded spacer options. Comparing the two, CUMARS has been extensively reported to have better inter-stage functionality, easier removal with good infection eradication [ 11 , 12 ]. CUMARS was developed in 2001, and this spacer system includes the Exeter Universal Femoral stem (Stryker, Mahwah, NJ, USA) and a polyethylene acetabular liner [ 10 ]. In the infected THA, Tsung et al. described a 1.5-stage THA using CUMARS where 44.7% of patients kept a spacer that had satisfactory functional outcomes [ 10 ]. This provides the benefit of avoiding a second surgery, yet not precluding the surgeon from performing a two-stage exchange THA as the articulating spacer can be left in situ for as long as possible until the spacer loosens, implant fails or infection recurs. Currently, in the literature, both 1.5-stage THA and CUMARS have only been described in the context of PJI, which has been shown to be an effective management option [ 7 , 10 – 12 ]. In future, the use of 1.5-stage THA with CUMARS in the context of native hip SA would be advantageous for effective infection eradication, cost-effectiveness and reducing physical and psychological burden in avoiding a potential second surgery. All whilst not precluding the surgeon from performing a two-stage exchange THA with ease. However, this procedure requires experience to address the deformities and poor bone stock caused by the SA. To achieve high success rate in the treatment of septic hip arthritis with 1.5-stage THA, it is important to adhere to a strict protocol. This is inclusive of but not limited to: Obtaining joint aspirate pre-operatively for microbial data Radical and meticulous debridement of all infected tissue (if performed) Copious amounts of irrigation Re-drape and re-gown Using a new set of surgical instruments for the reconstruction Use of appropriate organism-specific antibiotic for the cement spacer Summary SA is a rare but morbid condition that can have a significant impact on one’s function and quality of life rapidly. Management of SA is largely dependent on duration and activity level of the infection and extent of joint destruction. In a significantly deformed hip joint due to SA, 1.5-stage THA with CUMARS is a viable option with benefits of effective infection eradication, cost-effectiveness with reduced physical and psychological burden in avoiding a second operation, yet not precluding the possibility of a two-stage exchange THA if required. Declarations Patient Consent: Informed consent obtained from patient and family. Publication Consent: Informed consent obtained from patient and family for publication of case report or identifying information/images in an online open-access publication. Availability of data and materials: Not applicable Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Acknowledgements: I sincerely thank Dr Moo Ing How for the assistance and supervision in the editing and writing of the manuscript. Funding: No funding obtained. Author’s Contribution: L.H.S.A wrote the main manuscript. M.I.H conceptualized the idea and wrote the main manuscript. Y.K.S.A, R.R and C.K.K.K supervised in the writing of the manuscript. All authors reviewed the manuscript. Author’s Information: Not applicable. References Mathews CJ, Weston VC, Jones A, Field M, Coakley G. Bacterial septic arthritis in adults. Lancet. 2010;375(9717):846–55. Brand RA. Acute Pyogenic Arthritis of the Hip: An Operation Giving Free Access and Effective Drainage: GR Girdlestone BM OXFD, FRCS. Clin Orthop Relat Res. 2008;466:258–63. McElwaine J, Colville J. Excision arthroplasty for infected total hip replacements. J Bone Joint Surg Br Volume. 1984;66(2):168–71. Gao X, He R-x. Yan S-g. Total hip arthroplasty for patients with osteoarthritis secondary to hip pyogenic infection. Chin Med J. 2010;123(02):156–9. Aalirezaie A, Arumugam SS, Austin M, Bozinovski Z, Cichos KH, Fillingham Y et al. 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J Arthroplast. 1997;12(6):615–23. Tsung JD, Rohrsheim JA, Whitehouse SL, Wilson MJ, Howell JR. Management of periprosthetic joint infection after total hip arthroplasty using a custom made articulating spacer (CUMARS); the Exeter experience. J Arthroplast. 2014;29(9):1813–8. Burastero G, Basso M, Carrega G, Cavagnaro L, Chiarlone F, Salomone C, et al. Acetabular spacers in 2-stage hip revision: is it worth it? A single-centre retrospective study. Hip Int. 2017;27(2):187–92. Quayle J, Barakat A, Klasan A, Mittal A, Stott P. External validation study of hip peri-prosthetic joint infection with cemented custom-made articulating spacer (CUMARS). Hip Int. 2022;32(3):379–85. Prostalac Hip System. Depuy Orthopaedics, Inc2004. Yacoub YI, Amine B, Hajjaj-Hassouni N. Bilateral septic arthritis of the hip with osteitis and psoas abcess in a 17-year-old adolescent. J Pediatr Orthop B. 2011;20(4):238–41. Balato G, de Matteo V, Ascione T, de Giovanni R, Marano E, Rizzo M, et al. 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Clinical outcomes and survivorship of two-stage total hip or knee arthroplasty in septic arthritis: a retrospective analysis with a minimum five-year follow-up. Int Orthop. 2021;45:1683–91. Hipfl C, Karczewski D, Oronowicz J, Pumberger M, Perka C, Hardt S. Total hip arthroplasty for destructive septic arthritis of the hip using a two-stage protocol without spacer placement. Arch Orthop Trauma Surg. 2023;143(1):19–28. Romanò CL, Romanò D, Meani E, Logoluso N, Drago L. Two-stage revision surgery with preformed spacers and cementless implants for septic hip arthritis: a prospective, non-randomized cohort study. BMC Infect Dis. 2011;11(1):1–7. Masri BA, Duncan CP, Beauchamp CP. Long-term elution of antibiotics from bone-cement: an in vivo study using the prosthesis of antibiotic-loaded acrylic cement (PROSTALAC) system. J Arthroplast. 1998;13(3):331–8. Anagnostakos K, Jung J, Schmid NV, Schmitt E, Kelm J. Mechanical complications and reconstruction strategies at the site of hip spacer implantation. Int J Med Sci. 2009;6(5):274. Pignatti G, Nitta S, Rani N, Dallari D, Sabbioni G, Stagni C, et al. Two stage hip revision in periprosthetic infection: results of 41 cases. open Orthop J. 2010;4:193. Palmer CK, Gooberman-Hill R, Blom AW, Whitehouse MR, Moore AJ. Post-surgery and recovery experiences following one-and two-stage revision for prosthetic joint infection—A qualitative study of patients’ experiences. PLoS ONE. 2020;15(8):e0237047. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3992730","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":276369845,"identity":"292da990-683a-40f1-a143-6e292ddef626","order_by":0,"name":"Angela Lim 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2","display":"","copyAsset":false,"role":"figure","size":585411,"visible":true,"origin":"","legend":"\u003cp\u003eNormal right hip X-rays on first admission\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3992730/v1/a5095667953642f4b9340882.png"},{"id":52186956,"identity":"d1898018-f838-437e-b2d1-e86729932bee","added_by":"auto","created_at":"2024-03-07 18:37:51","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":845174,"visible":true,"origin":"","legend":"\u003cp\u003eX-rays after five months of functional decline showing right hip joint destruction and superior subluxation with left hip onset of degenerative changes\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-3992730/v1/87fea79d1859ca7590bd367d.png"},{"id":52183549,"identity":"708e8a58-1a94-4705-bc66-aa0370abdfc2","added_by":"auto","created_at":"2024-03-07 18:13:51","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":682727,"visible":true,"origin":"","legend":"\u003cp\u003eCoronal MRI showing bilateral femoral head osteomyelitis and hip effusion\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-3992730/v1/626fac3b5015209764eb7fa3.png"},{"id":52183552,"identity":"f862cf5b-8d36-42c3-9a26-c355b57cab29","added_by":"auto","created_at":"2024-03-07 18:13:52","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":740779,"visible":true,"origin":"","legend":"\u003cp\u003eFollow-up Coronal MRI showing bilateral hip effusion (left more than right) with interval worsening of the left hip joint with osteomyelitis (coronal view)\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-3992730/v1/d84bd0595b570891dd3e69da.png"},{"id":52185396,"identity":"583022c2-00c1-4155-872a-62079709d2c6","added_by":"auto","created_at":"2024-03-07 18:21:51","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":721279,"visible":true,"origin":"","legend":"\u003cp\u003eFollow-up X-rays showing interval destruction of left femoral head and distal left acetabulum, stable right hip destruction\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-3992730/v1/c1c6ba56e01e76be6223f260.png"},{"id":52185398,"identity":"65f66f57-cf46-4019-9255-2c9157521f18","added_by":"auto","created_at":"2024-03-07 18:21:52","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":815327,"visible":true,"origin":"","legend":"\u003cp\u003eAmbulating independently using walking frame on 1-year review\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-3992730/v1/3bde153147c95541adf97dd6.png"},{"id":52186452,"identity":"f0204d59-b02b-42b1-8d4c-ff114429549f","added_by":"auto","created_at":"2024-03-07 18:29:52","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":716655,"visible":true,"origin":"","legend":"\u003cp\u003ePost-operative X-rays on day 0 (left), at 1-month (middle) and at 1-year (right)\u003c/p\u003e","description":"","filename":"8.png","url":"https://assets-eu.researchsquare.com/files/rs-3992730/v1/f138c3633d777df3a5b9f401.png"},{"id":54493205,"identity":"86e6f5de-5008-4101-901e-f20530178958","added_by":"auto","created_at":"2024-04-11 11:05:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4479232,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3992730/v1/d41f099f-d637-442a-be0e-9d4408bbdd6e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"One and a half-stage Total Hip Arthroplasty with Custom-Made Articulating Spacers (CUMARS) for Management of Bilateral Destructive Hip Septic Arthritis – A Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePrimary septic arthritis (SA) of the hip joint in an adult is relatively rare, but a potentially devastating condition that can cause accelerated joint degeneration, osteonecrosis, functional disability with estimated mortality rates of 11% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Prompt diagnosis and management is pivotal for early source control of the infection and prevention of quality-of-life consequences. However, its heterogenous etiology and multifactorial pattern of clinical presentation pose a challenge for both diagnosis and treatment. Hence, there is no consensus on the treatment algorithm for these group of patients.\u003c/p\u003e \u003cp\u003eThe management of acute SA of the hip with preserved anatomic structures include open or arthroscopic joint washout and debridement, followed by systemic antibiotics. However, the treatment of destructive and recalcitrant septic hip arthritis can be complicated and remains controversial. In these cases, there is osteomyelitis of the acetabulum and proximal femur resulting in destruction of articular cartilage and underlying bone with significant joint deformity. Traditionally, hip SA was treated with resection arthroplasty as described by GR Girdlestone [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. While this procedure successfully controlled infection, patients often have chronic joint pain, limb length discrepancy, inability to weight bear on the affected limb and significantly poor functional results [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Total hip arthroplasty (THA) has been introduced in the last decades as a new therapeutic surgical treatment for patients with hips destroyed secondary to chronic SA. However, an existing infection is a contraindication to joint arthroplasty [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] due to the risk of periprosthetic joint infection [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and can be associated with high morbidity and mortality.\u003c/p\u003e \u003cp\u003eAn ideal surgery for this group of patients is one that can eradicate infection while preserving hip function. It is well documented that 1.5-stage and 2-stage exchange arthroplasty is an established form of management for infected THA that controls infection and improves pain and function [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, in the context of primary hip SA, study on the use of 2-stage exchange arthroplasty is limited and few. 2-stage exchange THA has been has been reported in a two case series\u0026rsquo; by Fleck et al. and Younger et al. of with a subset of fourteen and sixty-one patients respectively [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Both case series by Fleck et al. and Younger et al. used primary Prosthesis with Antibiotic-Loaded Acrylic Cement (PROSTALAC) articulating spacer with 14.2% and 3% of patients electing to not proceed with 2-stage exchange respectively as their spacer provided adequate function. Infection was controlled in majority of these patients, except a single case reported by Fleck et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and three cases reported by Younger et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo our knowledge, 1.5-stage THA has only been described in infected THA but not in the context of native hip SA. In infected THA, Tsung et al. described a 1.5-stage THA using Custom-Made Articulating Spacers (CUMARS) where 44.7% of patients kept a spacer that was functional [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Comparing PROSTALAC and CUMARS, several factors are taken into consideration. Firstly, CUMARS was designed for the possibility of a 1.5-stage THA which is defined as a single stage THA that remains permanent, whist allowing for a second-stage exchange THA if required [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, PROSTALAC was designed to remain in-situ short term thereafter requiring a second surgery for implantation of a permanent THA prosthesis [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Secondly, PROSTALAC is a semi-constraint implant that has the benefit of stability but risk of increased stress on the prosthesis and bone interface unlike CUMARS which is a THA without constraints. Lastly, PROSTALAC has limited sizes unlike CUMARS which is also more common and readily available.\u003c/p\u003e \u003cp\u003eAccounting for the small percentage of patients electively choosing not to proceed with 2-stage exchange arthroplasty due to adequate functionality in the two case series, it led us to consider antibiotic-loaded CUMARS in a 1.5-stage operation as a viable option in the context of native hip SA with the benefit of infection eradication, functional weight bearing, whilst not precluding the possibility of a 2-stage revision arthroplasty with ease.\u003c/p\u003e \u003cp\u003eWe describe a novel technique using antibiotic-loaded CUMARS in a 1.5-stage THA in the management of a case of chronic destructive SA in bilateral hip joints.\u003c/p\u003e"},{"header":"Case History","content":"\u003cp\u003eA 67-year-old male was admitted three times under various specialties over a span of eight months. He was pre-morbidly independent in Activities of Daily Living (ADL) and community ambulant without aids. Significant past medical history includes diabetes mellitus, hypertension, hyperlipidaemia and ischemic heart disease with heart failure with reduced ejection fracture. Others include prostate cancer status post cystoscopy, insertion of ureter guidewires and robot-assisted radical prostatectomy, and he remains in remission till date.\u003c/p\u003e\n\u003cp\u003eHe was first admitted under General Medicine for a 4-month-history of unintentional loss of weight, borderline blood pressure, high white blood cell counts and functional decline since his prostate cancer resection surgery. Laboratory tests revealed serum white blood cell count of 21.39\u0026times; 10\u003csup\u003e9\u003c/sup\u003e/L, C-reactive protein level of 122.7 mg/L and procalcitonin level of 0.58 ug/L. A Computed Tomography scan of the Thorax, Abdomen and Pelvis (CT TAP) (Fig. 1) was done to find the source of infection which incidentally revealed a mild non-specific right hip effusion and a rheumatology review was obtained. X-rays appeared normal (Fig. 2). In view of no inflammatory symptoms, he was diagnosed to have right hip osteoarthritis and was discharged after two weeks hospitalization. At this time, no additional assessment or Orthopaedic referral was done to rule out the possibility of SA.\u003c/p\u003e\n\u003cp\u003eOver five months, he continued to functionally decline, being unable to tolerate prolong sitting and was mostly bedbound. He was re-admitted under Geriatric Medicine due to a fall secondary to lower limb weakness, right worse than left. Physical examination revealed right lower limb shortening, limited hip ranging with mild tenderness. X-rays revealed right hip destruction of the superior acetabulum with superior subluxation and left hip degenerative changes (Fig. 3). In view of significant progression of his condition, an Orthopaedic review was requested and Magnetic Resonance Imaging (MRI) of the pelvis and right hip showed evidence of moderate to severe bilateral hip effusion, worst on the right, with moderate joint effusion partially decompressing into periarticular soft tissues (Fig. 4). In addition, there was acute osteomyelitis of the right acetabulum and femoral head with bony destruction and subluxation and blood cultures grew pseudomonas aeruginosa. Ultrasound-guided right hip joint aspiration and core biopsy had no bacterial yield despite not having antibiotics started. Intravenous (IV) tazocin was started for pseudomonas bacteraemia coverage.\u003c/p\u003e\n\u003cp\u003eTo ensure proper source control, the patient underwent bilateral arthrotomy, debridement, synovectomy and washout via an ABMS approach. Intra-operative cultures yielded pseudomonas aeruginosa and he received organism-specific IV ciprofloxacin daily for two weeks post-surgery, followed by oral ciprofloxacin for 6 more weeks. Post-operatively, his hip pain improved significantly but functionally, he remained bedbound requiring assistance for transfers.\u003c/p\u003e\n\u003cp\u003eFollow-up MRI 2 months post-operation revealed interval progression of SA worse over the left hip (Fig.\u0026nbsp;5). Inflammatory markers remained raised with serum white blood cell count of 15.7\u0026times; 10\u003csup\u003e9\u003c/sup\u003e/L and C-reactive protein level of 28.6 mg/L. Interval X-rays showed left hip progressive destruction while the right hip remained grossly stable since last discharge (Fig. 6). He was re-admitted for repeat bilateral hip joint washout, synovectomy debridement and a 1.5-stage antibiotic-loaded THA with CUMARS via ABMS approach, with both operations done in a single setting. An anterior-based approach was chosen to preserve soft tissue, muscle and reduce the risk of dislocation after THA. The surgery was performed under general anaesthesia in lateral decubitus position. The hip joint was fully exposed. Intra-operative right hip findings include recalcitrant SA and osteomyelitis with synovitis and no purulent fluid, false acetabulum with Paprosky 3A bone loss and subluxation more than 3cm. Meanwhile, intra-operative left hip findings include SA with synovitis with no purulent fluid, deformed and unhealthy femoral head, superolateral acetabular wall contained bone loss with superior wall intact. The damaged femoral head and neck were excised. Meticulous and radical debridement were performed to remove remnant infective tissues. The acetabulum was debrided using an acetabular reamer. Five tissues from each side were taken and sent for culture. The surgical site was then washed with iodine and saline. Prior to reconstruction, a surgical site was re-draped and surgical team re-gowned. A new set of surgical instruments was used for the reconstruction. The articulating spacers for the right hip were prepared using a Stryker Rimfit cup 50mm OD 32mm ID, Stryker LFIT V40 femoral head 32mm OD, +\u0026thinsp;4 offset and Exeter V40 cemented hip stem 35.5 offset stem length 125mm stem length. The articulating spacers for the left hip were prepared using a Stryker Rimfit cup 52mm OD 36mm ID, Stryker LFIT V40 femoral head 36mm OD, 0 offset and Exeter V40 cemented hip stem 35.5 offset stem length 125mm stem length (Stryker NY). The Palacos cement was loaded with 8g of ceftazidime total per hip. Due to the significant amount of acetabulum bone loss for the right hip, additional 2x3.5cm cancellous screw was inserted to the superior acetabular wall defect. At the end of each section of the surgery, first being wound debridement and joint washout with subsequent 1.5-stage THA, the hip was irrigated with copious amounts of normal saline, chlorhexidine subsequently soaked in 9mls of 10% iodine mixed with 250mls of normal saline.\u003c/p\u003e\n\u003cp\u003ePost-operatively, intra-operative cultures came back negative for bacterial growth, he completed 2 more weeks of oral ciprofloxacin and was allowed to full weight bear immediately. However, his rehabilitation recovery was slow requiring moderate to maximum assistance for ADLs due to sarcopenia from prolonged functional decline and bedrest. Post-operative X-rays done on day 0, 1-month and 1-year review revealed\u003c/p\u003e\n\u003cp\u003eOn one-month review, he is able to ambulate with walking frame with minimum assistance. There was no clinical or biochemical evidence of recurrent infection with serum white blood cell count of 9.1 \u0026times; 10\u003csup\u003e9\u003c/sup\u003e/L, C-reactive protein level of 0.9 mg/L. On one-year review, he was he is able to ambulate with walking frame independently (Fig. 7) and there is no clinical evidence of infection recurrence. Overall, post-operative X-rays done on day 0, 1-month and 1-year review revealed stable bilateral hip replacement prostheses with no evidence of periprosthetic fractures or loosening (Fig. 8).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSeptic hip arthritis is a rare condition that commonly occurs secondary to haematogenic spread of bacteraemia from other locations and typically occurs unilaterally, rarely involving bilateral hips [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOptimal treatment of patients with a degenerative joint disease secondary to SA of the hip is unclear. Several papers have described that the ideal treatment choice largely depends on duration of symptoms and the type of infection \u0026ndash; active vs quiescent [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In early onset native hip SA, it can be managed arthroscopically or via open debridement as described by Cargnelli et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Traditionally, hip SA with significant joint destruction was managed with resection hip arthroplasty for infection eradication. However, this resulted in poor functional outcomes [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. To allow for satisfactory clinical and functional outcomes whilst ensuring infection eradication, two-stage THA is currently considered the treatment of choice [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn a two-stage THA, the first step can be resection arthroplasty or the implantation of an antibiotic-loaded hip spacer with the former having significantly poorer outcomes. However, patients with chronic destructive SA tend to have multiple comorbidities, are deconditioned and may be unfit or unwilling to undergo a second surgery.\u003c/p\u003e \u003cp\u003eHipfl et al. reported the result of largest series of two-stage THA after resection arthroplasty for destructive hip SA [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] of which 33% have treatment failure with a considerable number of patients who failed to undergo definitive THA. Additionally, resection hip arthroplasty in the first stage can lead to muscle contractures, pain, further deconditioning, poor functional result and hamper reimplantation surgery at the second stage. In contrast, multiple papers studying two-stage THA using antibiotic-loaded hip spacer as first stage has been proven to be effective in infection eradication with success rates ranging from 92 to 100 percent while providing excellent functional outcomes [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Antibiotic-loaded spacers offers the advantage of distributing highly concentrated antibiotics to a localized area while maintaining the joint space and soft tissue tension for future component reimplantation [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. However, high rates of cement spacer-related complications have been reported, including spacer migration, dislocation and spacer fracture [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Hence, the strength of the spacer is important and must be able to resist stress and shear force.\u003c/p\u003e \u003cp\u003eThe ideal operation for this group of patients is one that can achieve high infection eradication rates while preserving hip function and potentially avoiding a second operation. In avoiding a second operation with a 1.5-stage THA, it is more cost effective, provides satisfactory functional outcomes and eliminates the physical and psychological burden of a repeat operation [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This is an important consideration, especially in frail patients with multiple comorbidities. However, in the unfortunate context of spacer-related complications or infection recurrence, it is ideal to have the option of a second stage exchange THA.\u003c/p\u003e \u003cp\u003ePROSTALAC and CUMARS are both possible antibiotic-loaded spacer options. Comparing the two, CUMARS has been extensively reported to have better inter-stage functionality, easier removal with good infection eradication [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. CUMARS was developed in 2001, and this spacer system includes the Exeter Universal Femoral stem (Stryker, Mahwah, NJ, USA) and a polyethylene acetabular liner [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In the infected THA, Tsung et al. described a 1.5-stage THA using CUMARS where 44.7% of patients kept a spacer that had satisfactory functional outcomes [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This provides the benefit of avoiding a second surgery, yet not precluding the surgeon from performing a two-stage exchange THA as the articulating spacer can be left in situ for as long as possible until the spacer loosens, implant fails or infection recurs.\u003c/p\u003e \u003cp\u003eCurrently, in the literature, both 1.5-stage THA and CUMARS have only been described in the context of PJI, which has been shown to be an effective management option [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In future, the use of 1.5-stage THA with CUMARS in the context of native hip SA would be advantageous for effective infection eradication, cost-effectiveness and reducing physical and psychological burden in avoiding a potential second surgery. All whilst not precluding the surgeon from performing a two-stage exchange THA with ease.\u003c/p\u003e \u003cp\u003eHowever, this procedure requires experience to address the deformities and poor bone stock caused by the SA. To achieve high success rate in the treatment of septic hip arthritis with 1.5-stage THA, it is important to adhere to a strict protocol. This is inclusive of but not limited to:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eObtaining joint aspirate pre-operatively for microbial data\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eRadical and meticulous debridement of all infected tissue (if performed)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eCopious amounts of irrigation\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eRe-drape and re-gown\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eUsing a new set of surgical instruments for the reconstruction\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eUse of appropriate organism-specific antibiotic for the cement spacer\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"Summary","content":"\u003cp\u003eSA is a rare but morbid condition that can have a significant impact on one\u0026rsquo;s function and quality of life rapidly. Management of SA is largely dependent on duration and activity level of the infection and extent of joint destruction. In a significantly deformed hip joint due to SA, 1.5-stage THA with CUMARS is a viable option with benefits of effective infection eradication, cost-effectiveness with reduced physical and psychological burden in avoiding a second operation, yet not precluding the possibility of a two-stage exchange THA if required.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003ePatient Consent:\u003c/strong\u003e Informed consent obtained from patient and family.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePublication Consent:\u003c/strong\u003e Informed consent obtained from patient and family for publication of case report or identifying information/images in an online open-access publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e I sincerely thank Dr Moo Ing How for the assistance and supervision in the editing and writing of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e No funding obtained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s Contribution:\u0026nbsp;\u003c/strong\u003eL.H.S.A wrote the main manuscript. M.I.H conceptualized the idea and wrote the main manuscript. Y.K.S.A, R.R and C.K.K.K supervised in the writing of the manuscript. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s Information:\u003c/strong\u003e Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMathews CJ, Weston VC, Jones A, Field M, Coakley G. Bacterial septic arthritis in adults. Lancet. 2010;375(9717):846\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrand RA. Acute Pyogenic Arthritis of the Hip: An Operation Giving Free Access and Effective Drainage: GR Girdlestone BM OXFD, FRCS. Clin Orthop Relat Res. 2008;466:258\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcElwaine J, Colville J. Excision arthroplasty for infected total hip replacements. J Bone Joint Surg Br Volume. 1984;66(2):168\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGao X, He R-x. Yan S-g. Total hip arthroplasty for patients with osteoarthritis secondary to hip pyogenic infection. Chin Med J. 2010;123(02):156\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAalirezaie A, Arumugam SS, Austin M, Bozinovski Z, Cichos KH, Fillingham Y et al. Hip and knee section, prevention, risk mitigation: Proceedings of International Consensus on Orthopedic Infections. The Journal of arthroplasty. 2019;34(2):S271-S8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePapanna MC, Chebbout R, Buckley S, Stockley I, Hamer A. Infection and failure rates following total hip arthroplasty for septic arthritis: a case-controlled study. Hip Int. 2018;28(1):63\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNace J, Chen Z, Bains SS, Kahan ME, Gilson GA, Mont MA, et al. 1.5-Stage versus 2-stage exchange total hip arthroplasty for chronic periprosthetic joint infections: a Comparison of Survivorships, reinfections, and patient-reported outcomes. J Arthroplast. 2023;38(7):S235\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFleck EE, Spangehl MJ, Rapuri VR, Beauchamp CP. An articulating antibiotic spacer controls infection and improves pain and function in a degenerative septic hip. Clin Orthop Relat Research\u0026reg;. 2011;469:3055\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYounger A, Duncan CP, Masri B, McGraw R. The outcome of two-stage arthroplasty using a custom-made interval spacer to treat the infected hip. 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PLoS ONE. 2020;15(8):e0237047.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Infection, Septic arthritis, Hip, Custom-made articulating spacer (CUMARS), Antibiotic cement","lastPublishedDoi":"10.21203/rs.3.rs-3992730/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3992730/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eSeptic arthritis (SA) is a rare but potentially debilitating condition that can have quality-of-life impacting consequences. Prompt diagnosis and management is pivotal for early infection eradication and prevention of severe joint destruction. However, in a severely destructed joint, surgical options include resection arthroplasty or total hip arthroplasty (THA). Two-stage THA has been described in native hip SA with joint destruction while 1.5-stage THA has only been described in infected THA. This led to the consideration of 1.5-stage THA for management of chronic destructive hip SA.\u003c/p\u003e \u003cp\u003eWe report a 67-year-old patient with functional decline over eight months. Work-up revealed raised inflammatory markers and bilateral destructive hip SA. He underwent bilateral 1.5-stage THA with antibiotic-loaded Custom-Made Articulating Spacers (CUMARS). Post-operatively, he remains infection free is progressing well with rehabilitation.\u003c/p\u003e \u003cp\u003eManagement of SA varies largely depending on infection duration, activity level and extent of joint destruction. In primary destructive hip SA, a 1.5-stage THA with CUMARS can be considered due to the benefits of effective infection eradication, cost-effectiveness with reduced physical and psychological burden in avoiding a second operation, yet not precluding the possibility of a two-stage exchange THA if required.\u003c/p\u003e","manuscriptTitle":"One and a half-stage Total Hip Arthroplasty with Custom-Made Articulating Spacers (CUMARS) for Management of Bilateral Destructive Hip Septic Arthritis – A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-07 18:13:47","doi":"10.21203/rs.3.rs-3992730/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cb6486c4-697f-4919-b2d7-9a9928f17e36","owner":[],"postedDate":"March 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-04-11T10:56:57+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-07 18:13:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3992730","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3992730","identity":"rs-3992730","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}