Chronic infections in hip arthroplasties: comparing risk of reinfection following one-stage and two-stage revision: a systematic review and meta-analysis

Abstract

Background: Two-stage revision is regarded by many as the best treatment of chronic infection in hip arthroplasties. Some international reports, however, have advocated one-stage revision. No systematic review or meta-analysis has ever compared the risk of reinfection following one-stage and two-stage revisions for chronic infection in hip arthroplasties.

Methods: The review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Relevant studies were identified using PubMed and Embase. We assessed studies that included patients with a chronic infection of a hip arthroplasty treated with either one-stage or two-stage revision and with available data on occurrence of reinfections. We performed a meta-analysis estimating absolute risk of reinfection using a random-effects model.

Results: We identified 36 studies eligible for inclusion. None were randomized controlled trials or comparative studies. The patients in these studies had received either one-stage revision (n = 375) or two-stage revision (n = 929). Reinfection occurred with an estimated absolute risk of 13.1% (95% confidence interval: 10.0%-17.1%) in the one-stage cohort and 10.4% (95% confidence interval: 8.5%-12.7%) in the two-stage cohort. The methodological quality of most included studies was considered low, with insufficient data to evaluate confounding factors.

Conclusions: Our results may indicate three additional reinfections per 100 reimplanted patients when performing a one-stage versus two-stage revision. However, the risk estimates were statistically imprecise and the quality of underlying data low, demonstrating the lack of clear evidence that two-stage revision is superior to one-stage revision among patients with chronically infected hip arthroplasties. This systematic review underscores the need for improvement in reporting and collection of high-quality data and for large comparative prospective studies on this issue.

Keywords: arthroplasty; hip replacement; infection; one-stage; reoperation; two-stage.

Figure 1

PRISMA flow diagram. Abbreviation: PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analysis.

Figure 2

Forest plot illustrating absolute risk of reinfection in ascending order with relative weight of individual studies. Notes: Event rate, absolute risk of reinfection; lower/upper limits, 95% confidence interval; total, number reinfected/number reimplanted.

Figure 3

Forest plot illustrating stratified analysis by type of revision performed with relative weight of individual studies. Notes: Event rate, absolute risk of reinfection; lower/upper limits, 95% confidence interval; total, number reinfected/number reimplanted.

Figure 4

Forest plot illustrating two-stage revision stratified by implant used in reimplantation. Notes: Event rate, absolute risk of reinfection; lower/upper limits, 95% confidence interval; total, number reinfected/number reimplanted. Abbreviation: CI, confidence interval.