Diagnosis of infection after total hip replacement

Subclinical infection in patients with pain following total hip replacement (THR) is an underestimated condition that needs consideration because it mimics aseptic loosening, contributes to periprosthetic osteolysis, and necessitates proper treatment. We aimed to define the reliability of diagnostic parameters that are routinely used before revision surgery for the assessment of infection. A continuous series of 26 subjects who underwent THR revision surgery was considered, including 21 cases diagnosed as aseptic loosening (group A) and 5 hip revisions with a clinical diagnosis for infection (group B). Seven subjects at the time of the primary arthroplasty were used as negative controls (group C). Technetium-99m labeled hydroxymethylene diphosphonate [(99m)Tc-HDP]- and technetium-99m hexamethylpropyleneamine oxide [(99m)Tc-HMPAO)]-labeled granulocyte scintigraphy, histology of peri-implant tissues, laboratory tests for inflammation, and microbiology were performed. Scintigraphy was positive for loosening [positive (99m)Tc-HDP scan] but negative for infection [negative (99m)Tc-HMPAO-labeled granulocyte scan] in all group A patients, whereas in 11 cases (52%) a positive culture was unexpectedly obtained. Histology showed conflicting results: Polymorphonuclear cells (PMNs) were found only in 5 of 11 culture-positive patients, whereas in 2 cases the presence of PMNs did not correspond to a positive culture. In group B patients, both isotope scans and microbiology were found to be positive. All control subjects (group C) had negative cultures. In our opinion, smoldering infection could be present in a significant proportion of cases of failed hip implants currently diagnosed as "nonseptic." The inflammatory response to wear debris and the presence of superimposed, slowly growing bacteria could act synergically, both contributing to the pathogenesis of periprosthetic osteolysis.