During the past few years there has been an increase in the number of one-stage interventions for the septic revisions of the total knee and total hip replacement prosthetics, even though the most frequently used method in these situations remains the two-stage revision. The objective of this review is to identify and analyze data from field literature regarding the following outcome parameters for one-stage and two-stage revision: number of patients, reinfection rate in one-stage and two-stage revision, functional results (KSS score, HSS score), risk factors, post-operative range of motion and the type of spacer (static or articulating).

Review

We analyzed 23 internationally published articles between 2014-2020 which revealed the results of each type of approach regarding septic revisions and a minimum of 5 years patient fallow-up. Thirteen of the articles were about the two-stage revisions on 844 subjects, 6 about the one-stage revision on a total of 232 subjects and 4 articles which compared the two methods.

The results were similar, with a mid-value of 12.8% (range 0-33%) reinfection rate in one-stage revision (Jenny et al.² 13%, Silva et al.³ 5%, Tibrewal et al.⁴ 8%, Jenny et al.² 19%, Antony et al.⁵ 11%, Massin et al.⁶ 23%, Bauer et al.⁷ 33%) and with a mid-value of 14.6% (range 0-42%) reinfection rate in two-stage revision (Frank et al.⁸ 12%, Lichstein et al.⁹ 6%, Mortazavi et al.¹⁰ 28%, Siebel et al.¹¹ 0%, Massin et al.⁶ 31%, Castellani et al.¹² 16%, Haddad et al.¹³ 7%, Ford et al.¹⁴ 42%).

A fixed spacer^13,15 was used in 31.7% of cases with two-stage revision and an articulating spacer¹⁵ in 68.3% of cases.

The functional results^13,15-17 were similar, with a KSS score of 80 for the one-stage revision, and of 78 for the two-stage revision. The knee joint mobility was higher after the two-stage revision.

The reinfection rate^14,15,17 was 23% for the fixed spacer and 8% for the articulating one.

Regarding the post-operative functional score, this was similar for both techniques. For the one-stage revision, the KSS score values were between 72 and 88 with a mid-value of 80 and for the two-stage revision the KSS score was between 64 and 86 with a mid-value of 78.

We observed an improvement in knee joint mobility after the two-stage revision, with a mean of 97,8° flexion, range between 86-112° and with a mean of 91.4° flexion for the one-stage revision, with values between 76-100°.

The results are similar with the amendment that the one-stage revision is only suitable for certain carefully selected cases. While in most hospitals worldwide the two-stage revision is considered to be the gold standard, the one-stage revision is gaining more confidence through similar or even better results.

The indications^16-18 for one-stage septic revision are:

-identifying the pre-operative pathogen

-sensitivity to common antibiotics, especially those with high bone absorption and that can be administered orally (excluding MRSA)

-the presence of satisfactory bone stock (so that a bone graft is unnecessary)

-the soft tissues should be viable, in good condition with no difficulty for post-operative healing.

The one-stage revision is not indicated^16-19 in case of:

-systemic pathology

-immunodeficiency

-reinfection

-a history of unsuccessful one-stage revision

-the absence of one of the criteria listed in indications.

The main advantage for using the one-stage revision is that the extraction of the infected prosthesis and insertion of the new one can be performed during the same procedure, thus reducing the costs for treatment and more important sparing the patient of going through a new surgical trauma.

Moreover, mobility was more satisfactory in patients who went through the one-stage revision, with functional values discretely higher than in the two-stage revision. The articulated spacer allows knee mobility between the two procedures.

The one-step septic revision in knee arthroplasty is a truly viable option with results at least as good as the two-stage revision in carefully selected cases.

Limitations

There are many limitations when interpreting these data. No study in this review used blinding in choosing the type of revision or had a control group to compare the outcomes. The type of revision is dictated by surgeon selection, who has the tendency to perform a two-stage revision in patients who have bone defect, or have more virulent infections, which results in selection bias. There are different protocols among the hospitals regarding the type of revision, technique, diagnostic and antibiotherapy, making the results more difficult to compare. Prospective randomized studies, which respect the same protocols are needed to reduce bias.

Our data supports the indication of single-stage revision for periprosthetic knee infection, in carefully selected patients, as an alternative to a two-stage procedure. In these cases, the one-stage procedure was associated with a similar reinfection rate and similar functional outcomes as the two-stage did. The one-stage revision reduces the hospitalization, the cost and more important the patient’s surgery stress. The decision should be based upon preoperatory determination of the infectious organism, risk factors related to the patient and the contraindications previously mentioned. In cases of two-stage exchange, articulating spacers showed higher eradication rates and better functional outcomes. None of the studies described here offer definitive evidence to support either technique, so there is a great need for a large multi-centered randomized controlled trial, focusing on reinfection rates and functional outcomes to provide concrete guidelines.

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