Abstract
The two-staged exchange for periprosthetic joint infection (PJI) has become the “gold standard” worldwide. However, based on the first implementation of mixing antibiotics into bone cement by Prof. Buchholz in the 1970s, the ENDO-Klinik followed a distinct one staged exchange for PJI in over 85% of all our infected cases until today. Looking carefully at current literature and guidelines for the PJI treatment, there is no clear evidence, that a two-staged procedure has a clearly higher success rate than a one-staged approach.
A cemented one-stage exchange offers certain potential advantages, mainly the need for only one operative procedure resulting in reduced antibiotic administration, hospitalisation time, and relative overall costs. In order to fulfill a one-staged approach which results in the above described potential success, there are obligatory pre-, peri- and post-operative details, which need to be meticulously respected. The absolute mandatory infrastructural requirement is a clear knowledge of the infecting organism in combination with a distinct patient specific plan recommended by an experienced microbiologist, for the local antibiotics in the bone cement and the systemic antibiotics, administered to the patient post-operatively. This requires a mandatory pre-operative diagnostic test based on the joint aspiration with an exact identification of the bacteria. The presence of a positive bacterial culture and respective antibiogramm is essential, to identify the specific antibiotics loaded to the bone cement, which allows a high topic antibiotic elution directly at the surgical side.
Contraindications for a one staged exchange include:
Failure of > 2 previous one-staged procedures
Infection spreading to the nerve-vessel bundle, which allows no radical debridement
Unclear pre-operative bacteria specification
Unavailability of appropriate antibiotics due to high antibiotic resistance
The surgical success relies not only on the complete removal of all foreign material (including cement and restrictors), but also on the required aggressive and complete debridement of any infected soft tissues and bone material. The mixing of antibiotics into the cement must fulfill the following criteria: Appropriate antibiogramm, adequate elusion characteristics, bactericidal (exception clindamycin), powder form (never use liquid AB), maximum addition of 10%/PMMA powder. Current principles of modern cementing techniques should be applied. Post-operative systemic antibiotic administration is usually followed for only 10–14 days (exception: streptococci).
Persistence or recurrence of infection remains the most relevant complication in the one-staged technique. As failure rates with a two staged exchange have been described between 9% and 20% in non-resistant bacteria, the ENDO-Klinik data shows comparative results after 8 to10 years of follow-up.
In summary a cemented one-stage exchange offers various advantages. Mainly the need for only one operation, shorter hospitalisation, reduced systemic antibiotics, lower overall cost and a relatively high patient satisfaction rate. However, a well-defined pre-operative planning regime including an experienced surgeons team and microbiologist are absolutely mandatory for its overall success.
