Focus On One stage exchange arthroplasty: the devil is in the detail

The general management of periprosthetic infections after total joint replacement (TJR) remains a challenging procedure to any arthroplasty surgeon. The infection rate after primary TJR is reported to be between 0.5% and 2%, however in the field of revision arthroplasty, this might increase to over 10%.1-4 Consequently, periprosthetic infections remain a serious problem, despite modern techniques, implants and rigorous perioperative prophylaxis. The therapeutic goal in either one or more staged revisions of periprosthetic infections is, in general, defined by a complete eradication of the infection and maintenance of the joint function. While it has been widely accepted that the treatment of a late chronic infection should be undertaken with a twoor morestaged revision technique, a distinct single-staged revision approach has shown similar good results within the last 30 years in our own clinical setup.5-8 In general, both revision techniques should be available depending on the clinical situation, the local setup and the surgeon expertise. In the most frequent scenario, implant removal is followed by a defined six week or longer course of systemic antibiotic treatment and delayed implantation. In particular, the introduction of antibiotic impregnated spacers in infected total knee and hip revisions, seemed to improve the functional outcome of the two-staged approach and has gained increasing popularity within the last five to ten years.9-11 However, looking carefully at the current literature and guidelines for the treatment of infected TJRs, there is no clear evidence that a twoor more-staged procedure has a higher success rate than a one-staged approach.(Della Valle)12 Although a larger number of relevant articles4,10,13-15, describe the two-staged technique as the benchmark procedure for the eradication of infection, most of the recommendations (duration of antibiotic treatment, static vs mobile spacer, interval of spacer retention, cemented vs uncemented new implant fixation and especially overall success rates) are based on expert opinions and evidence level IV to III studies, rather than on prospective, randomised or comparative data.4,10,11,13-18 We consequently believe that a distinct one-stage exchange still offers certain advantages with a comparatively high success rate. The major advantages are the need for only one procedure (if no recurrence), reduced hospitalisation time, reduced overall cost and relatively improved patient satisfaction.8,19,20 Although obvious advantages exist, there are obligatory preand peri-operative details which need to be meticulously respected to achieve a successful one-staged revision. Consequently this article describes the author’s experience of their current institution’s management strategies, which have been in place for over 30 years, with the one-staged approach in the revision of an infected TJR. Emphasis is given to all detailed requirements that provide the basis for a high surgical and post-operative success rate.