Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 21, Issue 12, pp 2713–2720 | Cite as

Patient reported outcome measures after revision of the infected TKR: comparison of single versus two-stage revision

  • Paul Baker
  • Timothy G. Petheram
  • Steven Kurtz
  • Yrjö T. Konttinen
  • Paul Gregg
  • David Deehan



Two-stage revision is the ‘gold standard’ treatment for infected total knee replacement. Single-stage revision has been successful in the hip and, in carefully chosen knee revisions, may offer the advantage of a single surgical insult with improved functional outcome.


Patient Reported Outcome Measures (PROMs) for 33 single- and 89 two-stage revisions performed for infection were analysed in combination with data from the National Joint Registry for England and Wales. Outcomes including the Oxford Knee Score (OKS), Euroqol-5D (EQ5D) and patient satisfaction were examined with the aim of investigating the following questions: does single- or two-stage revision for infection result in (1) better knee function; (2) better overall perception of health status; (3) better patient perceived success and satisfaction?


No statistical difference was found between the groups for any reported outcome measure. Mean OKS following surgery was 24.9 (95 %CI, 20.5–29.4) for single- and 22.8 (95 %CI, 20.2–25.4) for two-stage (n.s.). Mean EQ5D index following surgery was 0.495 (95 %CI, 0.357–0.632) for single and 0.473 (95 %CI, 0.397–0.548) for two-stage (n.s.). Patients reporting Excellent/Very good/Good satisfaction were similar between the groups (single = 61 % vs. two stage = 57 %, (n.s.)). In total, 66 % single- and 60 % two-stage operations were rated ‘successful’ (n.s.).


This study found no demonstrable benefit of single-stage compared to two-stage revision for the infected total knee replacement using a variety of PROMs. Thus, we recommend that decision making must be based on other factors such as re-infection rate.

Level of evidence



Infection Revision Single stage Two stage Knee arthroplasty Outcomes 



We thank the patients and staff of all the hospitals in England and Wales, who have contributed data to the National Joint Registry. We are grateful to the Healthcare Quality Improvement Partnership (HQIP), the NJR Steering Committee and the staff at the NJR centre for facilitating this work. This work was funded by a fellowship from the National Joint Registry. The authors have conformed to the NJR’s standard protocol for data access and publication. The views expressed represent those of the authors and do not necessarily reflect those of the National Joint Register Steering Committee or the Health Quality Improvement Partnership (HQIP) who do not vouch for how the information is presented.


  1. 1.
    Antti-Poika I, Josefsson G, Konttinen Y, Lindgren L, Santavirta S, Sanzén L (1990) Hip arthroplasty infection. Current concepts. Acta Orthop Scand 61:163–169PubMedCrossRefGoogle Scholar
  2. 2.
    Baker PN, van der Meulen JH, Lewsey J, Gregg PJ (2007) The role of pain and function in determining patient satisfaction after total knee replacement. Data from the National Joint Registry for England and Wales. J Bone Jt Surg (Br) 89-B:893–900Google Scholar
  3. 3.
    Barrack RL, Engh GA, Rorabeck C, Sawhney J, Woolfrey M (2000) Patient satisfaction and outcome after septic versus aseptic revision total knee arthroplasty. J Arthroplast 15:990–993CrossRefGoogle Scholar
  4. 4.
    Bauer T, Piriou P, lhotellier L, Leclerc P, Mamoudy P, Lortat-Jacob A (2006) Results of reimplantation for infected total knee arthroplasty: 107 cases. Rev Chir Orthop Reparatrice Appar Mot 92:692–700PubMedCrossRefGoogle Scholar
  5. 5.
    Borden LS, Gearen PF (1987) Infected total knee arthroplasty: a protocol for management. J Arthroplast 2:27–36CrossRefGoogle Scholar
  6. 6.
    Buechel FF, Femino FP, D’Alessio J (2004) Primary exchange revision arthroplasty for infected total knee replacement: a long-term study. Am J Orthop (Belle Mead NJ) 33:190–198Google Scholar
  7. 7.
    Cohen JC, Hozack WJ, Cucker KM, Booth RE (1988) Two-stage reimplantation of septic total knee arthroplasty. J Arthroplast 3:369–377CrossRefGoogle Scholar
  8. 8.
    Dunbar MJ, Robertsson O, Ryd L, Lidgren L (2001) Appropriate questionnaires for knee arthroplasty. Results of a survey of 3600 patients from the Swedish knee Arthroplasty Registry. J Bone Jt Surg (Br) 83:339–344CrossRefGoogle Scholar
  9. 9.
    Euroqol (EQ5D) score. Accessed at Last Accessed 8th June 2011
  10. 10.
    Fehring TK, Odum S, Calton TF, Mason JB (2000) Articulating versus static spacers in revision total knee arthroplasty for sepsis. The Ranawat Award. Clin Orthop Relat Res 380:9–16PubMedCrossRefGoogle Scholar
  11. 11.
    Gardner J, Gloe J, Tatman P (2011) Can this prosthesis be saved? Implant salvage attempts in infected primary TKA. Clin Orthop Relat Res 469:970–976PubMedCrossRefGoogle Scholar
  12. 12.
    Göksan SB, Freeman MAR (1992) One-Stage reimplantation for infected total knee arthroplasty. J Bone Jt Surg (Br) 74-B:78–82Google Scholar
  13. 13.
    Gooding CR, Masri BA, Duncan CP, Greidanus NV, Garbuz DS (2011) Durable infection control and function with the PROSTALAC spacer in two-stage revision for infected knee arthroplasty. Clin Orthop Relat Res 469:985–993PubMedCrossRefGoogle Scholar
  14. 14.
    Hofmann AA, Kane KR, Tkach TK, Plaster RL, Camargo MP (1995) Treatment of infected total knee arthroplasty using an articulating spacer. Clin Orthop Relat Res 321:45–54PubMedGoogle Scholar
  15. 15.
    Insall JN, Thompson FM, Brause BD (1983) Two-stage reimplantation for the salvage of infected total knee arthroplasty. J Bone Jt Surg (Am) 65:1087–1098Google Scholar
  16. 16.
    Jämsen E, Stogiannidis I, Malmivaara A, Pajamäki J, Puolakka T (2009) Outcome of prosthesis exchange for infected knee arthroplasty: the effect of treatment approach. A systematic review of the literature. Acta Orthop 80:67–77PubMedCrossRefGoogle Scholar
  17. 17.
    Laffer RR, Graber P, Ochsner PE, Zimmerli W (2006) Outcome of prosthetic knee-associated infection: evaluation of 40 consecutive episodes at a single centre. Clin Microbiol Infect 12:433–439PubMedCrossRefGoogle Scholar
  18. 18.
    Lentino JR (2003) Prosthetic joint infections: Bane of orthopaedists, challenge for infectious disease specialists. Clin Infect Dis 36:1157–1161PubMedCrossRefGoogle Scholar
  19. 19.
    Leone S, Borre S, D’Arminio Monforte A, Mordente G, Petrosillo N, Signore A, Venditti M, Viale P, Nicastri E, Lauria FN, Carosi G, Moroni M, Ippolito G, and the GISIG (2010) Consensus document on controversial issues in the diagnosis and treatment of prosthetic joint infections. Int J Infect Dis 14S4:S67–S77Google Scholar
  20. 20.
    Macmull S, Bartlett W, Miles J, Blunn GW, Pollock RC, Carrington RWJ, Skinner JA, Cannon SR, Briggs TWR (2010) Custom-made hinged spacers in revision knee surgery for patients with infection, bone loss and instability. Knee 17:403–406PubMedCrossRefGoogle Scholar
  21. 21.
    Malviya A, Bettinson K, Kurtz SM, Deehan DJ (2012) When do patient-reported assessments peak after revision KNEE arthroplasty? Clin Orthop Relat Res 470:1728–1734PubMedCrossRefGoogle Scholar
  22. 22.
    Mittal Y, Fehring TK, Hanssen A, Marculescu C, Odum SM, Osmon D (2007) Two-stage reimplantation for periprosthetic knee infection involving resistant organisms. J Bone Jt Surg (Am) 89:1227–1231CrossRefGoogle Scholar
  23. 23.
    Moyad TF, Thornhill T, Estok D (2008) Evaluation and management of the infected total hip and knee. Orthopedics 31:581PubMedCrossRefGoogle Scholar
  24. 24.
    Parkinson RW, Kay PR, Rawal A (2011) A case for one-stage revision in infected total knee arthroplasty? Knee 18:1–4PubMedCrossRefGoogle Scholar
  25. 25.
    Scott IR, Stockley I, Getty CJM (1993) Exchange arthroplasty for infected knee replacements. A new two-staged method. J Bone Jt Surg (Br) 75-B:28–31Google Scholar
  26. 26.
    Smith SC, Cano S, Lamping DL, Staniszewska S, Browne J, Lewsey J, van der Meulen J, Ciarns J, Black N (2005) Patient-Reported Outcome Measures (PROMs) for routine use in Treatment Centres: recommendations based on a review of the scientific evidence. Final report to the Department of Health, December 2005. PROMS %20Final %20report %20Dec %2005.pdf
  27. 27.
    Sofer D, Regenbrecht B, Pfeil J (2005) Early results of one-stage septic revision arthroplasties with antibiotic-laden cement. A clinical and statistical analysis. Orthopade 34:592–602PubMedCrossRefGoogle Scholar
  28. 28.
    von Foerster G, Klüber D, Käbler U (1991) Mid- to long-term results after treatment of 118 cases of periprosthetic infections after knee joint replacement using one-stage exchange surgery. Orthopade 20:244–252Google Scholar
  29. 29.
    Wang CJ, Hsieh MC, Huang TW, Wang JW, Chen LS, Liu CY (2004) Clinical outcome and patient satisfaction in aseptic and septic revision total knee arthroplasty. Knee 11:45–49PubMedCrossRefGoogle Scholar
  30. 30.
    Whiteside LA, Peppers M, Nayfeh TA, Roy ME (2011) Methicillin-resitant staphylococcus aureus in TKA treated with revision and direct intraarticular antibiotic infusion. Clin Orthop Relat Res 469:26–33PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  • Paul Baker
    • 1
  • Timothy G. Petheram
    • 2
  • Steven Kurtz
    • 3
  • Yrjö T. Konttinen
    • 4
  • Paul Gregg
    • 5
  • David Deehan
    • 6
  1. 1.Institute of Cellular MedicineUniversity of NewcastleNewcastle upon TyneUK
  2. 2.Wansbeck General HospitalAshington, NorthumberlandUK
  3. 3.Philadelphia Office, ExponentPhiladelphiaUSA
  4. 4.Department of MedicineInstitute of Clinical MedicineHelsinki (HUS)Finland
  5. 5.Department of Orthopaedic SurgeryJames Cook University HospitalMiddleboroughUK
  6. 6.Department of Orthopaedic SurgeryRoyal Victoria InfirmaryNewcastle upon TyneUK

Personalised recommendations