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    The Evidence for 1-Stage vs. 2-Stage Revision for Treatment of PJI

    The idea that a 1-stage revision can eradicate an infectious organism as effectively as a 2-stage revision challenges the orthopaedic dogma that 2-stage revision is the best, most-effective option for managing periprosthetic joint infection (PJI) in total joint arthroplasty patients.

    Simply put, 2-stage revision is considered to be the gold standard for treating PJI.

    Should it be? Unquestionably, a 2-stage revision can cause significant morbidity and mortality because the patient is undergoing 2 separate surgical procedures. The cost to the healthcare system is also not inconsequential. [1]

    RELATED: Register for the 8th Annual ICJR South Hip & Knee Course

    But, 2-stage revision has a high success rate, historically quoted as 90%. [2,3]

    Maybe, maybe not: More recent literature puts the success rate for 2-stage revision for PJI at 80%, possibly lower, Gwo-Chin Lee, MD, told attendees at ICJR’s inaugural course for senior residents and fellows, Advanced Techniques in Total Hip & Knee Arthroplasty. And that puts the success rate in the range of 1-stage revision.

    Dr. Lee, from the University of Pennsylvania in Philadelphia, noted that Leonard et al [4] found equivalent infection control for 1-stage and 2-stage revision in joint replacement patients with PJI. When successful, 1-stage revision has a lower complication rate and a lower cost to the healthcare system compared with 2-stage revision. [4,5]

    The key in this study, Dr. Lee said, was patient selection. Not all patients are good candidates for 1-stage revision. Multiple studies have identified the ideal patients for 1-stage revision. [6-8] Among them:

    • The patient has good soft tissue and good bone stock. Bone grafting is not needed.
    • The infecting organism has been identified preoperatively and it is susceptible to oral antibiotic agents.
    • Antibiotic-impregnated bone cement can be used for fixation.
    • The patient is not immunocompromised.

    RELATED: What Surgeons Can Do Perioperatively to Prevent Infections

    The literature also shows that 1-stage revision should be treated like 2 separate surgeries: After completing the first part of the revision, the team regowns, repreps the surgical field, and brings in new instruments for the second part of the revision. [9,10] This is essential for reducing the risk of reinfection.

    The bottom line, Dr. Lee said, is that more data from randomized controlled trials are needed to understand the role of a 1-stage procedure in the management of PJI. [11] Until then, 2-stage revision will remain the treatment of choice in his practice.

    Click the image above to watch Dr. Lee’s presentation and learn more about the evidence for 1-stage versus 2-stage revision in total joint arthroplasty patients with PJI.

    Bryan D. Springer, MD, and Matthew P. Abdel, MD, also spoke on PJI during the same session as Dr. Lee. Click the images below to watch their presentations.

    Current Algorithm for the Diagnosis for Periprosthetic Joint Infection
    Bryan D. Springer, MD

    Current Results and Indications for I&D with Component Retention
    Matthew P. Abdel, MD

    Disclosures: Dr. Lee, Dr. Springer, and Dr. Abdel have no disclosures relevant to these presentations.

    References

    1. Kasch R, Merk S, Assmann G, Lahm A, Napp M, Merk H, Flessa S. Comparative analysis of direct hospital care costs between aseptic and two-stage septic knee revision. PLoS One. 2017 Jan 20;12(1):e0169558. doi: 10.1371/journal.pone.0169558. eCollection 2017.
    2. Biring GS, Kostamo T, Garbuz DS, Masri BA, Duncan CP. Two-stage revision arthroplasty of the hip for infection using an interim articulated Prostalac hip spacer: a 10- to 15-year follow-up study. J Bone Joint Surg Br. 2009 Nov;91(11):1431-7. doi: 10.1302/0301-620X.91B11.22026.
    3. Sanchez-Sotelo J, Berry DJ, Hanssen AD, Cabanela ME. Midterm to long-term followup of staged reimplantation for infected hip arthroplasty. Clin Orthop Relat Res. 2009 Jan;467(1):219-24. doi: 10.1007/s11999-008-0480-4. Epub 2008 Sep 24.
    4. Leonard HAC, Liddle AD, Burke O, Murray DW, Pandit H. Single- or two-stage revision for infected total hip arthroplasty? A systematic review of the literature. Clin Orthop Rel Res. 2014;472(3):1036-42. doi: 10.1007/s11999-013-3294-y.
    5. Wolf CF, Gu NY, Doctor JN, Manner PA, Leopold SS. Comparison of one and two-stage revision of total hip arthroplasty complicated by infection: a Markov expected-utility decision analysis. J Bone Joint Surg Am. 2011 Apr 6;93(7):631-9. doi: 10.2106/JBJS.I.01256.
    6. Pangaud C, Ollivier M, Argenson JN. Outcome of single-stage versus two-stage exchange for revision knee arthroplasty for chronic periprosthetic infection. EFORT Open Rev. 2019 Aug 2;4(8):495-502. doi: 10.1302/2058-5241.4.190003. eCollection 2019 Aug. Review.
    7. Haddad FS, Sukeik M, Alazzawi S. Is single-stage revision according to a strict protocol effective in treatment of chronic knee arthroplasty infections? Clin Orthop Relat Res. 2015 Jan;473(1):8-14. doi: 10.1007/s11999-014-3721-8.
    8. George DA, Konan S, Haddad FS. Single-stage hip and knee exchange for periprosthetic joint infection. J Arthroplasty. 2015 Dec;30(12):2264-70. doi: 10.1016/j.arth.2015.05.047. Epub 2015 May 30.
    9. Dietz MJ, Bostian PA, Ernest EP, Klein AE, LaSala PR, Frye BM, Lindsey BA. Rate of surface contamination in the operating suite during revision total joint arthroplasty. Arthroplast Today. 2018 Oct 29;5(1):96-99. doi: 10.1016/j.artd.2018.09.007. eCollection 2019 Mar.
    10. George DA, Haddad FS. One-Stage Exchange Arthroplasty: A Surgical Technique Update. J Arthroplasty. 2017 Sep;32(9S):S59-S62. doi: 10.1016/j.arth.2017.02.025. Epub 2017 Feb 24.
    11. Hanssen AD. CORR Insights: is single-stage revision according to a strict protocol effective in treatment of chronic knee arthroplasty infections? Clin Orthop Relat Res. 2015 Jan;473(1):15-6. doi: 10.1007/s11999-014-3799-z. Epub 2014 Aug 9.