Which Patients Meet the Criteria for Single-Stage Revision?
Single-stage revision to treat an infected total joint arthroplasty (TJA) is much more common in Europe than in North America, where 2-stage revision is still the norm.
European surgeons are making a good case for single-stage revision, demonstrating eradication rates for periprosthetic joint infection (PJI) that are comparable to those of 2-stage revision. [1-4] Single-stage revision has other potential advantages: It’s more convenient for the patient, it’s less costly for the healthcare system, and it may be associated with a lower risk of complications than with a 2-stage procedure. 
The key, though, is patient selection: Not every patient will be a good candidate for single-stage revision, for a variety of reasons. For example, an ongoing multi-center study in the US, under the direction of principal investigator Thomas K. Fehring, MD, has a narrow list of inclusion criteria and a lengthy list of exclusion criteria, such as culture-negative infections in which the infecting organism has not identified and the presence of a fungal infection. 
Given the necessity of applying stringent inclusion and exclusion criteria, how many patients undergoing revision TJA for an infection would actually qualify for a single-stage procedure?
That’s what researchers from the University of Pittsburgh Medical Center wanted to know about their own patients. Their impression was that the number would be low, but they wanted to quantify just how low “low” would be.
Their retrospective review identified 91 patients with a chronic PJI – with PJI being defined by criteria from the Musculoskeletal Infection Society – who had undergone a 2-stage exchange between 2012 and 2016 at their institution and who had at least 2 years of follow-up visits. They then applied the International Consensus Meeting criteria for a single-stage revision to determine how many of their patients could have undergone the single-stage procedure. Patients were included if they had a preoperatively identified non-virulent pathogen, were immunocompetent, and had an uncompromised soft tissue envelope without a sinus tract.
Of the 91 patients with a PJI, only 15 (16.4%) would have been considered for a single-stage revision based on the current criteria. Looking at reinfection rates, the researchers noted that 3 of the 15 patients who met the inclusion criteria for a single-stage revision had been treated for reinfection after a 2-stage exchange, demonstrating that the inclusion criteria are not perfect.
The researchers concluded that with so few of their patients meeting the current inclusion/exclusion criteria, “[o]ffering single-stage exchange to all patients is not a logical step based on existing data.”
Dombrowski M, Wilson AE Jr, O’Malley M, Urish K, Hamlin BR, Crossett LS, Klatt BA. A Low Percentage of Patients Meet Inclusion Criteria for Single-Stage Exchange Arthroplasty. Paper 711. AAOS Virtual Education Experience.
- Ahmed SS, Yaghmour KM, Haddad FS. The changing face of infection, diagnosis, and management in the United Kingdom. Orthop Clin North Am.. 2020 Apr;51(2):141-146. doi: 10.1016/j.ocl.2019.12.003. Epub 2020 Feb 4.
- Ohlmeier M, Filitarin S, Delgado G, et al. Improved treatment strategies can result in better outcomes following one-stage exchange surgery for MRSA periprosthetic joint infection. J Med Microbiol. 2020 Aug;69(8):1100-1104. doi: 10.1099/jmm.0.001229. Epub 2020 Jul 8.
- Sotiriou D, Stigbrand H, Ullmark G. Is two-stage revision surgery for infected hip arthroplasty worth the suffering, resources and results compared to one-stage? Hip Int. 2020 Aug 10;1120700020949162. doi: 10.1177/1120700020949162. Online ahead of print.
- Zahar A, Gerhrke TA. One-stage revision for infected total hip arthroplasty. Orthop Clin North Am. 2016 Jan;47(1):11-8. doi: 10.1016/j.ocl.2015.08.004.
- Thiesen DM, Sobhani H, Gehrke T, Suero EM, Klatte TO, Citak M. A comparison of short term complication rate between 44 two- and 385 one-stage septic exchange arthroplasties in chronic periprosthetic joint infections. Orthop Traumatol Surg Res. 2020 Aug 11;S1877-0568(20)30212-7. doi: 10.1016/j.otsr.2020.05.008. Online ahead of print.
- Fehring TK, principal investigator. One Stage Versus Two Stage for Periprosthetic Hip And Knee Infection. ClinicalTrials.gov Identifier: NCT02734134. Available at ClinicalTrials.gov; accessed September 30, 2020.