Two-Stage Revision for Periprosthetic Joint Infection: Eradication Rates and Functional Recovery
DOI:
https://doi.org/10.5281/zenodo.22327467Keywords:
Periprosthetic joint infection, Two-stage revision, Antibiotic spacer, Reinfection rate, Functional outcomesAbstract
Background: Periprosthetic joint infection (PJI) remains one of the most feared complications of hip and knee arthroplasty, and
two-stage exchange has long been considered the reference standard for chronic infection. Objective: To synthesise evidence on spacer selection, antibiotic delivery, interstage timing, eradication and reinfection rates, comparison with one-stage revision, functional recovery, and risk factors for failure. Methods: Narrative review of systematic reviews, meta-analyses, registry studies, randomised trials, and cohort literature. Findings: Pooled reinfection rates after two-stage revision are approximately 8% for both hip and knee, statistically indistinguishable from one-stage revision in aggregate data and in the INFORM randomised trial. Articulating spacers preserve range of motion and function without compromising eradication compared with static spacers. Roughly one in ten to one in four patients never reaches reimplantation. Conclusions: Two-stage revision achieves reliable infection control, but attrition, mortality, and variable functional recoveryremain substantial unresolved burdens.
References
Kurtz, S.M., Lau, E., Watson, H., Schmier, J.K., Parvizi, J. (2012) Economic burden of periprosthetic joint infection in the United States. Journal of Arthroplasty, 27(8 Suppl): 61-65.e1.
Premkumar, A., Kolin, D.A., Farley, K.X., Wilson, J.M., McLawhorn, A.S., Cross, M.B., Sculco, P.K. (2021) Projected economic burden of periprosthetic joint infection of the hip and knee in the United States. Journal of Arthroplasty, 36(5): 1484-1489.e3.
Zmistowski, B., Karam, J.A., Durinka, J.B., Casper, D.S., Parvizi, J. (2013) Periprosthetic joint infection increases the risk of one-year mortality. Journal of Bone and Joint Surgery (American), 95(24): 2177-2184.
Parvizi, J., Tan, T.L., Goswami, K., Higuera, C., Della Valle, C., Chen, A.F., Shohat, N. (2018) The 2018 definition of periprosthetic hip and knee infection: an evidence-based and validated criteria. Journal of Arthroplasty, 33(5): 1309-1314.e2.
Insall, J.N., Thompson, F.M., Brause, B.D. (1983) Two-stage reimplantation for the salvage of infected total knee arthroplasty. Journal of Bone and Joint Surgery (American), 65(8): 1087-1098.
Osmon, D.R., Berbari, E.F., Berendt, A.R., Lew, D., Zimmerli, W., Steckelberg, J.M., Rao, N., Hanssen, A., Wilson, W.R. (2013) Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clinical Infectious Diseases, 56(1): e1-e25.
Kini, S.G., Gabr, A., Das, R., Sukeik, M., Haddad, F.S. (2016) Two-stage revision for periprosthetic hip and knee joint infections. Open Orthopaedics Journal, 10(1): 579-588.
Ding, H., Yao, J., Chang, W., Liu, F. (2017) Comparison of the efficacy of static versus articular spacers in two-stage revision surgery for the treatment of infection following total knee arthroplasty: a meta-analysis. Journal of Orthopaedic Surgery and Research, 12(1): 151.
Vasarhelyi, E., Sidhu, S.P., Somerville, L., Lanting, B., Naudie, D., Howard, J. (2022) Static vs articulating spacers for two-stage revision total knee arthroplasty: minimum five-year review. Arthroplasty Today, 13: 171-175.
Oladipo, V.A., Tseng, J., Sporer, S., Levine, B.R. (2023) Modern description of antibiotic spacer options for PJI in revision total knee arthroplasty: clinical outcomes and infection eradication rates. Journal of Arthroplasty, 38(6): S318-S325.
Haddad, F.S., Masri, B.A., Campbell, D., McGraw, R.W., Beauchamp, C.P., Duncan, C.P. (2000) The PROSTALAC functional spacer in two-stage revision for infected knee replacements. Journal of Bone and Joint Surgery (British), 82(6): 807-812.
Puetzler, J., Schulze, M., Gosheger, G., Schwarze, J., Moellenbeck, B., Theil, C. (2023) Is long time to reimplantation a risk factor for reinfection in two-stage revision for periprosthetic infection? A systematic review of the literature. Frontiers in Surgery, 10: 1113006.
Tsai, M-L., Hsu, A.H-S., Wu, C-T., Lin, P-C., Tan, T.L., Kuo, F-C. (2024) Optimal reimplantation timing in two-stage exchange for periprosthetic joint infection: an observative cohort study in Asian population. BMC Musculoskeletal Disorders, 25(1): 28.
Rajgopal, A., Dahiya, V., Bhatnagar, A., Kumar, S., Aggarwal, K. (2024) Predictors of outcome following two-stage revision total knee arthroplasty. Archives of Orthopaedic and Trauma Surgery, 144(12): 5283-5291.
Kunutsor, S.K., Whitehouse, M.R., Blom, A.W., Beswick, A.D., INFORM Team (2015) Re-infection outcomes following oneand two-stage surgical revision of infected hip prosthesis: a systematic review and meta-analysis. PLOS ONE, 10(9): e0139166.
Kunutsor, S.K., Whitehouse, M.R., Lenguerrand, E., Blom, A.W., Beswick, A.D., INFORM Team (2016) Re-infection outcomes following one- and two-stage surgical revision of infected knee prosthesis: a systematic review and meta-analysis. PLOS ONE, 11(3): e0151537.
Nagra, N.S., Hamilton, T.W., Ganatra, S., Murray, D.W., Pandit, H. (2016) One-stage versus two-stage exchange arthroplasty for infected total knee arthroplasty: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy, 24(10): 3106-3114.
Otten, M.R., Kildow, B.J., Sayles, H.R., Drummond, D., Garvin, K.L. (2021) Two-stage reimplantation of a prosthetic hip infection: systematic review of long-term reinfection and pathogen outcomes. Journal of Arthroplasty, 36(7): 2630-2641.
Triantafyllopoulos, G.K., Memtsoudis, S.G., Zhang, W., Ma, Y., Sculco, T.P., Poultsides, L.A. (2017) Periprosthetic infection recurrence after 2-stage exchange arthroplasty: failure or fate? Journal of Arthroplasty, 32(2): 526-531.
Blom, A., Lenguerrand, E., Strange, S., Noble, S., Beswick, A., Burston, A., Garfield, K., Gooberman-Hill, R., Harris, S., Kunutsor, S., Lane, J.A., MacGowan, A., Mehendale, S., Moore, A.J., Rolfson, O., Webb, J., Wilson, M., Whitehouse, M. (2022) Clinical and cost effectiveness of single stage compared with two stage revision for hip prosthetic joint infection (INFORM): pragmatic, parallel group, open label, randomised controlled trial. BMJ, 379: o2924.
Lenguerrand, E., Whitehouse, M.R., Beswick, A.D., Kunutsor, S.K., Webb, J.C.J., Mehendale, S., Porter, M., Blom, A.W. (2023) Mortality and re-revision following single-stage and two-stage revision surgery for the management of infected primary hip arthroplasty in England and Wales. Bone and Joint Research, 12(5): 321-330.
Festa, E., Ascione, T., De Mauro, D., Di Gennaro, D., Baldini, A., Balato, G. (2025) Can a 1.5-stage revision be an effective alternative for chronic periprosthetic hip and knee infections? A systematic review and meta-analysis. Journal of Arthroplasty, 40(3): 809-818.
Chen, Y-C., Lin, Y-C., Chang, C-H., Lee, S-H., Chang, Y. (2023) Risk factors for treatment failure in patients who have knee periprosthetic joint infection treated with two-stage exchange arthroplasty as well as their fate. Journal of Arthroplasty, 38(2): 355-360.
Lee, W-S., Park, K.K., Cho, B-W., Park, J.Y., Kim, I., Kwon, H.M. (2024) Risk factors for early septic failure after two-stage exchange total knee arthroplasty for treatment of periprosthetic joint infection. Journal of Orthopaedics and Traumatology, 25(1): 6.
Choi, H-R., Kwon, Y-M., Freiberg, A.A., Nelson, S.B., Malchau, H. (2013) Periprosthetic joint infection with negative culture results: clinical characteristics and treatment outcome. Journal of Arthroplasty, 28(6): 899-903.
Wang, Q., Goswami, K., Kuo, F-C., Xu, C., Tan, T.L., Parvizi, J. (2019) Two-stage exchange arthroplasty for periprosthetic joint infection: the rate and reason for the attrition after the first stage. Journal of Arthroplasty, 34(11): 2749-2756.
Barton, C.B., Wang, D.L., An, Q., Brown, T.S., Callaghan, J.J., Otero, J.E. (2020) Two-stage exchange arthroplasty for periprosthetic joint infection following total hip or knee arthroplasty is associated with high attrition rate and mortality. Journal of Arthroplasty, 35(5): 1384-1389.
