Indications for a single-stage exchange arthroplasty for chronic prosthetic joint infection

Abstract

Aims Prosthetic joint infections (PJIs) of the hip and knee are associated with significant morbidity and socioeconomic burden. We undertook a systematic review of the current literature with the aim of proposing criteria for the selection of patients for a single-stage exchange arthroplasty in the management of a PJI. Material and Methods A comprehensive review of the current literature was performed using the OVID-MEDLINE, EMBASE, and Cochrane Library databases and the search terms: infection and knee arthroplasty OR knee revision OR hip arthroplasty OR hip revision, and one stage OR single stage OR direct exchange. All studies involving fewer than ten patients and follow-up of less than two years in the study group were excluded as also were systematic reviews, surgical techniques, and expert opinions. Results The initial search revealed 875 potential articles of which 22 fulfilled the inclusion and exclusion criteria. There were 16 case series and six comparative studies; five were prospective and 14 were retrospective. The studies included 962 patients who underwent single stage revision arthroplasty of an infected hip or knee joint. The rate of recurrent infection ranged from 0% to 18%, at a minimum of two years’ follow-up. The rate was lower in patients who were selected on the basis of factors relating to the patient and the local soft-tissue and bony conditions. Conclusion We conclude that single-stage revision is an acceptable form of surgical treatment for the management of a PJI in selected patients. The indications for this approach include the absence of severe immunocompromise and significant soft-tissue or bony compromise and concurrent acute sepsis. We suggest that a two-stage approach should be used in patients with multidrug resistant or atypical organisms such as fungus.

The Girdlestone situation: a historical essay

“…In most cases, GRA is part of two-stage revision arthroplasty in the treatment of PJI. However, single-stage revision has become more popular in recent years to treat PJI 8. The Girdlestone situation could result in a permanent clinical situation when 1) bone quality or soft tissue coverage is not strong enough to insert a new prosthesis, 2) the infection cannot be controlled, or 3) patients are unfit for surgery due to e.g.…”

Improved treatment strategies can result in better outcomes following one-stage exchange surgery for MRSA periprosthetic joint infection

“…In conclusion, the available literature has shown dismal rates in the management of MRSA-PJIs, with some studies understandably including the presence of MRSA as a contraindication to performing single-exchange surgery [15, 26, 32, 33]. However, the high infection-free rate of 93.1% achieved in this case-series gives us a positive outlook that MRSA-PJIs can be satisfactorily managed with predictable outcomes, even by single-stage exchange surgery providing current infectious agents eradication strategies.…”

An Alternative One-Stage Exchange Arthroplasty Technique: For the Chronic Infected Total Hip

“…Patient selection must be considered when determining the treatment strategy for prosthetic joint infections. Thakrar et al concluded that a one-stage exchange is an acceptable form of surgical treatment in patients without severe immunocompromise, significant soft-tissue or bony compromise, or concurrent acute sepsis [13]. Another study reported that the absence of wound complications after the initial total hip replacement, good general health of the patient, infecting organism of methicillin-sensitive Staphylococcus epidermidis, Staphylococcus aureus, or Streptococcus species, and an organism sensitive to the antibiotic mixed into the bone cement were factors associated with a successful one-stage exchange THA [19].…”

“…However, reported failure rates after a two-stage hip revision range from 5 to 18% [11,12]. Thus, there has been debate whether a one-stage exchange or two-stage exchange offers the correct treatment [13]. One-stage exchange arthroplasty has particularly gained interest due to less morbidity, mortality, and functional impairment [14].…”