Higher failure rate of two-stage revision for infected knee arthroplasties in significantly compromised (host-C) patients



To evaluate clinical outcomes of two-stage revision arthroplasty for managing infected knee arthroplasties in significantly compromised patients (host-C).


This was a prospective consecutive series of two-stage revisions of infected total knee arthroplasties in host-C-type patients with a minimum 2-year follow-up using objective and patient-reported outcome measures. Thirteen consecutive patients were included and prospectively followed with a median 5-year follow-up (range 2–10). Median age was 68 years (range 59–73) at time of initial presentation. All patients were type-C host using McPherson classification system. All patients had primary arthroplasties in situ with confirmed chronic infections; the infecting pathogens were Staphylococcus aureus in 5/13 patients, coagulase-negative Staphylococci in 5/13, and the remaining three patients had mixed growth. All patients underwent two-stage revision protocol.


At the final follow-up, 9/13 patients were infection free achieving satisfactory outcomes. Two patients had recurrent infections with different organisms and treated with suppressive antibiotics and salvage knee arthrodesis, respectively. Furthermore, two patients had chronic pain and poor functional outcomes with deficient extensor mechanism and significant bone loss; later underwent salvage knee arthrodesis. The preoperative knee society score (median 35.5; range 22–51; n = 10) showed a statistically significant improvement at the final follow-up (median 79.5; range 49–87; n = 10) p < 0.05. Patients reported outcome scores at the final follow-up were WOMAC-knee (median 59.1; range 47.7–94.7; n = 13) and Oxford knee score (median 26; range 11 to 43; n = 13).


This study highlights the challenge of treating infected knee arthroplasties in physiologically compromised patients with 9/13 (69%) having satisfactory clinical outcomes.

Level of evidence

Case series, level IV.

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  1. 1.

    Baker P, Petheram TG, Kurtz S, Konttinen YT, Gregg P, Deehan D (2013) Patient reported outcome measures after revision of the infected TKR: comparison of single versus two-stage revision. Knee Surg Sports Traumatol Arthrosc 21:2713–2720

    Article  PubMed  Google Scholar 

  2. 2.

    Barrack RL (1996) Economics of the infected total knee replacement. Orthopedics 19:780–782

    CAS  PubMed  Google Scholar 

  3. 3.

    Bartlett W, Vijayan S, Pollock R, Skinner J, Blunn G, Cannon S et al (2011) The Stanmore knee arthrodesis prosthesis. J Arthroplasty 26:903–908

    Article  PubMed  Google Scholar 

  4. 4.

    Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW (1988) Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol 15:1833–1840

    CAS  PubMed  Google Scholar 

  5. 5.

    Buechel FF (2004) The infected total knee arthroplasty: just when you thought it was over. J Arthroplasty 19:51–55

    Article  PubMed  Google 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) 33:190–198; discussion 198

    Google Scholar 

  7. 7.

    Cancienne JM, Granadillo VA, Patel KJ, Werner BC, Browne JA (2018) Risk factors for repeat debridement, spacer retention, amputation, arthrodesis, and mortality after removal of an infected total knee arthroplasty with spacer placement. J Arthroplasty 33:515–520

    Article  PubMed  Google Scholar 

  8. 8.

    Cochran AR, Ong KL, Lau E, Mont MA, Malkani AL (2016) Risk of reinfection after treatment of infected total knee arthroplasty. J Arthroplasty 31:156–161

    Article  PubMed  Google Scholar 

  9. 9.

    Davies DG, Parsek MR, Pearson JP, Iglewski BH, Costerton JW, Greenberg EP (1998) The involvement of cell-to-cell signals in the development of a bacterial biofilm. Science 280:295–298

    Article  CAS  PubMed  Google Scholar 

  10. 10.

    Dawson J, Fitzpatrick R, Murray D, Carr A (1998) Questionnaire on the perceptions of patients about total knee replacement. J Bone Joint Surg Br 80:63–69

    Article  CAS  PubMed  Google Scholar 

  11. 11.

    Di Benedetto P, Di Benedetto ED, Buttironi MM, De Franceschi D, Beltrame A, Gissoni R et al (2017) Two-stage revision after total knee arthroplasty. Acta Biomed 88:92–97

    PubMed  PubMed Central  Google Scholar 

  12. 12.

    Dripps RD (1963) New classification of physical status. Anesthesiol 24:111

    Google Scholar 

  13. 13.

    Dzaja I, Howard J, Somerville L, Lanting B (2015) Functional outcomes of acutely infected knee arthroplasty: a comparison of different surgical treatment options. Can J Surg 58:402–407

    Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Haddad FS, Sukeik M, Alazzawi S (2015) Is single-stage revision according to a strict protocol effective in treatment of chronic knee arthroplasty infections? Clin Orthop Relat Res 473:8–14

    Article  PubMed  Google Scholar 

  15. 15.

    Insall JN, Dorr LD, Scott RD, Scott WN (1989) Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res 248:13–14

    Google Scholar 

  16. 16.

    Jones RE, Russell RD, Huo MH (2012) Alternatives to revision total knee arthroplasty. J Bone Joint Surg Br 94:137–140

    Article  CAS  PubMed  Google Scholar 

  17. 17.

    Kamath AF, Ong KL, Lau E, Chan V, Vail TP, Rubash HE et al (2015) Quantifying the burden of revision total joint arthroplasty for periprosthetic infection. J Arthroplasty 30:1492–1497

    Article  PubMed  Google Scholar 

  18. 18.

    Kunutsor SK, Whitehouse MR, Lenguerrand E, Blom AW, Beswick AD (2016) Re-infection outcomes following one- and two-stage surgical revision of infected knee prosthesis: a systematic review and meta-analysis. PLoS One 11:e0151537

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Masters JP, Smith NA, Foguet P, Reed M, Parsons H, Sprowson AP (2013) A systematic review of the evidence for single stage and two stage revision of infected knee replacement. BMC Musculoskelet Disord 14:222

    Article  PubMed  PubMed Central  Google Scholar 

  20. 20.

    McPherson EJ, Tontz W Jr, Patzakis M, Woodsome C, Holtom P, Norris L et al (1999) Outcome of infected total knee utilizing a staging system for prosthetic joint infection. Am J Orthop (Belle Mead NJ) 28:161–165

    CAS  Google Scholar 

  21. 21.

    McPherson EJ, Woodson C, Holtom P, Roidis N, Shufelt C, Patzakis M (2002) Periprosthetic total hip infection: outcomes using a staging system. Clin Orthop Relat Res 403:8–15

    Article  Google Scholar 

  22. 22.

    Moyad TF, Thornhill T, Estok D (2008) Evaluation and management of the infected total hip and knee. Orthopedics 31:581–588 (quiz 589–590)

    Article  PubMed  Google Scholar 

  23. 23.

    Nagra NS, Hamilton TW, Ganatra S, Murray DW, Pandit H (2016) One-stage versus two-stage exchange arthroplasty for infected total knee arthroplasty: a systematic review. Knee Surg Sports Traumatol Arthrosc 24:3106–3114

    Article  PubMed  Google Scholar 

  24. 24.

    Nickinson RS, Board TN, Gambhir AK, Porter ML, Kay PR (2010) The microbiology of the infected knee arthroplasty. Int Orthop 34:505–510

    Article  CAS  PubMed  Google Scholar 

  25. 25.

    Parvizi J, Gehrke T, Chen AF (2013) Proceedings of the international consensus on periprosthetic joint infection. Bone Joint J 95:1450–1452

    Article  PubMed  Google Scholar 

  26. 26.

    Parvizi J, Zmistowski B, Berbari EF, Bauer TW, Springer BD, Della Valle CJ et al (2011) New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res 469:2992–2994

    Article  PubMed  PubMed Central  Google Scholar 

  27. 27.

    Ribeiro M, Monteiro FJ, Ferraz MP (2012) Infection of orthopedic implants with emphasis on bacterial adhesion process and techniques used in studying bacterial-material interactions. Biomatter 2:176–194

    Article  PubMed  PubMed Central  Google Scholar 

  28. 28.

    Saleh KJ, Dykes DC, Tweedie RL, Mohamed K, Ravichandran A, Saleh RM et al (2002) Functional outcome after total knee arthroplasty revision: a meta-analysis. J Arthroplasty 17:967–977

    Article  PubMed  Google Scholar 

  29. 29.

    Salgado CD, Dash S, Cantey JR, Marculescu CE (2007) Higher risk of failure of methicillin-resistant Staphylococcus aureus prosthetic joint infections. Clin Orthop Relat Res 461:48–53

    PubMed  Google Scholar 

  30. 30.

    Son MS, Lau E, Parvizi J, Mont MA, Bozic KJ, Kurtz S (2017) What are the frequency, associated factors, and mortality of amputation and arthrodesis after a failed infected TKA? Clin Orthop Relat Res 475:2905–2913

    Article  PubMed  PubMed Central  Google Scholar 

  31. 31.

    Stammers J, Kahane S, Ranawat V, Miles J, Pollock R, Carrington RW et al (2015) Outcomes of infected revision knee arthroplasty managed by two-stage revision in a tertiary referral centre. Knee 22:56–62

    Article  PubMed  Google Scholar 

  32. 32.

    White CJ, Palmer AJR, Rodriguez-Merchan EC (2017) External fixation vs intramedullary nailing for knee arthrodesis after failed infected total knee arthroplasty: a systematic review and meta-analysis. J Arthroplasty. https://doi.org/10.1016/j.arth.2017.10.055

    Article  PubMed  Google Scholar 

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Correspondence to Hosam E. Matar.

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The authors declare that they have no conflict of interest.

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The study was approved by the local research and clinical effectiveness department.

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Matar, H.E., Stritch, P. & Emms, N. Higher failure rate of two-stage revision for infected knee arthroplasties in significantly compromised (host-C) patients. Knee Surg Sports Traumatol Arthrosc 27, 2206–2210 (2019). https://doi.org/10.1007/s00167-018-5051-y

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  • Total knee arthroplasty
  • Periprosthetic joint infection
  • two-stage revisions
  • Host-C patients