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75 (); 163-167
doi:
10.1016/j.jor.2026.02.021

Comparison of single-stage versus two-stage revision for the treatment of chronic periprosthetic hip joint infections

, , , , ,
a University of Minnesota Medical School, Minneapolis, MN, USA
b Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
c Department of Orthopedic Surgery, Regions Hospital, Saint Paul, MN, USA

⁎Corresponding author: Scott B. Marston. scott.b.marston@healthpartners.com

Received: , Accepted: ,
Professor P K Surendran Memorial Education Foundation
Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

While two-stage revision is considered the gold standard, single-stage revision continues to gain popularity for the treatment of chronic periprosthetic joint infections. In this single-provider, single-protocol study, the outcomes between the two approaches were compared.

This was a retrospective study that included 63 consecutive adult patients who underwent single-stage or two-stage total hip revision arthroplasty for chronic periprosthetic joint infection between 2009 and 2020. Only the two-stage approach was performed between 2009 and 2014, while only single stage was performed between 2015 and 2020. Infections were classified using the Delphi-based consensus criteria. Three major outcomes were compared between the revision approaches: the rates of postoperative complications, reinfections, and reoperations.

There were 43 (68.3%) single-stage and 20 (31.8%) two-stage revisions. The mean age was 59.5 ± 13 years with 35 (55.6%) women. The mean body mass index was 35.8 ± 9.1 kg/m2. At the mean follow-up rate of 6.9 years (range, 2.1-10.8 years), the rate of no recurrence of infection was 81.4% in the single-stage cohort compared to 80.0% in the two-stage cohort (p = 1.000). Reoperation rate for single-stage revision due to a non-infectious reason was higher than two-stage (20.9% versus 15.0%; p = 0.7367). No statistically significant differences were noted for other postoperative complications.

Single-stage revision is as effective as two-stage revision for the treatment of chronic periprosthetic hip joint infections in patients with limited exclusion criteria.

Abstract

Highlights

•Single-stage revision is as effective as two-stage revision for treating chronic hip periprosthetic joint infections.•No differences in rates of postoperative complications were found between the single-stage and two-stage cohorts.•The overall no recurrence of infection rate was similar for both cohorts.

Keywords

Single-stage revision
Two-stage revision
Chronic periprosthetic joint infections
Risk factors
Reinfection
1

1 Introduction

Total hip arthroplasty (THA) is the standard of care for patients with end-stage degenerative hip osteoarthritis who do not respond to conservative treatment.1–3 It is also one of the top 5 most common surgeries performed in the United States. In the last 15 years, the number of patients receiving THA has grown 30%.4,5 More growth is projected given the aging population.6,7 While THA allows patients with debilitating pain to regain their quality of life, there are potential complications such as loosening, instability, implant failure, and infection.8–10 One of the most devastating complications and a leading cause for revision surgery is a periprosthetic joint infection (PJI), with an incidence of approximately 1%0.11–15 Revision surgeries are associated with a higher incidence of mental health disorders and psychosocial stress.16,17 The average cost is between $35,500 and $100,000 per revision, resulting in a high financial burden to the healthcare system.18,19

There are two major revision approaches for management of chronic PJI: two-stage exchange arthroplasty or single-stage exchange arthroplasty. The two-stage approach is considered the gold standard in the United States for chronic PJI treatment.20,21 This includes explantation of the implants, debridement of the joint, and placement of an antibiotic temporary spacer as the first stage. After 6-8 weeks of antibiotics, the patient is then brought back to the operating room for re-implantation.22,23 Complications associated with two-stage exchange include higher costs, unclear reimplantation criteria, and postoperative instability.24,25 One study found a 24% mortality rate at 2-year follow-up.26 In contrast, the single stage technique, popularized in Europe, involves explanation, debridement, and reimplantation all under one anesthesia event.27,28 Reported benefits include reduced morbidity, decreased healthcare costs, and earlier return to function.29 Moreover, the success rate in a recent meta-analysis was reported as 60 to 100%,30,31 which was similar to two-stage at 65 to 93%.32

Studies comparing revision approaches are often challenging to apply given small, heterogeneous populations and varied surgical protocols. This study provides a new single-surgeon and single-protocol without selection bias as both cohorts were a consecutive series for the treatment of all patients with chronic PJI. In this study, the authors sought to compare single-stage and two-stage exchange hip arthroplasty for chronic hip PJI treatment.

2

2 Material & methods

2.1

2.1 Study design

After obtaining institutional review board approval, patients who required a single-stage or two-stage revision for chronic periprosthetic joint infection (PJI) of the hip were retrospectively reviewed. Intervals were designated for the two cohorts to eliminate any overlap or selection bias. The two-stage approach was performed between 2009 and 2014, while only the single stage was performed between 2015 and 2020. All operations were performed by the same surgeon at a Level I Trauma Center in the Midwestern United States based on his single-stage or two-stage protocol. Before and after imaging are shown in Fig. 1. Included patients required a diagnosis of chronic PJI based on the Delphi-based consensus criteria after a primary THA,33 minimum of 2-year follow-up after their single- or two-stage procedure and were at least 18 years of age. The McPherson staging system for PJI was used to categorize patients based on host grade.34 No patients were excluded based on medical comorbidities, prior procedures on the infected joint, bacteremia, extensive bone loss, type of infectious organism, or antibiotic sensitivity. Charts were reviewed to collect demographics and laboratory test results. Operative reports, charts, and radiographs were reviewed for surgical history. Three major outcomes were compared between the revision approaches: the rates of postoperative complications, reinfections, and reoperations.

Preoperative and postoperative anteroposterior (AP) and lateral (LAT) radiographs for single-stage and two-stage hip revision.
Fig. 1 Preoperative and postoperative anteroposterior (AP) and lateral (LAT) radiographs for single-stage and two-stage hip revision.
2.2

2.2 Statistical analysis

Statistical analysis was completed using SAS V9.4 (SAS Institute Inc., Cary, NC) with significance set at p < 0.05. Descriptive statistics were used to summarize demographic and clinical characteristics. Fisher's exact tests and student t-tests or Wilcoxon rank sum tests were used to compare demographics, baseline characteristics, and outcomes for categorical and continuous variables, respectively. Cox's regression was used to compare time-to-event outcomes, while adjusting for potential confounders such as age, sex, body mass index, American Society of Anesthesiologists score, and prior procedures. Kaplan-Meier curves were created for survivability analysis. Log-rank tests were used to compare time-to-revision outcomes.

3

3 Results

Overall, 100 patients underwent total hip revision for a chronic periprosthetic joint infection during the study period. Of these, 37 had less than a 2-year follow-up. Of the remaining 63, twenty consecutive patients underwent two-stage, and 43 consecutive patients underwent single-stage. The mean follow-up was 5.9 years (range, 2.1-10.8 years) with longer follow-up in the two-stage group (8.6 versus 3.2 years). There were no significant differences in baseline demographics between the cohorts (Table 1). Both the single-stage and two-stage groups were women-dominant (63.0% versus 40.0%). Prevalence of diabetes mellites type II (14.0% versus 25.0%), peripheral vascular disease (2.3% versus 10.0%), and laboratory values such as c-reactive protein (11.2 ± 8.1 versus 9.3 ± 9.5) and erythrocyte sedimentation rate (56.7 ± 34.1 versus 46.7 ± 28.9) were similar between the two cohorts.

Table 1 Summary of demographic and clinical characteristics of patients who underwent single-stage or two-stage revision.
Overall Single-stage revision Two-stage revision P-value†
Demographics
Sex, n (%) 0.1087
Men 28 (44.4) 16 (37.2) 12 (60.0)
Women 35 (55.6) 27 (62.8) 8 (40.0)
Age in years, mean (SD) 59.8 (13.0) 60.0 (12.8) 59.5 (13.8) 0.8885
Tobacco use, n (%) 15 (23.8) 8 (18.6) 7 (35.0) 0.2063
Alcohol use, n (%) 32 (50.8) 22 (52.1) 10 (50.0) 1.000
BMI, mean (SD) 35.8 (9.1) 36.6 (9.4) 34.1 (8.3) 0.3078
Comorbidities
CAD, n (%) 7 (11.1) 3 (7.0) 4 (20.0) 0.1948
CKD, n (%) 9 (14.3) 6 (14.0) 3 (15.0) 1.000
Hypertension, n (%) 38 (60.3) 24 (55.8) 14 (70.0) 0.4077
Dialysis, n (%) 0 0 0
T2DM, n (%) 11 (17.5) 6 (14.0) 5 (25.0) 0.3040
PVD, n (%) 3 (4.8) 1 (2.3) 2 (10.0) 0.2344
RA, n (%) 5 (7.9) 5 (11.6) 0 0.1688
Preoperative Lab Values
CRP, mean (SD) 10.6 (8.6) 11.2 (8.1) 9.3 (9.5) 0.3986
ESR, mean (SD) 53.4 (32.5) 56.7 (34.1) 46.7 (28.9) 0.2618
Absolute neutrophil, n (%) 7.3 (4.2) 7.1 (4.3) 7.9 (4.0) 0.5314
WBC, mean (SD) 10.1 (4.5) 10.1 (3.8) 10.1 (5.9) 0.9653
Surgical Summary
Procedures performed between initial THA and revision, n (%) 35 (55.6) 22 (51.2) 13 (65.0) 0.4155
Sinus tract, n (%) 8 (12.7) 5 (11.6) 3 (15.0) 0.7009
Synchronous infection, n (%) 7 (11.1) 6 (14.0) 1 (5.0) 0.4151
Microbial pattern, n (%) 0.1743
Culture negative 5 (7.9) 2 (4.7) 3 (15.0)
Monomicrobial 46 (73.0) 34 (79.1) 12 (60.0)
Polymicrobial 12 (19.0) 7 (16.3) 5 (25.0)
Time from initial THA to revision in months, median (IQR) 13.0 (2.0-68.0) 6.0 (1.0-103.0) 14.0 (5.0-35.5) 0.5290
Host type, n (%) 0.5848
A 25 (39.7) 19 (44.2) 6 (30.0)
B 28 (44.4) 18 (41.9) 10 (50.0)
C 10 (15.9) 6 (14.0) 4 (20.0)
ASA score, mean (SD) 2.7 (0.6) 2.8 (0.6) 2.5 (0.6) 0.0588
Plastic surgery, n (%) 3 (4.8) 2 (4.7) 1 (5.0) 1.0000
Wound closure type, n (%) 0.5376
Gastrocnemius flap 1 (1.6) 0 1 (5.0)
Primary 61 (96.8) 42 (97.7) 19 (95.0)
Skin graft 1 (1.6) 1 (2.3) 0
† t-tests (or Wilcoxon rank sum test) for continuous variables and Fisher's exact tests for categorical variables.

Regarding the rate of reinfection, the overall success rate with no recurrence of infection was similar for both cohorts (Table 2). In the single-stage cohort, 35 of 43 (81.4%) had no recurrence of their infection. There were 8 of 43 (18.6%) patients who required reoperation for infectious reasons, and 9 of 43 (20.9%) who required reoperation for non-infectious reasons. In the two-stage cohort, 16 of 20 (80.0%) had successful eradication of the infection. There were 4 of 20 (20.0%) patients who required reoperation for infectious reasons, and 3 of 20 (15.0%) who required reoperation for non-infectious reasons. Overall, there were no statistically significant differences in eradication of infection (p = 1.000), requiring reoperation for an infectious reason (p = 1.000), or requiring reoperation for a non-infectious reason (p = 0.7367) between the two cohorts.

Table 2 Clinical outcomes of patients who underwent single-stage or two-stage revision.
Overall Single-stage revision Two-stage revision P-value†
Primary Outcomes
Eradication of infection 51 (81.0) 35 (81.4) 16 (80.0) 1.0000
Reoperation procedure, n (%) 19 (30.2) 14 (32.6) 5 (25.0) 0.7688
Reoperation procedure required for an infectious reason, n (%) 12 (19.0) 8 (18.6) 4 (20.0) 1.0000
Reoperation procedure required for a non-infectious reason, n (%) 12 (19.0) 9 (20.9) 3 (15.0) 0.7367
Secondary Outcomes
Wound drainage >7 days, n (%) 23 (36.5) 18 (41.9) 5 (25.0) 0.2645
Pulmonary embolism, n (%) 0 0 0 -
Deep vein thrombosis, n (%) 1 (1.6) 1 (2.3) 0 1.0000
Urinary tract infection, n (%) 1 (1.6) 0 1 (5.0) 0.3175
Acute renal failure, n (%) 5 (7.9) 4 (9.3) 1 (5.0) 1.0000
Long term antibiotics, n (%) 19 (30.2) 13 (30.2) 6 (30.0) 1.0000
Length of hospital stay in days, median (IQR) 6.0 (4.0-7.0) 6.0 (4.0-7.0) 5.0 (4.0-7.5) 0.7656
† t-tests (or Wilcoxon rank sum test) for continuous variables and Fisher's exact tests for categorical variables.

There were no significant differences in secondary clinical outcomes between the cohorts (Table 2). Time from revision to reinfection was similar (p = 0.9291), even when adjusting for age, sex, body mass index, American Society of Anesthesiology score, and having a prior procedure in a Cox's regression model (HR = 0.87; 95% CI = 0.24-3.15; p = 0.8305) (Fig. 2). Similarly, there was no statistically significant difference between the two cohorts when comparing time to follow-up procedure for any reason (p = 0.4734), even when adjusting for age, sex, body mass index, American Society of Anesthesiology score, and having a prior procedure in a Cox's regression model (HR = 1.36; 95% CI = 0.46-4.02; p = 0.5732) (Fig. 3).

Probability of requiring further surgical procedure for infectious reasons based on time from single-stage or two-stage revision.
Fig. 2 Probability of requiring further surgical procedure for infectious reasons based on time from single-stage or two-stage revision.
Probability of requiring further surgical procedures for either an infectious or non-infectious reason based on time from single-stage or two-stage revision.
Fig. 3 Probability of requiring further surgical procedures for either an infectious or non-infectious reason based on time from single-stage or two-stage revision.
4

4 Discussion

Several reviews have been performed to consolidate current evidence comparing the success of single-stage versus two-stage revisions for chronic periprosthetic joint infection (PJI) of the hip. A recent study by Goud et al. found a no recurrence of infection rate of 94.3% in 1234 patients and 91.8% in 5009 patients for single-stage and two-stage revision, respectively.35 Other review articles found similar results.36,37 Unfortunately, most of these reviews included studies that did not directly compare the two revision approaches or protocols. A recent review by Patel et al. only included studies that directly compared the two and found success rates to be 84.4% for single-stage and 87.1% for two-stage revision.38 These review articles also include a wide variety of inclusion criteria, treatment protocols, and often heterogeneous cohort characteristics, which can often be challenging to control even within individually published studies.39 In the present study, success rates for single-stage and two-stage revisions were 81.4% and 80.0%, respectively, which is similar to current literature, and suggest that there are no differences in rates of no recurrence of infection between the cohorts. In addition, there was found to be no differences in rates of postoperative complications. To date, there is little literature available that compares the postoperative outcomes as most current publications focus on rates of infection recurrence.

Given the present study's findings and current literature, a strong case can be made for the benefits of single-stage revision. First, the cost of a two-stage revision is approximately 1.7 times more expensive than a single-stage revision.40 Also, it is estimated that performing a single-stage revision over a two-stage revision can save a hospital system around $391,000 per patient.41 Second, two-stage revision can be associated with high mortality rate. Toulson et al. and Leung et al. found the mortality rate for two-stage revision to be 25.8% and 24.0%, respectively.42,43 However, Lenguerrand et al. found comparable mortality rates between the approaches.44 A meta-analysis is potentially warranted to compare these studies to further clarify mortality rate between the two approaches. Third, the two-stage revision is psychologically and physically more demanding for the patients. One study found the incidence of both depression and anxiety is increased in patients during the phase when the antibiotic spacer was in place compared to other times of the treatment.45 At this point in time, there is no current literature analyzing psychological health in patients undergoing single-stage revision.

This study has potential limitations. We did not report patient-reported outcomes such as Ontario and McMaster Universities Osteoarthritis-Hip, Oxford Hip Score, or the Hip Disability and Osteoarthritis Outcome Score. However, our aim was to focus on surgical outcomes including the rate of recurrence of infection and other postoperative complications. Furthermore, although 37.0% of patients were lost to follow-up before 2 years, analysis of 1-year eradication of infection for single-stage and two-stage revision was 85.0% (53/62) and 84.0% (27/32) respectively, which was similar to our 2-year follow-up rates. Moreover, our study may lack generalizability given the single-surgeon protocol. A limited exclusion criteria was included to try to improve this. Lastly, the overall sample size of our cohort was small with a combined cohort of 63 patients. However, this study provides results from a large single-provider, single-institution, single-protocol study for both consecutive single-stage and two-stage revisions for treatment of hip PJI, eliminating confounders that could be influencing the variables.

5

5 Conclusion

Single-stage revision is as effective as two-stage revision for treatment of chronic periprosthetic joint infection of the hip. No differences in rates of postoperative complications were found. The senior author's clinical practice will continue to use single-stage revision for the management of all chronic periprosthetic joint infections of the hip.

Institutional ethical committee approval

The study was IRB approved (A18-283) and was conducted in accordance with the ethical principles mentioned in the Declaration of Helsinski (2013).

CRediT author statement

Austin M. DeBoer: Data curation, Formal analysis, Investigation, Visualization, Writing-Original Draft.

Nickolas L. Van Roekel: Data curation, Formal analysis, Investigation, Methodology, Writing-Review & Editing.

Travis D. Parkulo: Data curation, Formal analysis, Investigation, Methodology, Writing-Review & Editing.

Gaonhia Y. Moua: Data curation, Formal analysis, Methodology, Project administration, Writing-Review & Editing.

Sandy Vang: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Supervision, Writing-Review & Editing.

Scott B. Marston: Conceptualization, Formal analysis, Investigation, Methodology, Supervision, Validation, Writing-Review & Editing.

Institutional ethical committee approval

The study was IRB approved (A18-283) and was conducted in accordance with the ethical principles mentioned in the Declaration of Helsinski (2013).

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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