Two-Stage Revision Surgery for Infected Hip and Knee Replacements
The gold standard surgical treatment for established periprosthetic joint infection (PJI) of the hip and knee. Mr Hussain performs two-stage revision at the Royal Orthopaedic Hospital Birmingham, working closely with specialist microbiology and infectious disease teams.
Total procedures
498 verified reviews
ENDO-Klinik Hamburg
Understanding Infection
What Is Periprosthetic Joint Infection?
Periprosthetic joint infection (PJI) is a bacterial infection that develops around a hip or knee replacement implant. It is one of the most serious complications of joint replacement surgery, but it is treatable with the right specialist care and a structured surgical and antibiotic strategy.
PJI can present at different times after surgery and in different ways:
- Early infection (within 4 to 6 weeks of surgery): typically presents with wound redness, discharge, swelling and fever. Often caused by skin organisms such as Staphylococcus aureus introduced at the time of surgery.
- Delayed infection (6 weeks to 2 years post-surgery): may present more subtly with progressive pain. Often caused by less virulent organisms such as coagulase-negative staphylococci or Propionibacterium, which form a slow-growing biofilm on the implant surface.
- Late haematogenous infection (over 2 years post-surgery): typically arises from a distant bacterial source such as a urinary tract infection, chest infection, or dental procedure. May present acutely with pain, swelling and fever in a previously well-functioning joint.
If you notice pain, swelling, warmth, wound discharge, or fever around a joint replacement, seek urgent specialist assessment. Blood tests (CRP, ESR, white cell count) and joint aspiration with microbiology culture are used to confirm the diagnosis and guide antibiotic selection.
Surgical Treatment
The Two-Stage Surgical Process
Two-stage revision surgery separates the infection management and reconstruction phases into two distinct operations, maximising the chance of permanent infection eradication before committing to a new permanent implant.
Removal, Debridement and Spacer Insertion
The first stage is a full explantation of all implant components, including any cement that may be present. There is no selective component retention: every piece of metal, polyethylene, and cement is removed to eliminate the biofilm-coated surfaces that harbour bacteria and resist antibiotic penetration.
Following explantation, the joint is thoroughly debrided. All infected, necrotic, and devitalised tissue is excised. Synovial membrane, granulation tissue, and any sinus tract are also removed. Multiple tissue samples are sent to microbiology for culture and sensitivity to identify the causative organism and direct antibiotic therapy.
An antibiotic-loaded cement spacer is then inserted. The spacer serves two purposes: it maintains the space between the bones to prevent shortening and soft tissue contracture, and it delivers high local concentrations of antibiotic directly to the site of infection, concentrations that systemic antibiotics alone cannot achieve. The spacer can be articulating (allowing some movement between stages) or static, depending on clinical circumstances.
After surgery, the patient receives a course of intravenous antibiotics, transitioning to oral antibiotics guided by the microbiology results, typically for 6 to 12 weeks. Inflammatory markers (CRP and ESR) are monitored regularly throughout this period.
Reimplantation of New Permanent Implants
Stage 2 is performed once there is high confidence that the infection has been eradicated. This is determined by clinical assessment (no signs of ongoing infection), normalisation of CRP and ESR, and, where appropriate, joint aspiration with culture in the week before reimplantation. A positive aspiration result delays Stage 2 until the infection is fully controlled.
At Stage 2, the spacer is removed, the joint is again thoroughly debrided and lavaged, and new permanent implant components are inserted. Because infection and the spacer period both cause additional bone loss, Stage 2 reconstruction is often more complex than the original primary surgery would have been. Long stems, augments, bone grafting, and dual mobility cups may all be required.
Intraoperative tissue samples are again sent for culture to confirm infection eradication. A period of post-operative antibiotics is typically prescribed, guided by the infectious disease or microbiology team.
- Infection eradication confirmed before Stage 2 proceeds
- Full spectrum of revision implants available for complex bone loss reconstruction
- Published success rates of 85 to 92% for long-term infection control
- Close multidisciplinary collaboration with microbiology and infectious disease
Choosing the Right Approach
Two-Stage Revision vs DAIR: Which Is Right?
The choice between two-stage revision and DAIR (Debridement, Antibiotics and Implant Retention) depends primarily on the duration of infection, the condition of the implant, the causative organism, and the presence or absence of a sinus tract. Both approaches have a role in the management of periprosthetic joint infection, and the decision is made on an individual case basis.
Two-Stage Revision: Established or Chronic Infection
Two-stage revision is the preferred treatment when:
- ✓ Infection has been present for more than 4 to 6 weeks
- ✓ A sinus tract (discharging wound) is present
- ✓ The causative organism is resistant or difficult to treat with antibiotics
- ✓ The implant is loose or structurally compromised
- ✓ Significant soft tissue damage or necrosis is present
DAIR: Early or Acute Infection with Implant Retention
DAIR is considered when:
- ✓ Infection is within 4 to 6 weeks of primary surgery
- ✓ Or: acute haematogenous infection with symptoms for less than 3 weeks in a well-functioning joint
- ✓ The implant is well fixed and structurally sound
- ✓ There is no sinus tract
- ✓ The organism is sensitive to antibiotics that can penetrate biofilm
Revision Surgery in Birmingham
Why Choose Mr Hussain for Revision Surgery?
Mr Hussain holds a subspecialty fellowship from ENDO-Klinik Hamburg, one of the world's leading centres for revision arthroplasty, and has contributed 33 peer-reviewed publications to the orthopaedic literature. His practice at the Royal Orthopaedic Hospital, Priory Hospital Edgbaston, and Harborne Hospital is built on a foundation of 5,000+ procedures and a Doctify rating of 4.98 from 498 verified reviews.
Patient Questions
Frequently Asked Questions
Ready to Discuss Your Revision Surgery?
Book a private consultation with Mr Hussain at the Royal Orthopaedic Hospital, Priory Hospital Edgbaston, or Harborne Hospital.