Abstract
Periprosthetic joint infection (PJI) is one of the most devastating complications
following total joint arthroplasty, accounting for a projected 10,000 revision surgeries
per year by 2030. Chronic PJI is complicated by the presence of bacterial biofilm,
requiring removal of components, thorough debridement, and administration of antibiotics
for effective eradication. Chronic PJI is currently managed with single-stage or 2-stage
revision surgery. To date, there are no randomized, prospective studies available
evaluating eradication rates and functional outcomes between the 2 techniques. In
this review, both treatment options are described with the most current literature
to guide effective surgical decision-making that is cost-effective while decreasing
patient morbidity.
Keywords
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References
- Periprosthetic joint infection increases the risk of one-year mortality.J Bone Joint Surg Am. 2013; 95: 2177-2184
- The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization.J Bone Joint Surg Am. 2005; 87: 1746-1751
- Future clinical and economic impact of revision total hip and knee arthroplasty.J Bone Joint Surg Am. 2007; 89: 144-151
- Current and future trends in the diagnosis of periprosthetic hip infection.Orthop Clin North Am. 2014; 45: 287-293
- Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030.J Bone Joint Surg Am. 2007; 89: 780-785
- Two-stage exchange is better than direct exchange in the infected THA.Orthopedics. 1999; 22: 918
- Evaluation and management of the infected total hip and knee.Orthopedics. 2008; 31 (quiz 589-90): 581-588
- Two-stage treatment of hip periprosthetic joint infection is associated with a high rate of infection control but high mortality.Clin Orthop Relat Res. 2013; 471: 510-518
- Management of deep infection of total hip replacement.J Bone Joint Surg Br. 1981; 63-B: 342-353
- One-stage revision of infected total hip replacements with discharging sinuses.J Bone Joint Surg Br. 1994; 76: 721-724
- Direct-exchange arthroplasty for the treatment of infection after total hip replacement. An average ten-year follow-up.J Bone Joint Surg Am. 1998; 80: 961-968
- Re-infection outcomes following one- and two-stage surgical revision of infected knee prosthesis: a systematic review and meta-analysis.PLoS One. 2016; 11: e0151537
- Does cemented or cementless single-stage exchange arthroplasty of chronic periprosthetic hip infections provide similar infection rates to a two-stage? A systematic review.BMC Infect Dis. 2016; 16: 553
- Use of erythrocyte sedimentation rate and C-reactive protein level to diagnose infection before revision total knee arthroplasty. A prospective evaluation.J Bone Joint Surg Am. 2007; 89: 1409-1416
- Perioperative testing for joint infection in patients undergoing revision total hip arthroplasty.J Bone Joint Surg Am. 2008; 90: 1869-1875
- A simple, cost-effective screening protocol to rule out periprosthetic infection.J Arthroplasty. 2008; 23: 65-68
- Diagnosis of periprosthetic joint infection-an algorithm-based approach.J Arthroplasty. 2017; 32: 2047-2050
- The value of aspiration of the hip joint before revision total hip arthroplasty.J Bone Joint Surg Am. 1993; 75: 66-76
- White cell scans and infected joint replacements. Failure to detect chronic infection.J Bone Joint Surg Br. 1993; 75: 371-374
- Aspiration of the hip joint before revision total hip arthroplasty. Clinical and laboratory factors influencing attainment of a positive culture.J Bone Joint Surg Am. 1996; 78: 749-754
- Role of core biopsy in diagnosing infection before revision hip arthroplasty.J Arthroplasty. 2004; 19: 78-87
- The value of hip aspiration versus tissue biopsy in diagnosing infection before exchange hip arthroplasty surgery.J Arthroplasty. 2004; 19: 582-586
- Synovial fluid white cell and differential count in the diagnosis or exclusion of prosthetic joint infection.Bone Joint J. 2013; 95-B: 554-557
- Perioperative testing for persistent sepsis following resection arthroplasty of the hip for periprosthetic infection.J Arthroplasty. 2010; 25: 87-91
- Cell count and differential of aspirated fluid in the diagnosis of infection at the site of total knee arthroplasty.J Bone Joint Surg Am. 2008; 90: 1637-1643
- Diagnosis of periprosthetic joint infections of the hip and knee.J Am Acad Orthop Surg. 2010; 18: 760-770
- Synovial fluid cell count for diagnosis of chronic periprosthetic hip infection.J Bone Joint Surg Am. 2017; 99: 753-759
- Diagnosis of periprosthetic joint infection.J Arthroplasty. 2014; 29: 77-83
- Combined measurement of synovial fluid alpha-defensin and C-reactive protein levels: highly accurate for diagnosing periprosthetic joint infection.J Bone Joint Surg Am. 2014; 96: 1439-1445
- Diagnosis of periprosthetic joint infection: the potential of next-generation sequencing.J Bone Joint Surg Am. 2018; 100: 147-154
- Preliminary results after changing from two-stage to one-stage revision arthroplasty protocol using cementless arthroplasty for chronic infected hip replacements.J Arthroplasty. 2018; 33: 527-532
- Is single-stage revision according to a strict protocol effective in treatment of chronic knee arthroplasty infections?.Clin Orthop Relat Res. 2015; 473: 8-14
- Single-stage treatment of chronically infected total hip arthroplasty with cementless reconstruction: results in 126 patients with broad inclusion criteria.Bone Joint J. 2019; 101-B: 396-402
- Single-stage revision arthroplasty for infection-an underutilized treatment strategy.J Arthroplasty. 2017; 32: 2051-2055
- One-stage versus two-stage exchange.J Orthop Res. 2014; 32: S141-S146
- Executive summary: diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America.Clin Infect Dis. 2013; 56: 1-10
- One-stage exchange arthroplasty: a surgical technique update.J Arthroplasty. 2017; 32: S59-S62
- One-stage exchange: it all began here.Bone Joint J. 2013; 95-B: 77-83
- Periprosthetic Joint Infection of the Hip and Knee.Springer, New York, NY2014: 126-144
- Mechanical properties of bone cements containing large doses of antibiotic powders.J Biomed Mater Res. 1976; 10: 929-938
- Long-term results of revision total hip arthroplasty with a cemented femoral component.Arch Orthop Trauma Surg. 2018; 138: 1609-1616
- Revision total hip arthroplasty using cemented collarless double-taper femoral components at a mean follow-up of 13 years (8 to 20): an update.Bone Joint J. 2015; 97-B: 1038-1045
- Minimum 20-year follow-up results of revision total hip arthroplasty with improved cementing technique.J Arthroplasty. 2014; 29: 236-241
- Revision total hip arthroplasty with a modular cementless femoral stem.J Arthroplasty. 2014; 29: 1803-1807
- Outcome of one-stage cementless exchange for acute postoperative periprosthetic hip infection.Clin Orthop Relat Res. 2013; 471: 3214-3222
- Treatment of the infected hip replacement.Clin Orthop Relat Res. 2004; : 63-71
- One-stage cementless revision arthroplasty for infected hip replacements.Int Orthop. 2009; 33: 1195-1201
- Cementless one-stage revision in chronic periprosthetic hip joint infection. Ninety-one percent infection free survival in 56 patients at minimum 2-year follow-up.J Arthroplasty. 2018; 33: 1160-1165
- Re-infection outcomes following one- and two-stage surgical revision of infected hip prosthesis: a systematic review and meta-analysis.PLoS One. 2015; 10: e0139166
- Single- or two-stage revision for infected total hip arthroplasty? A systematic review of the literature.Clin Orthop Relat Res. 2014; 472: 1036-1042
- Comparison of one-stage revision with antibiotic cement versus two-stage revision results for infected total hip arthroplasty.J Arthroplasty. 2013; 28: 66-70
- Ten-year results following one-stage septic hip exchange in the management of periprosthetic joint infection.J Arthroplasty. 2019; 34: 1221-1226
- One-stage revision of total hip arthroplasty for deep infection. Long-term followup.Clin Orthop Relat Res. 1995; : 202-207
- Primary total knee arthroplasty implants as functional prosthetic spacers for definitive management of periprosthetic joint infection: a multicenter study.J Arthroplasty. 2019; 34: 3040-3047
- One-stage revision with catheter infusion of intraarticular antibiotics successfully treats infected THA.Clin Orthop Relat Res. 2017; 475: 419-429
- Eradication of infection, survival, and radiological results of uncemented revision stems in infected total hip arthroplasties.Acta Orthop. 2016; 87: 637-643
- One-stage revision of infected total hip arthroplasty with bone graft.J Arthroplasty. 2008; 23: 1165-1177
- One-stage revision surgery of the infected hip. A minimum 10-year followup study.Clin Orthop Relat Res. 1999; : 139-143
- A protocol for staged arthroplasty to salvage infected nonunion of hip fractures.J Orthop Traumatol. 2017; 18: 43-50
- One-stage revision of infected hip arthroplasty: outcome of 39 consecutive hips.Int Orthop. 2016; 40: 913-918
- Single-stage revision for the infected total knee replacement: results from a single centre.Bone Joint J. 2014; 96-B: 759-764
- Primary exchange revision arthroplasty for infected total knee replacement: a long-term study.Am J Orthop. 2004; 33 (discussion 198): 190-198
- Results of direct exchange or debridement of the infected total knee arthroplasty.Clin Orthop Relat Res. 2002; : 125-131
- A multidisciplinary team approach to two-stage revision for the infected hip replacement: a minimum five-year follow-up study.Bone Joint J. 2014; 96-B: 1312-1318
- Six weeks of antibiotic treatment is sufficient following surgery for septic arthroplasty.J Infect. 2010; 61: 125-132
- What is the role of serological testing between stages of two-stage reconstruction of the infected prosthetic knee?.Clin Orthop Relat Res. 2011; 469: 1002-1008
- Treatment of periprosthetic hip infection caused by resistant microorganisms using 2-stage reimplantation protocol.J Arthroplasty. 2009; 24: 1264-1269
- Leukocyte esterase strip test can predict subsequent failure following reimplantation in patients with periprosthetic joint infection.J Arthroplasty. 2017; 32: 1976-1979
- Positive alpha-defensin at reimplantation of a two-stage revision arthroplasty is not associated with infection at 1 year.Clin Orthop Relat Res. 2019; 477: 1615-1621
- Deep infection following total hip arthroplasty.J Bone Joint Surg Am. 1977; 59: 1042-1044
- Intraoperative chlorhexidine irrigation to prevent infection in total hip and knee arthroplasty.Arthroplast Today. 2017; 3: 294-297
- Treatment of periprosthetic joint infection using antimicrobials: dilute povidone-iodine lavage.J Bone Jt Infect. 2017; 2: 10-14
- Acetic acid as part of a debridement protocol during revision total knee arthroplasty.J Arthroplasty. 2017; 32: 953-957
- Antibiotic-loaded bone cement for infection prophylaxis in total joint replacement.J Bone Joint Surg Am. 2006; 88: 2487-2500
- Elution characteristics of vancomycin and tobramycin combined in acrylic bone-cement.J Arthroplasty. 1996; 11: 939-944
- Systemic safety of high-dose antibiotic-loaded cement spacers after resection of an infected total knee arthroplasty.Clin Orthop Relat Res. 2004; : 47-51
- The two-stage standard in revision total hip replacement.Bone Joint J. 2013; 95-B: 84-87
- Elution and mechanical strength of vancomycin-loaded bone cement: in vitro study of the influence of brand combination.PLoS One. 2016; 11: e0166545
- Preformed antibiotic-loaded cement spacers for two-stage revision of infected total hip arthroplasty. Long-term results.Hip Int. 2012; 22: S46-S53
- Cementless two-stage exchange arthroplasty for infection after total hip arthroplasty.J Arthroplasty. 2007; 22: 72-78
- An articulating antibiotic spacer controls infection and improves pain and function in a degenerative septic hip.Clin Orthop Relat Res. 2011; 469: 3055-3064
- Treatment outcome of two-stage revision total hip arthroplasty for infected hip arthroplasty using antibiotic-impregnated cement spacer.J Orthop Sci. 2003; 8: 26-31
- Clinical effectiveness of antibiotic-impregnated cement spacers for the treatment of infected implants of the hip joint.J Orthop Sci. 2003; 8: 823-828
- Two-stage revision hip arthroplasty for infection with a custom-made, antibiotic-loaded, cement prosthesis as an interim spacer.J Trauma. 2004; 56: 1247-1252
- Preformed gentamicin spacers in two-stage revision hip arthroplasty: functional results and complications.Int Orthop. 2011; 35: 1471-1476
- Are preformed articulating spacers superior to surgeon-made articulating spacers in the treatment of PJI in THA? A literature review.Open Orthop J. 2015; 9: 255-261
- Ten-year experience using an articulating antibiotic cement hip spacer for the treatment of chronically infected total hip.J Arthroplasty. 2005; 20: 874-879
- Treatment of infection associated with segmental bone loss in the proximal part of the femur in two stages with use of an antibiotic-loaded interval prosthesis.J Bone Joint Surg Am. 1998; 80: 60-69
- Hip prosthesis of antibiotic-loaded acrylic cement for the treatment of infections following total hip arthroplasty.J Bone Joint Surg Am. 2002; 84-A: 123-128
- Two-stage revision hip arthroplasty for infection: comparison between the interim use of antibiotic-loaded cement beads and a spacer prosthesis.J Bone Joint Surg Am. 2004; 86-A: 1989-1997
- Two-stage uncemented revision hip arthroplasty for infection.J Bone Joint Surg Br. 2000; 82: 689-694
- Complications associated with reimplantation after girdlestone arthroplasty.Clin Orthop Relat Res. 2003; : 119-126
- Static and mobile antibiotic-impregnated cement spacers for the management of prosthetic joint infection.J Am Acad Orthop Surg. 2009; 17: 356-368
- The treatment of the infected hip replacement. The complex case.Clin Orthop Relat Res. 1999; : 144-156
- Two-stage revisions of infected hip replacements: subspecialisation and patient-reported outcome measures.J Orthop. 2019; 16: 179-181
- Two-stage revision after total knee arthroplasty.Acta Biomed. 2017; 88: 92-97
- Preoperative prediction of failure following two-stage revision for knee prosthetic joint infections.J Arthroplasty. 2014; 29: 115-121
- Reinfection after two-stage revision for periprosthetic infection of total knee arthroplasty.Int Orthop. 2012; 36: 65-71
- Assessing the gold standard: a review of 253 two-stage revisions for infected TKA.Clin Orthop Relat Res. 2012; 470: 2730-2736
- Revision total knee arthroplasty infection: incidence and predictors.Clin Orthop Relat Res. 2010; 468: 2052-2059
- Staged revision for knee arthroplasty infection: what is the role of serologic tests before reimplantation?.Clin Orthop Relat Res. 2009; 467: 1699-1705
- Surgical treatment approaches and reimbursement costs of surgical site infections post hip arthroplasty in Australia: a retrospective analysis.BMC Health Serv Res. 2013; 13: 91
- Total hip arthroplasty revision due to infection: a cost analysis approach.Orthop Traumatol Surg Res. 2010; 96: 124-132
- One-stage revision for infected total hip arthroplasty.Orthop Clin North Am. 2016; 47: 11-18
- One-stage exchange arthroplasty for chronic periprosthetic hip infection: results of a large prospective cohort study.J Bone Joint Surg Am. 2014; 96: e1
- The Mark Coventry, MD, Award: oral antibiotics reduce reinfection after two-stage exchange: a multicenter, randomized controlled trial.Clin Orthop Relat Res. 2017; 475: 56-61
Article info
Publication history
Accepted:
October 27,
2019
Received in revised form:
October 27,
2019
Received:
September 30,
2019
Footnotes
This article is published as part of a supplement supported by an educational grant from OsteoRemedies, LLC.
One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2019.10.051.
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