The Role of One-Stage Exchange for Prosthetic Joint Infection

Abstract

Purpose of review: In an era of increasing numbers of hip and knee replacements, strategies to manage prosthetic joint infection (PJI) that are effective at infection control with good patient-reported outcomes and cost containment for health systems are needed. Interest in single-stage exchange for PJI is rising and we assess evidence from the last 5 years related to this treatment strategy.

Recent findings: Only five series for total knee replacement and ten series for total hip replacement have been reported in the last five years. More review articles and opinion pieces have been written. Reinfection rates in these recent studies range from 0 to 65%, but a meta-analysis and systematic review of all studies showed a reinfection rate of 7.6% (95% CI 3.4-13.1) and 8.8% (95% CI 7.2-10.6) for single-stage and two-stage revisions respectively. There is emerging evidence to support single-stage revision in the setting of significant bony deficiency and atypical PJIs such as fungal infections. Prospective randomised studies are recruiting and are necessary to guide the direction of single-stage revision selection criteria. The onus of surgical excellence in mechanical removal of implants, necrotic tissue, and biofilms lies with the arthroplasty surgeon and must remain the cornerstone of treatment. Single-stage revision may be considered the first-line treatment for all PJIs unless the organism is unknown, the patient is systemically septic, or there is a poor tissue envelope.

Keywords: Prosthetic joint infection; Revision hip replacement; Revision knee replacement; Single-stage revision.

Fig. 1

Single exchange of total knee replacement demonstrating aqueous povidone-iodine (1% available iodine) solution in the wound after implant removal and excision of necrotic tissue. The solution is left to settle for up to 5 min and is washed away with 0.9% sodium chloride solution

Fig. 2

A mix of 100 mL of 3% hydrogen peroxide and 100 mL of sterile water solution is applied to the surgical field after the povidone-iodine bath. The hydrogen peroxide mix is washed away by 0.9% sodium chloride and povidone-iodine-soaked gauzes are packed into the wound. The wound edges are approximated with a continuous nylon and the field is dried. A new antimicrobial drape is used to seal the wound and the surgical team un-scrubs and prepares for the reimplantation