Two stage revision: indications, techniques and results

Abstract

Periprosthetic joint infection (PJI) is one of the most challenging complications a surgeon has to face after prosthetic replacement of a joint and one of the most devastating complications for the patient. During the 2018 International Consensus Meeting (ICM) in Philadelphia a numerical diagnostic tool was proposed. Contraindications to single stage revision include significant soft tissue injury with the inability to provide soft tissue cover, the presence of unknown or multi resistant organisms, lack of access to appropriate antibiotics or lack of appropriate expertise. Two stage revision surgery is indicated in these situations. Insall et al. described the surgical two-stage prosthetic revision technique in 1983: the in situ prosthesis is removed, a thorough debridement of bone and soft tissue is performed, an interval spacer is inserted, antibiotics administered. The 2 nd stage of definitive reconstruction is performed once the infection is deemed to have resolved. The interval between stages can range from 6 weeks to several months. PJI are very challenging for every surgeon skilled in prosthetic surgery. It’s necessary to make an exact preoperative diagnosis and to treat them with the proper technique. Further studies are needed to establish the perfect timing between the two stages, the duration of the antibiotic therapy and to standardize the diagnostic chart.

Comparison of Patient-Reported Outcomes Measures and Quality-Adjusted Life Years Following One- and Two-Stage Septic Knee Exchange

“…The antibiotic therapy is continued after the 2nd stage for another 4–6 weeks. In most cases, a minimum of a 12-week period of systemic antibiotic therapy is recommended [ 16 , 17 , 18 , 19 ].…”

Two-stage revision in periprosthetic knee joint infections

“…The interim period between the two stages includes administration of intravenous antibiotics and close monitoring of the patient clinically and serologically for resolution of infection. Once the infection has resolved, the second stage, which comprises the use of antibiotic-loaded cement for reimplantation of the definitive prosthesis[ 12 , 41 ]. The time between stages can range from 6 wk to several months.…”

“…The time between stages can range from 6 wk to several months. Both stages necessitate aggressive debridement of all infected and necrotic tissue[ 41 ]. The following are indications for using a two-stage rather than a single-stage revision procedure[ 12 ]: (1) Systemic infection (sepsis) with signs of infection but an unidentified causative microorganism; (2) Antibiotic-resistant microorganisms identified by preoperative cultures; (3) Presence of a sinus tract; and (4) Insufficient soft tissue coverage to allow a single-stage procedure.…”

“…The first stage of the procedure entails a thorough and vigorous debridement of the whole effective joint space after the removal of all implanted materials and cement[ 41 ] (Figure 2 ). Whenever possible, the use of antibiotics is postponed until all microbiological samples have been collected.…”

A review of current practices in periprosthetic joint infection debridement and revision arthroplasty

“…In many cases, the indication to perform a two-stage revision is the contraindication to a one-stage one. For example, the signs and symptoms of systemic infection, inadequate tissue coverage, the presence of a sinus tract, and an unidentified infecting pathogen [ 71 , 130 ].…”