Single-stage revision for the infected total knee replacement

Abstract

Peri-prosthetic infection is amongst the most common causes of failure following total knee replacement (TKR). In the presence of established infection, thorough joint debridement and removal of all components is necessary following which new components may be implanted. This can be performed in one or two stages; two-stage revision with placement of an interim antibiotic-loaded spacer is regarded by many to be the standard procedure for eradication of peri-prosthetic joint infection. We present our experience of a consecutive series of 50 single-stage revision TKRs for established deep infection performed between 1979 and 2010. There were 33 women and 17 men with a mean age at revision of 66.8 years (42 to 84) and a mean follow-up of 10.5 years (2 to 24). The mean time between the primary TKR and the revision procedure was 2.05 years (1 to 8). Only one patient required a further revision for recurrent infection, representing a success rate of 98%. Nine patients required further revision for aseptic loosening, according to microbiological testing of biopsies taken at the subsequent surgery. Three other patients developed a further septic episode but none required another revision. These results suggest that a single-stage revision can produce comparable results to a two-stage revision. Single-stage revision offers a reduction in costs as well as less morbidity and inconvenience for patients.

Can Good Infection Control Be Obtained in One-stage Exchange of the Infected TKA to a Rotating Hinge Design? 10-year Results

“…Our results in terms of survivorship free from infection with the single-stage approach appear comparable to those offered by a systematic review of the results of septic TKA revision, which reported mean eradication rates of 90.6% for two-stage and 89.2% for one-stage surgery [32] as well as with other recent studies on the subject of one-stage exchange [36,39,40]. The higher eradication rate after the two-stage revision, especially in combination with a mobile spacer, was based on numerous publications with shortterm followup and/or a low number of study patients with an eradication rate of up to 100%.…”

“…Standardized diagnostic and therapeutic algorithms for one-stage exchange have been described to make multicenter studies possible with comparable cohorts [13]. Two-stage revision with mobile or static spacers requires at least two surgeries, a longer period of time with limited mobility in the interval, and more possibility for perioperative complications and morbidity [24,28,32,39].…”

“…Some studies have shown possible advantages of one-stage exchange for the infected TKA in selected patients [14], including the need for only one surgical procedure, shorter hospitalization time, reduced time on antibiotic therapy, reduced overall costs, and improved patient satisfaction [16,29,39,40]. In addition, an increasing number of publications have reported on one-stage exchange in TKA and THA within the last few years, showing high success rates [14,20,36,39,40]. However, these publications share certain limitations: small numbers of patients (\ 20); short followup (\5 years); and strict exclusion criteria such as multiresistant organism-based infections, reinfection, significant bone loss, relevant comorbidities, sinus tract, and other relevant soft tissue complications [26].…”

Management of acute periprosthetic joint infection of the knee – Algorithms for the on call surgeon

“…This includes host factors such as the patients medical and immune status, local soft tissue factors and virulence of the microorganism (See Key Factors Box). 1,3,5,8,10,11 Key factors influencing outcome of treatment.…”

“…7e9 A one stage revision arthroplasty has also become a standardized treatment for chronic PJI in some specialized European centres, and has some potential benefits over a two stage revision. 8,10,11 Treatment for the acutely infected knee replacement is broader and can vary from irrigation and debridement with exchange of modular parts, to revision arthroplasty. Acute infection can present to the Orthopaedic surgeon on-call who may not have sub-speciality training in knee arthroplasty.…”