A systematic review of the evidence for single stage and two stage revision of infected knee replacement

James P M Masters, Nicholas A Smith, Pedro Foguet, Mike Reed, Helen Parsons, Andrew P Sprowson, James P M Masters, Nicholas A Smith, Pedro Foguet, Mike Reed, Helen Parsons, Andrew P Sprowson

Abstract

Background: Periprosthetic infection about the knee is a devastating complication that may affect between 1% and 5% of knee replacement. With over 79 000 knee replacements being implanted each year in the UK, periprosthetic infection (PJI) is set to become an important burden of disease and cost to the healthcare economy. One of the important controversies in treatment of PJI is whether a single stage revision operation is superior to a two-stage procedure. This study sought to systematically evaluate the published evidence to determine which technique had lowest reinfection rates.

Methods: A systematic review of the literature was undertaken using the MEDLINE and EMBASE databases with the aim to identify existing studies that present the outcomes of each surgical technique. Reinfection rate was the primary outcome measure. Studies of specific subsets of patients such as resistant organisms were excluded.

Results: 63 studies were identified that met the inclusion criteria. The majority of which (58) were reports of two-stage revision. Reinfection rated varied between 0% and 41% in two-stage studies, and 0% and 11% in single stage studies. No clinical trials were identified and the majority of studies were observational studies.

Conclusions: Evidence for both one-stage and two-stage revision is largely of low quality. The evidence basis for two-stage revision is significantly larger, and further work into direct comparison between the two techniques should be undertaken as a priority.

Figures

Figure 1
Figure 1
Study selection flowchart.
Figure 2
Figure 2
Forest plot-one stage revision. X-axis is point estimate of reinfection at last follow up, which is variable, presented with 95% confidence intervals. ‘Borden 1987 a’ represents the results of the single stage revision presented in this paper.
Figure 3
Figure 3
Forest plot-two stage revisions. X-axis 1 Point estimate of reinfection rate at last follow-up which is variable (Mont 2000a-group 1 conventional two-stage revision, Mont 2000b-group 2 two stage revision with culture prior to reimplantation) ‘Borden 1987 c’ represents the two stage revision outcome presented in the paper. All estimates are presented with 95% confidence intervals.

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