Single- or Two-stage Revision for Infected Total Hip Arthroplasty? A Systematic Review of the Literature
Rent the article at a discountRent now
* Final gross prices may vary according to local VAT.Get Access
The best approach for surgical treatment of an infected THA remains controversial. Two-stage revision is believed to result in lower reinfection rates but may result in significant functional impairment. Some authors now suggest that single-stage revision may provide comparable results in terms of infection eradication while providing superior functional outcomes.
We performed a systematic review to determine whether single- or two-stage revision for an infected THA provides lower reinfection rates and higher functional outcome scores.
We conducted a comprehensive search of PubMed and Embase, using the search string [Infection AND (“total hip replacement” OR “total hip arthroplasty”) AND revision]. All studies comparing reinfection rates or functional scores for single- and two-stage revision were retrieved and reviewed. A systematic review was performed according to the PRISMA checklist.
The initial search retrieved 1128 studies. Following strict exclusion criteria, we identified nine comparative studies comparing reinfection rates (all nine studies) or functional scores (four studies) between single- and two-stage revisions. The overall quality of studies was poor with no randomized studies being identified. Groups often varied in their baseline characteristics. There was no consensus among the studies regarding the relative incidence of reinfection between the two procedures. There was a trend toward better functional outcomes in single-stage surgery, but this reached significance in only one study.
In appropriate patients, single-stage revision appears to be associated with similar reinfection rates when compared with two-stage revision with superior functional outcomes. This concurs with earlier studies, but given the methodologic quality of the included studies, these findings should be treated with caution. High-quality randomized studies are needed to compare the two approaches to confirm these findings, and, if appropriate, to determine which patients are appropriate for single-stage revision.
- Berend KR, Lombardi AV Jr, Morris MJ, Bergeson AG, Adams JB, Sneller MA. Two-stage treatment of hip periprosthetic joint infection is associated with a high rate of infection control but high mortality. Clin Orthop Relat Res. 2013;471:510–518. CrossRef
- Beswick AD, Elvers KT, Smith AJ, Gooberman-Hill R, Lovering A, Blom AW. What is the evidence base to guide surgical treatment of infected hip prostheses? Systematic review of longitudinal studies in unselected patients. BMC Med. 2012;10:18. CrossRef
- Bozic KJ, Ries MD. The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization. J Bone Joint Surg Am. 2005;87:1746–1751. CrossRef
- Carlsson AS, Egund N, Gentz CF, Hussenius A, Josefsson G, Lindberg L. Radiographic loosening after revision with gentamicin-containing cement for deep infection in total hip arthroplasties. Clin Orthop Relat Res. 1985;194:271–279.
- Dale H, Fenstad AM, Hallan G, Havelin LI, Furnes O, Overgaard S, Pederson AB, Karrholm J, Garellick G, Pulkkinen P, Eskelinen A, Makela K, Engesaeter LB. Increasing risk of prosthetic joint infection after total hip arthroplasty. Acta Orthop. 2012;83:449–458. CrossRef
- De Man FH, Sendi P, Zimmerli W, Maurer TB, Ochsner PE, Ilchmann T. Infectiological, functional, and radiographic outcome after revision for prosthetic hip infection according to a strict algorithm. Acta Orthop. 2011;82:27–34. CrossRef
- Engesaeter LB, Dale H, Schrama JC, Hallan G, Lie SA. Surgical procedures in the treatment of 784 infected THAs reported to the Norwegian Arthroplasty Register. Acta Orthop. 2011;82:530–537. CrossRef
- Garvin KL, Evans BG, Salvati EA, Brause BD. Palacos gentamicin for the treatment of deep periprosthetic hip infections. Clin Orthop Relat Res. 1994;298:97–105.
- Gehrke T, Kendoff D. Peri-prosthetic hip infections: in favour of one-stage. Hip Int. 2012;22(suppl 8):S40–45. CrossRef
- Higgins JP, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions. The Cochrane Collaboration. Available at: http://handbook.cochrane.org/. Accessed August 18, 2013.
- Hope PG, Kristinsson KG, Norman P, Elson RA. Deep infection of cemented total hip arthroplasties caused by coagulase-negative staphylococci. J Bone Joint Surg Br. 1989;71:851–855.
- Klouche S, Leonard P, Zeller V, Lhotellier L, Graff W, Leclerc P, Mamoudy P, Sariali E. Infected total hip arthroplasty revision: one- or two-stage procedure? Orthop Traumatol Surg Res. 2012;98:144–150. CrossRef
- Klouche S, Sariali E, Mamoudy P. Total hip arthroplasty revision due to infection: a cost analysis approach. Orthop Traumatol Surg Res. 2010;96:124–132. CrossRef
- Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89:780–785. CrossRef
- Lange J, Troelsen A, Thomsen RW, Soballe K. Chronic infections in hip arthroplasties: comparing risk of reinfection following one-stage and two-stage revision: a systematic review and meta-analysis. Clin Epidemiol. 2012;4:57–73. CrossRef
- Langlais F. Can we improve the results of revision arthroplasty for infected total hip replacement? J Bone Joint Surg Br. 2003;85:637–640.
- Luu A, Syed F, Raman G, Bhalla A, Muldoon E, Hadley S, Smith E, Rao M. Two-stage arthroplasty for prosthetic joint infection: a systematic review of acute kidney injury, systemic toxicity and infection control. J Arthroplasty. 2013 Apr 8 [Epub ahead of print].
- Matthews PC, Berendt AR, McNally MA, Byren I. Diagnosis and management of prosthetic joint infection. BMJ. 2009;338:b1773. CrossRef
- Merollini KM, Crawford RW, Graves N. Surgical treatment approaches and reimbursement costs of surgical site infections post hip arthroplasty in Australia: a retrospective analysis. BMC Health Serv Res. 2013;13:91. CrossRef
- Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535.
- Morscher E, Babst R, Jenny H. Treatment of infected joint arthroplasty. Int Orthop. 1990;14:161–165. CrossRef
- Oussedik SI, Dodd MB, Haddad FS. Outcomes of revision total hip replacement for infection after grading according to a standard protocol. J Bone Joint Surg Br. 2010;92:1222–1226. CrossRef
- Ovre S, Sandvik L, Madsen JE, Roise O. Comparison of distribution, agreement and correlation between the original and modified Merle d’Aubigne-Postel Score and the Harris Hip Score after acetabular fracture treatment: moderate agreement, high ceiling effect and excellent correlation in 450 patients. Acta Orthop. 2005;76:796–802. CrossRef
- Sanzen L, Carlsson AS, Josefsson G, Lindberg LT. Revision operations on infected total hip arthroplasties: two- to nine-year follow-up study. Clin Orthop Relat Res. 1988;229:165–172.
- Senthi S, Munro JT, Pitto RP. Infection in total hip replacement: meta-analysis. Int Orthop. 2011;35:253–260. CrossRef
- Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J. Methodological index for non-randomized studies (MINORS): development and validation of a new instrument. ANZ J Surg. 2003;73:712–716. CrossRef
- Vielpeau C, Lortat-Jacob A. [Management of the infected hip prostheses][in French]. Rev Chir Orthop Reparatrice Appar Mot. 2002;88(suppl 1):159–216.
- Wilson MG, Dorr LD. Reimplantation of infected total hip arthroplasties in the absence of antibiotic cement. J Arthroplasty. 1989;4:263–269. CrossRef
- Winkler H, Stoiber A, Kaudela K, Winter F, Menschik F. One stage uncemented revision of infected total hip replacement using cancellous allograft bone impregnated with antibiotics. J Bone Joint Surg Br. 2008;90:1580–1584. CrossRef
- Wolf BR, Gu NY, Doctor JN, Manner PA, Leopold SS. Comparison of one and two-stage revision of total hip arthroplasty complicated by infection: a Markov expected-utility decision analysis. J Bone Joint Surg Am. 2011;93:631–639.
- Single- or Two-stage Revision for Infected Total Hip Arthroplasty? A Systematic Review of the Literature
Clinical Orthopaedics and Related Research®
Volume 472, Issue 3 , pp 1036-1042
- Cover Date
- Print ISSN
- Online ISSN
- Springer US
- Additional Links
- Industry Sectors
- Author Affiliations
- 1. Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK
- 2. Department of Statistics, University of Oxford, South Parks Road, Oxford, OX1 3TG, UK