Two-stage revision arthroplasty is the gold standard for treatment of infection after total hip Arthroplasty and end stage septic arthritis of the hip. In the first stage we used a modified technique to insert an inexpensive modular femoral component coated with antibiotic-impregnated polymethylmethacrylate articulating with a polyethylene liner. The construct was used in 8 patients with infected arthroplasty, and 6 patients with septic arthritis of the hip. Two patients were excluded (no second stage). Of the remaining 12 patients, only one patient had persistent infection after the first stage; 11 patients received a successful re-implantation at the second-stage. The technique provide a construct that can be used safely and successfully in the awaiting period between the two stages of revision arthroplasty

Aims. Safety concerns surrounding osseointegration are a significant barrier to replacing socket prosthesis as the standard of care following limb amputation. While implanted osseointegrated prostheses traditionally occur in two stages, a one-stage approach has emerged. Currently, there is no existing comparison of the outcomes of these different approaches. To address safety concerns, this study sought to determine whether a one-stage osseointegration procedure is associated with fewer adverse events than the two-staged approach. Methods. A comprehensive electronic search and quantitative data analysis from eligible studies were performed. Inclusion criteria were adults with a limb amputation managed with a one- or two-stage osseointegration procedure with follow-up reporting of complications. Results. A total of 19 studies were included: four one-stage, 14 two-stage, and one article with both one- and two-stage groups. Superficial infection was the most common complication (one-stage: 38% vs two-stage: 52%). There was a notable difference in the incidence of osteomyelitis (one-stage: nil vs two-stage: 10%) and implant failure (one-stage: 1% vs two-stage: 9%). Fracture incidence was equivocal (one-stage: 13% vs two-stage: 12%), and comparison of soft-tissue, stoma, and mechanical related complications was not possible. Conclusion. This review suggests that the one-stage approach is favourable compared to the two-stage, because the incidence of complications was slightly lower in the one-stage cohort, with a pertinent difference in the incidence of osteomyelitis and implant failure. Cite this article: Bone Jt Open 2023;4(7):539–550

Aims. The duration of systemic antibiotic treatment following first-stage revision surgery for periprosthetic joint infection (PJI) after total hip arthroplasty (THA) is contentious. Our philosophy is to perform an aggressive debridement, and to use a high local concentration of targeted antibiotics in cement beads and systemic prophylactic antibiotics alone. The aim of this study was to assess the success of this philosophy in the management of PJI of the hip using our two-stage protocol. Methods. The study involved a retrospective review of our prospectively collected database from which we identified all patients who underwent an intended two-stage revision for PJI of the hip. All patients had a diagnosis of PJI according to the major criteria of the Musculoskeletal Infection Society (MSIS) 2013, a minimum five-year follow-up, and were assessed using the MSIS working group outcome-reporting tool. The outcomes were grouped into ‘successful’ or ‘unsuccessful’. Results. A total of 299 two-stage revision THAs in 289 patients met the inclusion criteria, of whom 258 (86%) proceeded to second-stage surgery. Their mean age was 68.1 years (28 to 92). The median follow-up was 10.7 years (interquartile range (IQR) 6.3 to 15.0). A 91% success rate was seen in those patients who underwent reimplantation, decreasing to 86% when including those who did not proceed to reimplantation. The median duration of postoperative systemic antibiotics following the first stage was five days (IQR 5 to 9). There was no significant difference in outcome between those patients who were treated with antibiotics for ≤ 48 hours (p = 0.961) or ≤ five days (p = 0.376) compared with those who were treated with longer courses. Greater success rates were seen for Gram-positive PJIs (87%) than for Gram-negative (84%) and mixed-Gram PJIs (72%; p = 0.098). Conclusion. Aggressive surgical debridement with a high local concentration of targeted antibiotics at the time of first-stage revision surgery for PJI of the hip, without prolonged systemic antibiotics, provides a high rate of success, responsible antibiotic stewardship, and reduced hospital costs. Cite this article: Bone Joint J 2023;105-B(5):511–517

Aims. We compared the risks of re-revision and mortality between two-stage revision surgery and single-stage revision surgery among patients with infected primary knee arthroplasty. Methods. Patients with a periprosthetic joint infection (PJI) of their primary knee arthroplasty, initially revised with a single-stage or a two-stage procedure in England and Wales between 2003 and 2014, were identified from the National Joint Registry. We used Poisson regression with restricted cubic splines to compute hazard ratios (HR) at different postoperative periods. The total number of revisions and re-revisions undergone by patients was compared between the two strategies. Results. A total of 489 primary knee arthroplasties were revised with single-stage procedure (1,390 person-years) and 2,377 with two-stage procedure (8,349 person-years). The adjusted incidence rates of all-cause re-revision and for infection were comparable between these strategies (HR overall five years, 1.15 (95% confidence interval (CI) 0.87 to 1.52), p = 0.308; HR overall five years, 0.99 (95% CI 0.70 to 1.39), p = 0.949, respectively). Patients initially managed with single-stage revision received fewer revision procedures overall than after two-stage revision (1.2 vs 2.2, p < 0.001). Mortality was lower for single-stage revision between six and 18 months postoperative (HR at six months, 0.51 (95% CI 0.25 to 1.00), p = 0.049 HR at 18 months, 0.33 (95% CI 0.12 to 0.99), p = 0.048) and comparable at other timepoints. Conclusion. The risk of re-revision was similar between single- and two-stage revision for infected primary knee arthroplasty. Single-stage group required fewer revisions overall, with lower or comparable mortality at specific postoperative periods. The single-stage revision is a safe and effective strategy to treat infected knee arthroplasties. There is potential for increased use to reduce the burden of knee PJI for patients, and for the healthcare system. Cite this article: Bone Joint Res 2022;11(10):690–699

Aims. We compared the risks of re-revision and mortality between two-stage and single-stage revision surgeries among patients with infected primary hip arthroplasty. Methods. Patients with a periprosthetic joint infection (PJI) of their primary arthroplasty revised with single-stage or two-stage procedure in England and Wales between 2003 and 2014 were identified from the National Joint Registry. We used Poisson regression with restricted cubic splines to compute hazard ratios (HRs) at different postoperative periods. The total number of revisions and re-revisions undergone by patients was compared between the two strategies. Results. In total, 535 primary hip arthroplasties were revised with single-stage procedure (1,525 person-years) and 1,605 with two-stage procedure (5,885 person-years). All-cause re-revision was higher following single-stage revision, especially in the first three months (HR at 3 months = 1.98 (95% confidence interval (CI) 1.14 to 3.43), p = 0.009). The risks were comparable thereafter. Re-revision for PJI was higher in the first three postoperative months for single-stage revision and waned with time (HR at 3 months = 1.81 (95% CI 1.22 to 2.68), p = 0.003; HR at 6 months = 1.25 (95% CI 0.71 to 2.21), p = 0.441; HR at 12 months = 0.94 (95% CI 0.54 to 1.63), p = 0.819). Patients initially managed with a single-stage revision received fewer revision operations (mean 1.3 (SD 0.7) vs 2.2 (SD 0.6), p < 0.001). Mortality rates were comparable between these two procedures (29/10,000 person-years vs 33/10,000). Conclusion. The risk of unplanned re-revision was lower following two-stage revision, but only in the early postoperative period. The lower overall number of revision procedures associated with a single-stage revision strategy and the equivalent mortality rates to two-stage revision are reassuring. With appropriate counselling, single-stage revision is a viable option for the treatment of hip PJI. Cite this article: Bone Joint Res 2023;12(5):321–330

Aims. Histology is widely used for diagnosis of persistent infection during reimplantation in two-stage revision hip and knee arthroplasty, although data on its utility remain scarce. Therefore, this study aims to assess the predictive value of permanent sections at reimplantation in relation to reinfection risk, and to compare results of permanent and frozen sections. Methods. We retrospectively collected data from 226 patients (90 hips, 136 knees) with periprosthetic joint infection who underwent two-stage revision between August 2011 and September 2021, with a minimum follow-up of one year. Histology was assessed via the SLIM classification. First, we analyzed whether patients with positive permanent sections at reimplantation had higher reinfection rates than patients with negative histology. Further, we compared permanent and frozen section results, and assessed the influence of anatomical regions (knee versus hip), low- versus high-grade infections, as well as first revision versus multiple prior revisions on the histological result at reimplantation. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), chi-squared tests, and Kaplan-Meier estimates were calculated. Results. Overall, the reinfection rate was 18%. A total of 14 out of 82 patients (17%) with positive permanent sections at reimplantation experienced reinfection, compared to 26 of 144 patients (18%) with negative results (p = 0.996). Neither permanent sections nor fresh frozen sections were significantly associated with reinfection, with a sensitivity of 0.35, specificity of 0.63, PPV of 0.17, NPV of 0.81, and accuracy of 58%. Histology was not significantly associated with reinfection or survival time for any of the analyzed sub-groups. Permanent and frozen section results were in agreement for 91% of cases. Conclusion. Permanent and fresh frozen sections at reimplantation in two-stage revision do not serve as a reliable predictor for reinfection. Cite this article: Bone Joint J 2024;106-B(4):372–379

Aims. Single-stage revision total knee arthroplasty (rTKA) is gaining popularity in treating chronic periprosthetic joint infections (PJIs). We have introduced this approach to our clinical practice and sought to evaluate rates of reinfection and re-revision, along with predictors of failure of both single- and two-stage rTKA for chronic PJI. Methods. A retrospective comparative cohort study of all rTKAs for chronic PJI between 1 April 2003 and 31 December 2018 was undertaken using prospective databases. Patients with acute infections were excluded; rTKAs were classified as single-stage, stage 1, or stage 2 of two-stage revision. The primary outcome measure was failure to eradicate or recurrent infection. Variables evaluated for failure by regression analysis included age, BMI, American Society of Anesthesiologists grade, infecting organisms, and the presence of a sinus. Patient survivorship was also compared between the groups. Results. A total of 292 consecutive first-time rTKAs for chronic PJI were included: 82 single-stage (28.1%); and 210 two-stage (71.9%) revisions. The mean age was 71 years (27 to 90), with 165 females (57.4%), and a mean BMI of 30.9 kg/m. 2. (20 to 53). Significantly more patients with a known infecting organism were in the single-stage group (93.9% vs 80.47%; p = 0.004). The infecting organism was identified preoperatively in 246 cases (84.2%). At a mean follow-up of 6.3 years (2.0 to 17.6), the failure rate was 6.1% in the single-stage, and 12% in the two-stage groups. All failures occurred within four years of treatment. The presence of a sinus was an independent risk factor for failure (odds ratio (OR) 4.97; 95% confidence interval (CI) 1.593 to 15.505; p = 0.006), as well as age > 80 years (OR 5.962; 95% CI 1.156 to 30.73; p = 0.033). The ten-year patient survivorship rate was 72% in the single-stage group compared with 70.5% in the two-stage group. This difference was not significant (p = 0.517). Conclusion. Single-stage rTKA is an effective strategy with a high success rate comparable to two-stage approach in appropriately selected patients. Cite this article: Bone Joint J 2021;103-B(8):1373–1379

Aims. Uncemented implants are now commonly used at reimplantation of a two-stage revision total hip arthoplasty (THA) following periprosthetic joint infection (PJI). However, there is a paucity of data on the performance of the most commonly used uncemented femoral implants – modular fluted tapered (MFT) femoral components – in this setting. This study evaluated implant survival, radiological results, and clinical outcomes in a large cohort of reimplantation THAs using MFT components. Methods. We identified 236 reimplantation THAs from a single tertiary care academic institution from September 2000 to September 2020. Two designs of MFT femoral components were used as part of an established two-stage exchange protocol for the treatment of PJI. Mean age at reimplantation was 65 years (SD 11), mean BMI was 32 kg/m. 2. (SD 7), and 46% (n = 109) were female. Mean follow-up was seven years (SD 4). A competing risk model accounting for death was used. Results. The 15-year cumulative incidence of any revision was 24%. There were 48 revisions, with the most common reasons being dislocation (n = 25) and infection (n = 16). The 15-year cumulative incidence of any reoperation was 28%. Only 13 revisions involved the fluted tapered component (FTC), for a 15-year cumulative incidence of any FTC revision of 8%. Only two FTCs were revised for aseptic loosening, resulting in a 15-year cumulative incidence of FTC revision for aseptic loosening of 1%. Stem subsidence ≥ 5 mm occurred in 2% of unrevised cases. All stems were radiologically stable at most recent follow-up. Mean Harris Hip Score was 69 (SD 20) at most recent follow-up. Conclusion. This series demonstrated that MFT components were durable and reliable in the setting of two-stage reimplantation THA for infection. While the incidence of aseptic loosening was very low, the incidence of any revision was 24% at 15 years, primarily due to dislocation and recurrent PJI. Cite this article: Bone Joint J 2024;106-B(5 Supple B):125–132

Complications such as implant loosening, infection, periprosthetic fracture or instability may lead to revision arthroplasty procedures. There is limited literature comparing single-stage and two-stage revision shoulder arthroplasty. This study aims to compare clinical outcomes and cost benefit between single-stage and two-stage revision procedures. Thirty-one revision procedures (mean age 72+/-7, 15 males and 16 females) performed between 2016 and 2021 were included (27 revision RSA, 2 revision TSA, 2 failed ORIFs). Two-stage procedures were carried out 4-6 weeks apart. Single-stage procedures included debridement, implant removal and washout, followed by re-prep, re-drape and reconstruction with new instrumentations. Clinical parameters including length of stay, VAS, patient satisfaction was recorded preoperatively and at mean 12-months follow up. Cost benefit analysis were performed. Seven revisions were two-stage procedures and 24 were single-stage procedures. There were 5 infections in the two-stage group vs 14 in the single-stage group. We noted two cases of unstable RSA and 8 other causes for single-stage revision. Majority of the revisions were complex procedures requiring significant glenoid and/or humeral allografts and tendon transfers to compensate for soft tissue loss. No custom implants were used in our series. Hospital stay was reduced from 41+/-29 days for 2-stage procedures to 16+/-13 days for single-stage (p<0.05). VAS improved from 9+/-1 to 2+/-4 for two-stage procedures and from 5+/-3 to 1+/-2 for single-stages. The average total cost of hospital and patient was reduced by two-thirds. Patient satisfaction in the single-stage group was 43% which was comparable to the two-stage group. All infections were successfully treated with no recurrence of infection in our cohort of 31 patients. There was no instability postoperatively. 3 patients had postoperative neural symptoms which resolved within 6 months. Single-stage procedures for revision shoulder arthroplasty significantly decrease hospital stay, improve patients’ satisfaction, and reduced surgical costs

Aim. The duration of systemic antibiotic therapy following first-stage surgery is contentious. Our Institution's philosophy is to perform an aggressive debridement, use high concentration targeted antibiotics through cement beads and systemic prophylactic antibiotics alone. In the presence of significant soft tissue infection or microbiological diagnostic uncertainty; systemic antibiotics may be prescribed for 5 days whilst awaiting tissue culture results. The aim of this study was to assess the success of our philosophy in the management of PJI of the hip using our two-stage protocol. Method. A retrospective review of our Institution's prospectively-collected database was performed to identify those patients who were planned to undergo a two-stage hip revision procedure for PJI. All patients had a confirmed diagnosis of PJI as per the major criteria of MSIS 2013, a minimum 5-years follow up and were assessed at the time of review using the MSIS working group outcome-reporting tool (2018). They were then grouped into “successful” or “unsuccessful” (suppressive antibiotics, further revision for infection, death within 1 year). Results. 299 intended two-stage hip revisions in 289 patients (6 repeat ipsilateral two-stage, 4 bilateral two-stage) met our inclusion criteria. 258 (86%) patients proceeded to 2. nd. stage surgery. Median follow up was 10.7 years. 91% success rate was observed for those patients who underwent reimplantation; dropping to 86% when including the patients who did not proceed to second stage surgery. The median duration of post-operative systemic antibiotics following first stage surgery was 5 days (IQR 5–9). No significant difference in outcome was observed in patients who received either; < / = 48 hours (86%; n=70) compared to > 48 hours antibiotics (86%; n=229; p=0.96) or </= 5 days of antibiotics (88%; n=202) compared to > 5 days antibiotics (82%; p=0.38). A significant majority had gram-positive (88%) infection with 30% being polymicrobial. Greater success rates were observed for gram-positive PJI (87%); than for gram-negative PJI (84%) and mixed Gram infection (72%; p=0.098). Conclusion. Aggressive surgical debridement with high concentration, targeted local antibiotic delivery at time of first stage hip surgery, without prolonged systemic antibiotics, provides a high rate of success, responsible antibiotic stewardship and reduced hospital costs

We compared the risks of re-revision and mortality between two-stage and single-stage revision surgeries among patients with infected primary hip arthroplasty. Patients with a periprosthetic joint infection (PJI) of their primary arthroplasty revised with single-stage or two-stage procedure in England and Wales between 2003 and 2014 were identified from the National Joint Registry. We used Poisson regression with restricted cubic splines to compute hazard ratios (HRs) at different postoperative periods. The total number of revisions and re-revisions undergone by patients was compared between the two strategies. In total, 535 primary hip arthroplasties were revised with single-stage procedure (1,525 person-years) and 1,605 with two-stage procedure (5,885 person-years). All-cause re-revision was higher following single-stage revision, especially in the first three months (HR at 3 months = 1.98 (95% confidence interval (CI) 1.14 to 3.43), p = 0.009). The risks were comparable thereafter. Re-revision for PJI was higher in the first three postoperative months for single-stage revision and waned with time (HR at 3 months = 1.81 (95% CI 1.22 to 2.68), p = 0.003; HR at 6 months = 1.25 (95% CI 0.71 to 2.21), p = 0.441; HR at 12 months = 0.94 (95% CI 0.54 to 1.63), p = 0.819). Patients initially managed with a single-stage revision received fewer revision operations (mean 1.3 (SD 0.7) vs 2.2 (SD 0.6), p < 0.001). Mortality rates were comparable between these two procedures (29/10,000 person-years vs 33/10,000). The risk of unplanned re-revision was lower following two-stage revision, but only in the early postoperative period. The lower overall number of revision procedures associated with a single-stage revision strategy and the equivalent mortality rates to two-stage revision are reassuring. With appropriate counselling, single-stage revision is a viable option for the treatment of hip PJI

Aims. Two-stage exchange revision total hip arthroplasty (THA) performed in case of periprosthetic joint infection (PJI) has been considered for many years as being the gold standard for the treatment of chronic infection. However, over the past decade, there have been concerns about its safety and its effectiveness. The purposes of our study were to investigate our practice, collecting the overall spacer complications, and then to analyze their risk factors. Methods. We retrospectively included 125 patients with chronic hip PJI who underwent a staged THA revision performed between January 2013 and December 2019. All spacer complications were systematically collected, and risk factors were analyzed. Statistical evaluations were performed using the Student's t-test, Mann-Whitney U test, and Fisher's exact test. Results. Our staged exchange practice shows poor results, which means a 42% mechanical spacer failure rate, and a 20% recurrent infection rate over the two years average follow-up period. Moreover, we found a high rate of spacer dislocation (23%) and a low rate of spacer fracture (8%) compared to the previous literature. Our findings stress that the majority of spacer complications and failures is reflecting a population with high comorbid burden, highlighted by the American Society of Anesthesiology grade, Charlson Comorbidity Index, and Lee score associations, as well as the cardiac, pulmonary, kidney, or hepatic chronic conditions. Conclusion. Our experience of a two-stage hip exchange revision noted important complication rates associated with high failure rates of polymethylmethacrylate spacers. These findings must be interpreted in the light of the patient’s comorbidity profiles, as the elective population for staged exchange has an increasing comorbid burden leading to poor results. In order to provide better results for this specific population, our conclusion suggests that comparative strategy studies are required to improve our therapeutic indication. Cite this article: Bone Jt Open 2022;3(6):485–494

Aims. To explore the effect of different durations of antibiotics after stage II reimplantation on the prognosis of two-stage revision for chronic periprosthetic joint infection (PJI). Methods. This study involved a retrospective collection of patients who underwent two-stage revision for chronic PJI and continued to use extended antibiotic prophylaxis in two regional medical centres from January 2010 to June 2018. The patients were divided into a short (≤ one month) or a long (> one month) course of treatment based on the duration of antibiotics following stage II reimplantation. The difference in the infection control rate between the two groups was compared, and prognostic factors for recurrence were analyzed. Results. A total of 105 patients with chronic PJI were enrolled: 64 patients in the short course group and 41 patients in the long course group. For 99 of the patients, the infection was under control during a follow-up period of at least 24 months after two-stage revision. For the short course group, the mean duration of antibiotic prophylaxis after stage II reimplantation was 20.17 days (SD 5.30) and the infection control rate was 95.3%; for the long course group these were 45.02 days (SD 15.03) and 92.7%, respectively. There was no significant difference in infection control rates between the two groups (p = 0.676). Cox regression analysis found that methicillin-resistant staphylococcus infection (p = 0.015) was an independent prognostic factor for recurrence. Conclusion. After stage II reimplantation surgery of two-stage revision for chronic PJI, extended antibiotic prophylaxis for less than one month can achieve good infection control rate. Cite this article: Bone Joint Res 2021;10(12):790–796

The duration of systemic antibiotics following first-stage surgery is contentious. Our Institution's philosophy is to perform an aggressive debridement, high concentration of targeted antibiotics through cement beads and systemic prophylactic antibiotics alone. In the presence of significant soft tissue infection or microbiological diagnostic uncertainty; systemic antibiotics may be prescribed for 5 days whilst awaiting tissue culture results. The aim of this study was to assess the success of our philosophy for two-stage hip revision. A retrospective review of our Institution's prospective database was performed to identify all intended two-stage hip revision procedures for PJI. All patients had a confirmed PJI as per MSIS 2013 criteria, minimum 5-years follow up and outcomes according to the MSIS working group outcome-reporting tool; then grouped into “successful” or “unsuccessful” (suppressive antibiotics, further revision for infection, death within 1 year). 383 intended two-stage hip revisions were identified; of which 299 met our inclusion criteria, in 289 patients (6 repeat ipsilateral two-stage, 4 bilateral two-stage). Median follow up was 10.7 years (IQR 6.3 – 15.0). 258 (86%) patients proceeded to 2. nd. stage surgery. 91% success rate was observed for those patients who underwent reimplantation, although dropping to 86% when including the patients who did not proceed to second stage. The median duration of post-operative systemic antibiotics was 5 days (IQR 5–9). No significant difference was observed in patients who received either; < / = 48 hours (86%; n=70) compared to > 48 hours antibiotics (86%; n=229; p=0.96) or </= 5 days of antibiotics (88%; n=202) compared to > 5 days antibiotics (82%; p=0.38). A significant majority had gram-positive (88%) infection with 30% being polymicrobial. Greater success rates were observed with two-stage exchange or gram-positive PJI (86%); than for gram-negative PJI (81%) and polymicrobial infection (74%) (p=0.36). Fungal PJI was observed to have a significantly reduced rate of success (n=3; 33%; p=0.03). Aggressive surgical debridement with high concentration, targeted local antibiotic delivery at time of first stage to manage PJI of the hip provides a high rate of success, responsible antibiotic stewardship and reduced hospital costs

Aims. In our unit, we adopt a two-stage surgical reconstruction approach using internal fixation for the management of infected Charcot foot deformity. We evaluate our experience with this functional limb salvage method. Methods. We conducted a retrospective analysis of prospectively collected data of all patients with infected Charcot foot deformity who underwent two-stage reconstruction with internal fixation between July 2011 and November 2019, with a minimum of 12 months’ follow-up. Results. We identified 23 feet in 22 patients with a mean age of 56.7 years (33 to 70). The mean postoperative follow-up period was 44.7 months (14 to 99). Limb salvage was achieved in all patients. At one-year follow-up, all ulcers have healed and independent full weightbearing mobilization was achieved in all but one patient. Seven patients developed new mechanical skin breakdown; all went on to heal following further interventions. Fusion of the hindfoot was achieved in 15 of 18 feet (83.3%). Midfoot fusion was achieved in nine of 15 patients (60%) and six had stable and painless fibrous nonunion. Hardware failure occurred in five feet, all with broken dorsomedial locking plate. Six patients required further surgery, two underwent revision surgery for infected nonunion, two for removal of metalwork and exostectomy, and two for dynamization of the hindfoot nail. Conclusion. Two-stage reconstruction of the infected and deformed Charcot foot using internal fixation and following the principle of ‘long-segment, rigid and durable internal fixation, with optimal bone opposition and local antibiotic elusion’ is a good form of treatment provided a multidisciplinary care plan is delivered. Cite this article: Bone Joint J 2021;103-B(10):1611–1618

Studies and meta-analyses worldwide show an increased use of one-stage revisions for treating periprosthetic hip infections, often yielding comparable or better outcomes than two-stage revisions. However, it remains unclear if these successful results can be consistently achieved nationwide besides large centers. This observational cohort study used data from the German Arthroplasty Registry (EPRD) to compare the mortality and re-revision rates between one-stage (n=8183) and two-stage (n=657) first-time revision total hip arthroplasty (RTHA). Kaplan-Meier estimates were applied to evaluate the re-revision rate and cumulative mortality for RTHA. There was a significant difference in mortality between one-stage and two-stage RTHA (p=0.02). One-year post-surgery, the mortality rate was 9.4% for one-stage revisions and 5.5% for two-stage revisions. At the five-year follow-up, the mortality rate for one-stage revisions was 25.5%, compared to 20.0% for two-stage revisions. No significant differences (p=0.30) were found in re-revision rates between one-stage and two-stage revisions after one year (one-stage 16.5% vs. two-stage 13.5%) or five years (one-stage 21.6% vs. two-stage 20.8%). For multiple revisions, the mortality differences were even larger (p<0.001), with a one-year mortality rate of 12.8% for one-stage RTHA and 5.7% for two-stage RTHA. Despite the excellent results of one-stage RTHA in the literature from individual large centers, it shows a significantly higher mortality rate with equal re-revision rate compared to two-stage revision in the nationwide care besides large centers. Significant differences can already be seen within the first year, indicating an increased perioperative mortality for one-stage revision, which might be explained by longer surgery duration, blood-loss and patient selection or maybe a lack of experience concerning proper surgical debridement for one-stage revision. This illustrates the need to establish centers for joint-revision surgery that provide interdisciplinary care and high case numbers to improve perioperative outcomes

Aims. The increasing infection burden after total hip arthroplasty (THA) has seen a rise in the use of two-stage exchange arthroplasty and the use of increasingly powerful antibiotics at the time of this procedure. As a result, there has been an increase in the number of failed two-stage revisions during the past decade. The aim of this study was to clarify the outcome of repeat two-stage revision THA following a failed two-stage exchange due to recurrent prosthetic joint infection (PJI). Patients and Methods. We identified 42 patients who underwent a two-stage revision THA having already undergone at least one previous two stage procedure for infection, between 2000 and 2015. There were 23 women and 19 men. Their mean age was 69.3 years (48 to 81). The outcome was analyzed at a minimum follow-up of two years. Results. A satisfactory control of infection and successful outcome was seen in 26 patients (57%). There therefore remained persistent symptoms that either required further surgery or chronic antibiotic suppression in 16 patients (38%). One-third of patients had died by the time of two years’ follow-up. Conclusion. The rate of failure and complication rate of repeat two-stage exchange THA for PJI is high and new methods of treatment including host optimization, immunomodulation, longer periods between stages, and new and more powerful forms of antimicrobial treatment should be investigated. Cite this article: Bone Joint J 2019;101-B(6 Supple B):110–115

Introduction. The surgical management of late PJI was usually done in two stages with the placement of a temporary cement spacer. The development of one-stage surgical care raises questions about the two-stage strategy. The objectives of this study are to identify the complications related to the presence of the cement spacer within a two-stage strategy. The septic recurrence rate is also evaluated after a minimum follow-up of two years. Material and methods. Medical files of 208 patients (101 knees and 107 hips) who underwent a two-stage revision for late PJI prosthesis infection were retrospectively reviewed. Antibiotic loaded articulated homemade cement spacers were used. Second stage was usually planned on average 4 to 6 weeks after the first stage. Patients were allowed to walk without loading. The success rate was defined as the absence of septic recurrence after a minimum follow-up of two years. Descriptive statistics and uni- and multivariate analysis were conducted. Results. The spacers were left in place for an average of 42 days for the knees and 30 days for the hips. Six patients (3%) died before performing the second stage. Hip spacers were associated with 8 fractures for only one observed in the knee (4%). Spacer dislocation (11%) was observed in 23 cases (13 for the hip and 10 for the knee respectively). Treatment failure with recurrence of the infection within 2 years was observed in 26 patients (12%). Resistance to the antibiotic present in the cement was found in one third of infectious failures. The presence of a prior cemented prosthesis was significantly associated with the presence of a germ resistant to gentamicin and the persistence of the germ at the second stage. However, it was not associated with failure at two years. Discussion. the two-stage management of PJI is associated with a non-negligible mortality rate before the second stage, rarely reported in studies. The presence of an initially cemented prosthesis is associated with the presence of germs resistant to the antibiotic contained in the cement and exposes to the persistence of the resistant germ at the second stage. Spacer fractures are observed more at the hip, but less frequently than in previous reports, while dislocations are observed at both the hip and the knee, particularly due to loss of tibial fixation in this area. These observations are all arguments for further consideration of revision surgery in 1 stage

Aims. Removal of infected components and culture-directed antibiotics are important for the successful treatment of chronic periprosthetic joint infection (PJI). However, as many as 27% of chronic PJI patients yield negative culture results. Although culture negativity has been thought of as a contraindication to one-stage revision, data supporting this assertion are limited. The aim of our study was to report on the clinical outcomes for one-stage and two-stage exchange arthroplasty performed in patients with chronic culture-negative PJI. Methods. A total of 105 consecutive patients who underwent revision arthroplasty for chronic culture-negative PJI were retrospectively evaluated. One-stage revision arthroplasty was performed in 30 patients, while 75 patients underwent two-stage exchange, with a minimum of one year's follow-up. Reinfection, re-revision for septic and aseptic reasons, amputation, readmission, mortality, and length of stay were compared between the two treatment strategies. Results. The patient demographic characteristics did not differ significantly between the groups. At a mean follow-up of 4.2 years, the treatment failure for reinfection for one-stage and two-stage revision was five (16.7%) and 15 patients (20.0%) (p = 0.691), and for septic re-revision was four (13.3%) and 11 patients (14.7%) (p = 0.863), respectively. No significant differences were observed between one-stage and two-stage revision for 30- 60- and 90-day readmissions (10.0% vs 8.0%; p = 0.714; 16.7% vs 9.3%; p = 0.325; and 26.7% vs 10.7%; p = 0.074), one-year mortality (3.3% vs 4.0%; p > 0.999), and amputation (3.3% vs 1.3%; p = 0.496). Conclusion. In this non-randomized study, one-stage revision arthroplasty demonstrated similar outcomes including reinfection, re-revision, and readmission rates for the treatment of chronic culture-negative PJI after TKA and THA compared to two-stage revision. This suggests culture negativity may not be a contraindication to one-stage revision arthroplasty for chronic culture-negative PJI in selected patients. Cite this article: Bone Joint J 2021;103-B(3):515–521

Aim. Analysis of microbiological spectrum and resistance patterns as well as the clinical outcome of patients who underwent a Debridement, antibiotics and implant retention (DAIR) procedure in the early phase following failed two-stage exchange arthroplasty of the knee and hip. Method. Of 312 patients treated with two-stage exchange arthroplasty between January 2011 and December 2019, 16 (5.1%) patients (9 knee, 7 hip) underwent a DAIR procedure within 6 months following second stage. We retrospectively analyzed the microbiological results as well as changes in the microbiological spectrum and antibiotic resistance patterns between stages of two-stage exchange arthroplasties and DAIR procedures. Patient's re-revision rates after a minimum follow-up of 12 months following DAIR procedure were evaluated. Moreover, differences between knee and hip and between infected primary total joint replacement (TJRs) and infected revision TJRs as well as patient's host factors and microbiological results regarding the outcome of DAIR were analyzed. Results. In 7/16 (43.8%) patients the first and second stage procedure was culture positive, in 5/16 (31.2%) patients the first and second stage procedure was culture negative and in 4/16 (25%) patients the first stage procedure was culture positive, and the second stage procedure was culture negative. Moreover, 6 (37.5%) out of 16 DAIR procedures showed a positive microbiological result. In 5/7 (71.4%) patients with culture positive second stage procedure a different microorganism compared to first stage procedure was detected. In 6/6 (100%) patients with culture positive DAIR procedure, the isolated microorganisms were not detected during first or second stage procedure. An additional re-revision surgery was necessary in 4/16 (25%) patients after a median time of 31 months (range, 12 to 138 months) at a mean follow up of 63.1 ± 32 months following DAIR procedure. Highest re-revision rates were found in patients with culture positive second stage procedures (3/7 [42.9%]) and patients with culture positive DAIR procedures (2/6 [33.3%]). Conclusions. DAIR procedure seems to be a useful early treatment option following failed two-stage exchange arthroplasty. The re-revision rates were independent of different combinations of culture positive and culture negative first and second stage procedures. The high number of changes in the microbiological spectrum needs to be considered in the treatment of PJI

Aim. The primary endpoint of this study is to characterize the progression of bone defects at the femoral and tibial side in patients who sustained PJI of the knee that underwent two-stage revision with spacer implantation. In addition, we want to analyze the differences between functional moulded and hand-made spacers. Methods. A retrospective analysis of patients that underwent two-stage revision due to PJI of the knee between January 2014 and December 2021 at our institution. Diagnosis of infection was based on the criteria of the Muscoloskeletal Infection Society. The bone defect evaluation was performed intraoperatively based on the AORI classification. The basal evaluation was performed at the time the resection arthroplasty and spacer implantation surgery. The final evaluation was performed at the second-stage surgery, at the time of spacer removal and revision implant positioning. The differences between groups were characterized by using T-test student for continuous variables, and by using chi-square for categorical variables. A p-value < 0.05 was defined as significant. Results. Complete data of 37 two-stage TKAs revision were included in the study. An articulating moulded functional spacer was used in 14 (35.9%) cases, while a hand-made spacer was used in 23 (58.9%) cases. The average length of interval period (excluding the time for patients that retained the spacer) was 146.6 days. A bone defects progression based on the AORI classification was documented in 24 cases at the femoral side (61.6%), a bone defect progression was documented in 17 cases at the tibial side (43.6%), and a bone defect at both sides was documented in 13 cases (33.3%). A statistically significant greater bone defect progression at the tibial side was observed when hand-made spacers were used. A complication during the interval period was reported in five cases (12.8%) and postoperative complication was reported in 9 cases (23.1%). Conclusions. When comparing patients in which a functional articulating spacer was used, with patients in which static spacer was used, we reported a statistically significant reduced bone defect progression during the interval period at the femoral side only when moulded spacers were used. We observed a higher incidence of bone defect progression also at the tibial and both sides when hand-made spacers were used. This is the first study that documented the bone defect progression during two-stage revision of the knee, the results observed in this study are very encouraging

Mechanical failure due to dislocation, fracture and acetabular wear as well as persistence of infection are the main complications associated with the use of hip spacers in the treatment of periprosthetic joint infections (PJI). We have developed a novel, custom-made spacer as part of two-stage septic hip replacement and present the two- to five-year results after reimplantation. We prospectively examined a total of 73 patients over our study period in whom our new spacer technique was used. The technique includes a dual mobility inlay and a cemented straight stem in combination with antibiotic-loaded PMMA bone cement which allows full weight bearing meanwhile the interim period. The follow-up ranged between 24 and 60 months after reimplantation as second stage of a two-stage approach. The patients were contacted as part of the follow-up using a questionnaire concerning reoperation, reinfection as well as hip function by using the Harris Hip Score. 72 patients (98,6%) could be reimplanted, one patient is still using the spacer prothesis for 45 months because of excellent functional results with a Harris Hip Score of 95, nevertheless reimplantation is planned. The reinfection rate was less than 7% after reimplantation. The dislocation rate was 5%, and in total there was an overall complication rate of less than 10%. The Harris Hip Score was significantly improved. The ENDO spacer surgical technique is a promising option in the treatment of periprosthetic joint infections (PJI) for two-stage septic exchange with a low dislocation rate and good infection control after reimplantation. In addition, it enables early mobilization with the possibility of full weight-bearing in the interval between spacer implantation and reimplantation

Aims. Our objective is to describe our early and mid-term results with the use of a new simple primary knee prosthesis as an articulating spacer in planned two-stage management for infected knee arthroplasty. As a second objective, we compared outcomes between the group with a retained first stage and those with a complete two-stage revision. Methods. We included 47 patients (48 knees) with positive criteria for infection, with a minimum two-year follow-up, in which a two-stage approach with an articulating spacer with new implants was used. Patients with infection control, and a stable and functional knee were allowed to retain the initial first-stage components. Outcomes recorded included: infection control rate, reoperations, final range of motion (ROM), and quality of life assessment (QoL) including Western Ontario and McMaster Universities osteoarthritis index, Knee Injury and Osteoarthritis Outcome Score, Oxford Knee Score, 12-Item Short-Form Health Survey questionnaire, and University of California Los Angeles (UCLA) activity score and satisfaction score. These outcomes were evaluated and compared to additional cohorts of patients with retained first-stage interventions and those with a complete two-stage revision. Mean follow-up was 3.7 years (2.0 to 6.5). Results. Eight knees failed directly related to lack of infection control (16%), and two patients (two knees) died within the first year for causes not directly related, giving an initial success rate of 79% (38/48). Secondary success rate after a subsequent procedure was 91% (44/48 knees). From the initially retained spacers, four knees (22%) required a second-stage revision for continuous symptoms and one (5%) for an acute infection. There were no significant differences regarding the failure rate due to infection, ROM, and QoL assessment between patients with a retained first-stage procedure and those who underwent a second-stage operation. Conclusion. Our protocol of two-stage exchange for infected knee arthroplasties with an articulating spacer and using new primary knee implants achieves adequate infection control. Retained first-stage operations achieve comparable results in selected cases, with no difference in infection control, ROM, and QoL assessment in comparison to patients with completed two-stage revision surgery. Cite this article: Bone Joint J 2020;102-B(7):852–860

Prosthetic joint infection (PJI) is an uncommon but serious complication of hip replacement. Over 1,000 operations are performed annually in the United Kingdom for PJI following hip replacement, using either one- or two-stage revision arthroplasty. It is unclear which is preferred by patients and which has the best long-term outcome. This qualitative study aims to describe patient experiences of treatment and recovery following one- and two-stage revision arthroplasty for PJI within the context of a pragmatic randomised controlled trial comparing these two approaches. Semi-structured interviews were conducted with 32 patients undergoing one- or two-stage revision treatment for PJI as part of a UK multi-centre randomised controlled trial. Patients were recruited from 12 participating National Health Service (NHS) Orthopaedic Departments and were interviewed 2–4 months after their first revision surgery and again approximately 18 months later. Final sample size was justified on the basis of thematic saturation. All patients consented to the interview being audio-recorded, transcribed, anonymised and analysed using an inductive thematic approach. Ethical approval was provided by NRES Committee South-West Frenchay, 14/SW/116. Patients in both the one- and two-stage treatment groups described prolonged hospital stays, with burdensome antibiotics and brief physiotherapy treatment. However, following discharge home and during recovery, participants undergoing two-stage revision with an ‘empty hip' or with a spacer reported being physically restricted in almost every aspect of their daily life, resulting in inactivity and confinement to home. Mobility aids were not sufficiently available through the health service for these patients. A key difference is that those with a spacer reported more pain than those without. Approximately one year following their second-stage revision, participants described being more independent and active, but two directly attributed muscle weakness to the lengthy period without a hip and described resulting falls or dislocations that had complicated their recovery. In contrast, those undergoing one-stage revision and CUMARS appeared to be more alike, reporting better mobility, functionality and independence, although still limited. Participants in these groups also reported minimal or no pain following their revision. A key difference between CUMARS and one-stage revision was the uncertainty of whether a second operation was necessary, which participants described as “hanging over them”, while those in the two-stage empty hip or spacer group described a more positive anticipation of a second definitive operation as it marked an end to what was described as a detachment from life. Our findings highlight the differences between patient experiences of recovery following revision arthroplasty, and how this is influenced by the surgical approach and presence or lack of spacers. An understanding of lived experiences following one- and two-stage surgical interventions will complement knowledge about the clinical effectiveness of these different types of revision surgery

Aims. Recurrent infection following two-stage revision total hip arthroplasty (THA) for prosthetic joint infection (PJI) is a devastating complication. The purpose of this study was to report the survival of repeat two-stage revision hip arthroplasty, describe complications, and identify risk factors for failure. Patients and Methods. We retrospectively identified 19 hips (19 patients) that had undergone repeat two-stage revision THA for infection between 2000 to 2013. There were seven female patients (37%) and the mean age was 60 years (30 to 85). Survival free from revision was assessed via Kaplan–Meier analysis. The patients were classified according to the Musculoskeletal Infection Society (MSIS) system, and risk factors for failure were identified. Mean follow-up was four years (2 to 11). Results. Gram-positive bacteria were responsible for 16/17 (94%) of the re-infections where microbes were identified. Following the repeat two-stage exchange arthroplasty, survival free from any revision was 74% (95% confidence interval (CI) 56% to 96%, 14 at risk) at two years and 45% (95% CI 25% to 75%, five at risk) at five years. Failure to control infection resulted in re-operation or revision in 42%A of patients (8/19). Survival free from revision was not dependent on host grade. Conclusion. Re-infection after two-stage exchange hip arthroplasty for PJI presents a challenging scenario. Repeat two-stage exchange arthroplasty has a low survival free from revision at five years (45%) and a high rate of re-infection (42%). Cite this article: Bone Joint J 2018;100-B:1157–61

Aims. Accurate diagnosis of chronic periprosthetic joint infection (PJI) presents a significant challenge for hip surgeons. Preoperative diagnosis is not always easy to establish, making the intraoperative decision-making process crucial in deciding between one- and two-stage revision total hip arthroplasty (THA). Calprotectin is a promising point-of-care novel biomarker that has displayed high accuracy in detecting PJI. We aimed to evaluate the utility of intraoperative calprotectin lateral flow immunoassay (LFI) in THA patients with suspected chronic PJI. Methods. The study included 48 THAs in 48 patients with a clinical suspicion of PJI, but who did not meet European Bone and Joint Infection Society (EBJIS) PJI criteria preoperatively, out of 105 patients undergoing revision THA at our institution for possible PJI between November 2020 and December 2022. Intraoperatively, synovial fluid calprotectin was measured with LFI. Cases with calprotectin levels ≥ 50 mg/l were considered infected and treated with two-stage revision THA; in negative cases, one-stage revision was performed. At least five tissue cultures were obtained; the implants removed were sent for sonication. Results. Calprotectin was positive (≥ 50 mg/l) in 27 cases; out of these, 25 had positive tissue cultures and/or sonication. Calprotectin was negative in 21 cases. There was one false negative case, which had positive tissue cultures. Calprotectin showed an area under the curve of 0.917, sensitivity of 96.2%, specificity of 90.9%, positive predictive value of 92.6%, negative predictive value of 95.2%, positive likelihood ratio of 10.6, and negative likelihood ratio of 0.04. Overall, 45/48 patients were correctly diagnosed and treated by our algorithm, which included intraoperative calprotectin measurement. This yielded a 93.8% concordance with postoperatively assessed EBJIS criteria. Conclusion. Calprotectin can be a valuable tool in facilitating the intraoperative decision-making process for cases in which chronic PJI is suspected and diagnosis cannot be established preoperatively. Cite this article: Bone Joint J 2024;106-B(5 Supple B):118–124

Aims. The success rates of two-stage revision arthroplasty for infection have evolved since their early description. The implementation of internationally accepted outcome criteria led to the readjustment of such rates. However, patients who do not undergo reimplantation are usually set aside from these calculations. The aim of this study was to investigate the outcomes of two-stage revision arthroplasty when considering those who do not undergo reimplantation, and to investigate the characteristics of this subgroup. Methods. A retrospective cohort study was conducted. Patients with chronic hip or knee periprosthetic joint infection (PJI) treated with two-stage revision between January 2010 and October 2018, with a minimum follow-up of one year, were included. Variables including demography, morbidity, microbiology, and outcome were collected. The primary endpoint was the eradication of infection. Patients who did not undergo reimplantation were analyzed in order to characterize this subgroup better. Results. A total of 162 chronic PJIs were included in the study. After a mean follow-up of 57.3 months (12.1 to 115.7), 18 patients (11.1%) did not undergo reimplantation, due either to medical issues (10), the patient’s choice (4), or death (4). When only considering those who underwent reimplantation, the success rate was 80.6%. However, when those who did not undergo reimplantation were included, the success rate dropped to 71.6%. Advanced age, American Society of Anesthesiologists grade ≥ III, McPherson’s C host, and Gram-negative related PJI were independent risk factors for retention of the spacer. The mortality was higher in the non-reimplanted group. Conclusion. The real success rate of two-stage revision may not be as high as previously reported. The exclusion of patients who do not undergo reimplantation resulted in a 9% overestimation of the success rate in this series. Many comorbidity-related risk factors for retention of the spacer were identified, as well as higher death rates in this group. Efforts should be made to optimize these patients medically in order to increase reimplantation and success rates, while decreasing mortality. Cite this article: Bone Joint J 2020;102-B(12):1682–1688

There is a paucity of long-term data on modular fluted tapered (MFT) stems for two-stage reimplantation following periprosthetic joint infection (PJI). The purpose of this study was to evaluate implant survivorship, radiographic results, and clinical outcomes in a large cohort of reimplantation THAs using MFT stems. We identified 236 reimplantation THAs from a single tertiary care academic institution from 2000 to 2020. Two designs of MFT stems were used as part of an established two-stage exchange protocol for the treatment of PJI. Mean age at reimplantation was 65 years, mean BMI was 32 kg/m. 2. , and 46% were female. Median stem diameter was 19 mm, and median stem length was 195 mm. Mean follow-up was 7 years. A competing risk model accounting for death was utilized. The 15-year cumulative incidence of any revision was 24%. There were 48 revisions, with the most common reasons being dislocation (n=25) and PJI (n=16). The 15-year cumulative incidence of any reoperation was 28%. Only 13 revisions involved the fluted tapered portion of the component (FTC), for a 15-year cumulative incidence of any FTC revision of 8%. Only 2 FTCs were revised for aseptic loosening, resulting in a 15-year cumulative incidence of FTC revision for aseptic loosening of 1%. Stem subsidence >5 mm occurred in 2% of unrevised cases, and all stems were radiographically stable at most recent follow-up. Mean HHS was 77 at most recent follow-up. This series demonstrated that MFT stems were durable and reliable even in the setting of two-stage reimplantation for infection. While the incidence of aseptic loosening was very low, the incidence of any revision was 24% at 15 years, primarily caused by dislocation and recurrent PJI. Level of Evidence: IV

Aims. Arthrodesis is rarely used as a salvage procedure for patients with a chronically infected total knee arthroplasty (TKA), and little information is available about the outcome. The aim of this study was to assess the reliability, durability, and safety of this procedure as the definitive treatment for complex, chronically infected TKA, in a current series of patients. Methods. We retrospectively identified 41 patients (41 TKAs) with a complex infected TKA, who were treated between 2002 and 2016 using a deliberate, two-stage knee arthrodesis. Their mean age was 64 years (34 to 88) and their mean body mass index (BMI) was 39 kg/m. 2. (25 to 79). The mean follow-up was four years (2 to 9). The extensor mechanism (EM) was deficient in 27 patients (66%) and flap cover was required in 14 (34%). Most patients were host grade B (56%) or C (29%), and limb grade 3 (71%), according to the classification of McPherson et al. A total of 12 patients (29%) had polymicrobial infections and 20 (49%) had multi-drug resistant organisms; fixation involved an intramedullary nail in 25 (61%), an external fixator in ten (24%), and dual plates in six (15%). Results. Survivorship free from amputation, persistent infection, and reoperation, other than removal of an external fixator, at five years was 95% (95% confidence interval (CI) 89% to 100%), 85% (95% CI 75% to 95%), and 64% (95% CI 46% to 82%), respectively. Reoperation, other than removal of an external fixator, occurred in 13 patients (32%). After the initial treatment, radiological nonunion developed in ten knees (24%). Nonunion was significantly correlated with persistent infection (p = 0.006) and external fixation (p = 0.005). Of those patients who achieved limb salvage, 34 (87%) remained mobile and 31 (79%) had ‘absent’ or ‘minimal’ pain ratings. Conclusion. Knee arthrodesis using a two-stage protocol achieved a survivorship free from amputation for persistent infection of 95% at five years with 87% of patients were mobile at final follow-up. However, early reoperation was common (32%). This is not surprising as this series included worst-case infected TKAs in which two-thirds of the patients had a disrupted EM, one-third required flap cover, and most had polymicrobial or multi-drug resistant organisms. Cite this article: Bone Joint J 2020;102-B(6 Supple A):170–175

Aims. Whether a combined anteroposterior fusion or a posterior-only fusion is more effective in the management of patients with Scheuermann’s kyphosis remains controversial. The aim of this study was to compare the radiological and clinical outcomes of these surgical approaches, and to evaluate the postoperative complications with the hypothesis that proximal junctional kyphosis would be more common in one-stage posterior-only fusion. Methods. A retrospective review of patients treated surgically for Scheuermann’s kyphosis between 2006 and 2014 was performed. A total of 62 patients were identified, with 31 in each group. Parameters were compared to evaluate postoperative outcomes using chi-squared tests, independent-samples t-tests, and z-tests of proportions analyses where applicable. Results. There were six postoperative infections in the two-stage anteroposterior group compared with three in the one-stage posterior-only group. A total of four patients in the anteroposterior group required revision surgery, compared with six in the posterior-only group. There was a significantly higher incidence of junctional failure associated with the one-stage posterior-only approach (12.9% vs 0%, p = 0.036). Proximal junction kyphosis (anteroposterior fusion (74.2%) vs posterior-only fusion (77.4%); p = 0.382) and distal junctional kyphosis (anteroposterior fusion (25.8%) vs posterior-only fusion (19.3%), p = 0.271) are common postoperative complications following both surgical approaches. Conclusion. A two-stage anteroposterior fusion was associated with a significantly greater correction of the kyphosis compared with a one-stage posterior-only fusion, with a reduced incidence of junctional failure (0 vs 3). There was a notably greater incidence of infection with two-stage anteroposterior fusion; however, all were medically managed. More patients in the posterior-only group required revision surgery. Cite this article: Bone Joint J 2020;102-B(10):1368–1374

The relative advantages and disadvantages of two-stage versus one-stage management of infected total hip arthroplasties are the current subject of intense debate. To understand the merits of each approach detailed information on the short and, importantly, longer-term outcomes of each must be known. The purpose of this study was to assess the long-term results of two-stage exchange arthroplasty for THAs in one of the largest series to date. We identified 331 infected THAs treated with a two-stage exchange arthroplasty between 1993 and 2021 at a single institution. Patients were excluded if they had prior treatment for infection. Mean age at reimplantation was 66 years, 38% were female, and mean BMI was 30 kg/m. 2. PJI diagnosis was based on the 2011 MSIS criteria. A competing risk model accounting for death was utilized. Mean follow up was 8 years. The cumulative incidence of reinfection was 7% at 1 year and 11% at 5 and 10 years. Factors predictive of reinfection included BMI>30 kg/m. 2. (HR 2; p=0.049), and need for a spacer exchange (HR 3.2; p=0.006). The cumulative incidence of any revision was 13% at 5 and 10 years. The cumulative incidence of aseptic revision was 3% at 1 year, 7% at 5 years, and 8% at 10 years. Dislocation occurred in 33 hips (11% at 10 years; 45% required revision). Factors predictive of dislocation were female sex (HR 2; p=0.047) and BMI<30 kg/m. 2. (HR 3; p=0.02). The mean HHS improved from 54 to 75 at 10 years. In this series of 331 two-stage exchange arthroplasties performed for infected hips, we found a low aseptic revision rate (8%) and a low rate of reinfection (11%) at 10 years. These long-term mechanical and infection data must be kept in mind when considering a paradigm shift to one-stage exchanges. Level of Evidence: Level III

Aim. Two-stage replacement is a frequent procedure in patients with chronic PJI. However, results in the literature after this procedure differ, ranging from 54% to 100% of infection eradication. Positive cultures at reimplantation, when performing the second stage, are perceived as a risk factor for reinfection. This study aims to determine the impact of positive cultures during the second stage on the outcome of patients undergoing a 2-stage septic replacement and the impact of antibiotic holidays between the first and the second stage. Method. We systematically searched four databases from inception to May 31, 2022. We combined terms related to PJI, joint replacement and culture results. We analysed the risk of failure when positive cultures at second stage and performed a subgroup analysis by antibiotic holiday period. Results. We included 24 studies with 2387 patients of which 432 had positive cultures during second stage (18.09%). Global failure rate was 18.01% (430 patients). When dividing failure by culture results during second stage, we found that failure in positive group was 37.01% (161/432 patients) and failure in negative group was 13.7% (269/1953 patients). In the meta-analysis (MA) the odds ratio (OR) was 4.047 (95% CI: 2.954–5.544). When performing the subgroup analysis by antibiotic holidays we found that the rate of positive cultures without and with holidays was 21.3% and 16.05%, respectively. Failure rate without holidays was 15% (90/600 patients) and with holidays was 17.3% (202/1165 patients) (p=0.21). Failure in each group was higher when cultures were positive (without holidays, 25% vs 12.2%, p=0.0003, and with holidays 41.1% vs 12.7%, p<0.0001). In the MA we found that those studies in which antibiotic holiday was reported had higher risk of failure when cultures were positive during second stage (OR 4.798 95%IC 3.142–7.325). When studies reported no antibiotic holidays also had a higher risk of failure when cultures where positive (OR 2.225 95%CI 1.103–4.489), though it was lower. Conclusions. There exists a higher risk of failure after a two-stage septic replacement when cultures are positive during reimplantation. Patients who followed no antibiotic holidays or antibiotic holidays before reimplantation have similar failure rate when cultures are negative. In both groups they have a higher risk of failure when cultures are positive, having higher risk those positive patients in the antibiotic holidays group. Therefore, importance in detecting these patients before reimplantation is crucial to ensure higher survival rates

Aim. To improve the challenging treatment of periprosthetic joint infections (PJI), researchers are constantly developing new handling methods and strategies. In patients with PJI after total knee arthroplasty (TKA) and severe local or systemic comorbidities, a two-stage exchange using a temporary antibiotic loaded PMMA-spacer is considered gold standard. This method has undisputed advantages, however, the increased risk of biofilm formation on the spacer surface, bone defects and soft tissue contractions after a six-week spacer interval are severe limitations. Our hypothesis is that a vacuum sealed foam in combination with constant instillation of an antiseptic fluid can address these drawbacks due to a significantly reduced spacer interval. Method. A pilot study was conducted in five PJI cases after TKA with severe comorbidities and/or multiple previous operations to evaluate the feasibility and safety of the proposed method. In the first step, surgical treatment included the explantation of the prosthesis, debridement, and the implantation of the VeraFlo-Dressing foam. The foam is connected to the VAC-Instill-Device via an inflow and an outflow tube. The surgical site is sealed airtight with the VAC-film. During the next 5 days, an antiseptic fluid (Lavasorb® or Taurolidine®) is instilled in a 30-minute interval using the VAC-Instill-Device. The limb is immobilized (no flexion in the knee joint, no weight bearing) for five days. Following that, the second operation is performed in which the VAC-VeraFlo. TM. -Therapy System is explanted and the revision TKA is implanted after debridement of the joint. Results. No serious adverse event occurred during the VAC-Instill spacer treatment. The TKA revision was performed after a mean of 5.4 ± 1.9 days. Mean patient age was 71±6 years with a mean of 6 previous PJI surgeries. Host classification according to McPherson was I/B/3, III/B/3 and III/C/3 in three cases. Out of the five cases included, four were successfully treated and remained infect free to date (mean 14.2 ± 12 months; germs: methicillin-resistant s. aureus, e. coli, staph. lugdunensis and one culture neg.). One case with candida infection of a total femur prosthesis had to be treated with an enucleation of the hip due to rising inflammation parameters and signs of sepsis 7 days after VAC-Instill implantation. Conclusions. The presented data on the VAC-Instill spacer method in septic two-stage revision TKA show promising results regarding feasibility and safety. A prospective randomized controlled examination is in progress to evaluate the possible advantages over a two-stage approach using a standard PMMA spacer

Aims. Periprosthetic joint infection (PJI) remains a challenging complication following total hip arthroplasty (THA). It is associated with high levels of morbidity, mortality and expense. Guidelines and protocols exist for the management of culture-positive patients. Managing culture-negative patients with a PJI poses a greater challenge to surgeons and the wider multidisciplinary team as clear guidance is lacking. Patients and Methods. We aimed to compare the outcomes of treatment for 50 consecutive culture-negative and 50 consecutive culture-positive patients who underwent two-stage revision THA for chronic infection with a minimum follow-up of five years. Results. There was no significant difference in the outcomes between the two groups of patients, with a similar rate of re-infection of 6%, five years post-operatively. Culture-negative PJIs were associated with older age, smoking, referral from elsewhere and pre-operative antibiotic treatment. The samples in the culture-negative patients were negative before the first stage (aspiration), during the first-stage (implant removal) and second-stage procedures (re-implantation). Conclusion. Adherence to strict protocols for selecting and treating culture-negative patients with a PJI using the same two-stage revision approach that we employ for complex culture-positive PJIs is important in order to achieve control of the infection in this difficult group of patients. Cite this article: Bone Joint J 2018;(1 Supple A)100-B:3–8

Aims. To explore the clinical efficacy of using two different types of articulating spacers in two-stage revision for chronic knee periprosthetic joint infection (kPJI). Methods. A retrospective cohort study of 50 chronic kPJI patients treated with two types of articulating spacers between January 2014 and March 2022 was conducted. The clinical outcomes and functional status of the different articulating spacers were compared. Overall, 17 patients were treated with prosthetic spacers (prosthetic group (PG)), and 33 patients were treated with cement spacers (cement group (CG)). The CG had a longer mean follow-up period (46.67 months (SD 26.61)) than the PG (24.82 months (SD 16.46); p = 0.001). Results. Infection was eradicated in 45 patients overall (90%). The PG had a better knee range of motion (ROM) and Knee Society Score (KSS) after the first-stage revision (p = 0.004; p = 0.002), while both groups had similar ROMs and KSSs at the last follow-up (p = 0.136; p = 0.895). The KSS in the CG was significantly better at the last follow-up (p = 0.013), while a larger percentage (10 in 17, 58.82%) of patients in the PG chose to retain the spacer (p = 0.008). Conclusion. Prosthetic spacers and cement spacers are both effective at treating chronic kPJI because they encourage infection control, and the former improved knee function status between stages. For some patients, prosthetic spacers may not require reimplantation. Cite this article: Bone Joint Res 2024;13(6):306–314

Two-stage exchange revision total hip arthroplasty performed in case of infection has been considered during many years the gold standard for treatment of chronic infection. Nevertheless, during the last decade, concerns have risen regarding its safety and its efficiency. The purpose of our study was to, first investigate the spacer complications, then to analyze their risks factors. We retrospectively included 125 patients with chronic hip periprosthetic joint infection who underwent a two stage exchange revision arthroplasty performed between January 2013 and December 2019. All spacer complications were systematically collected and risk factors were analyzed. Statistical evaluation were performed using the Student and Mann-Whitney tests. Our study confirms the hypothesis of a high-risk strategy with 42% of patients who had a mechanical spacer failure and a 20% recurrence of infection during the average two years period of follow-up. We found a high rate of spacer migration (23%) and a low rate of spacer fracture (8%) compared to literature. The most important finding was that the majority of spacer complications and failures were found in a population with high medical comorbidities as highlighted by the ASA, Charlson and Lee score associations, as well as with the cardiac, pulmonary, kidney or hepatic chronic conditions. This study showed that a two-stage hip exchange revision is a high-risk procedure regarding complications and mechanical failures of PMMA spacers. In patients with high medical comorbidities, other strategies may be considered and interdisciplinary cooperation with other facilities are needed to identify and control each risk factor

We retrospectively studied the major complications occurring after one- and two-stage bilateral unicompartmental knee replacements (UKR). Between 1999 and 2008, 911 patients underwent 1150 UKRs through a minimally invasive approach in our unit. Of these, 159 patients (318 UKRs) had one-stage and 80 patients (160 UKRs) had two-stage bilateral UKRs. The bilateral UKR groups were comparable in age and American Society of Anaesthesiology grade, but more women were in the two-stage group (p = 0.019). Mechanical thromboprophylaxis was used in all cases. Major complications were recorded as death, pulmonary embolus, proximal deep-vein thrombosis and adverse cardiac events within 30 days of surgery. No statistical differences between the groups were found regarding the operating surgeon, the tourniquet time or minor complications except for distal deep-vein thrombosis. The anaesthetic times were longer for the two-stage group (p = 0.0001). Major complications were seen in 13 patients (8.2%) with one-stage operations but none were encountered in the two-stage group (p = 0.005). Distal deep-vein thrombosis was more frequent in the two-stage group (p = 0.036). Because of the significantly higher risk of major complications associated with one-stage bilateral UKR we advocate caution before undertaking such a procedure

The increasing infection burden after hip arthroplasty has seen a growth of two-stage exchange and the use of increasingly powerful antibiotics at the time of this procedure. We have seen an increased number of failed two-stage revisions over the past decade. This study was aimed at clarifying the outcome of failed two-stage exchange arthroplasty after periprosthetic hip infection. We identified forty-two patients who had undergone at least one prior two-stage revision hip arthroplasty for periprosthetic infection between 2000 and 2012. These patients were referred to our center and treated with a further two-stage exchange. They have been analyzed with a minimum two-year follow-up. Control of infection at two-year follow-up was seen in 57% of patients. In 43% of patients there are still ongoing issues that either required further surgery or ongoing antibiotic suppression. A regression analysis was undertaken which suggested that the immunocompromised host and polymicrobial infection were the greatest predictors of failure. The number of previous interventions, the organism involved and the duration of antibiotic therapy after the initial two-stage revision were not linked to the ultimate outcome. The failure rate of repeat revision two-stage exchange is high and novel methods of treatment including host optimization, immunomodulation, longer interval periods, novel antimicrobial methods and more powerful antibiotic therapies should be investigated

We compared the safety and outcome of one-stage bilateral total hip arthroplasty with those of a two-stage procedure during different admissions in a prospective, randomised controlled trial in an Asian population. Of 168 patients included in the study, 83 had a single- and 85 a two-stage procedure. Most of the patients (59.9%) suffered from inflammatory arthritis. The intra-operative complications, early systemic complications, the operating time, positioning of the components, the functional score, restoration of limb length and survival rates at 96 months were similar in the two groups. The total estimated blood loss was significantly lower in patients undergoing a one-stage procedure than in patients who had a two-stage procedure, but the transfusion requirements were significantly higher in the former group (p = 0.001). The hospital stay was significantly shorter in the one-stage group, 7.25 days (. sd. 1.30; 5 to 20) compared with 10 days (. sd. 1.65; 8 to 24) in the two-stage group (p = 0.023). We believe that a one-stage procedure is safe and appropriate in our population

Deep peri-prosthetic infection after partial or total knee arthroplasty is a disconcerting problem for patient and surgeon alike. The diagnosis of infection is sometimes obvious but frequently requires that the surgeon maintain a substantial index of suspicion for infection as the cause of pain or poor outcome after any joint arthroplasty. While surgical debridement with component retention is appropriate in a subgroup of patients with an acute peri-prosthetic infection, most delayed and chronic infections are best treated with component resection. With carefully selected patients and very aggressive debridement protocols some success has been demonstrated in Europe with single-stage exchange for infection. Most surgeons in North America, however, are unfamiliar with the very aggressive debridement techniques employed at European centers that promote single stage replant; and few surgeons in North America are currently comfortable in cementing a hinged total knee replacement in place for the typical infected TKA nor do they have the patience to re-prep and drape with an entirely new OR setup after debridement and prior to the insertion of the new implant − 2 steps that are often mentioned as important to the success of single stage exchange. The pre-eminent role of two-stage exchange as the definitive treatment was established over 30 years ago. Two-stage exchange remains the gold-standard in treatment with an established track record from multiple centers and with multiple different types of infecting organisms. Some of the historical problems with two-stage exchange, such as limited mobility during the interval stage, have been mitigated with the development of effective articulating spacer techniques. Further, the emergence of drug resistant bacteria and the possibility of fungal infection make two-stage exchange the best choice for the majority of patients with deep periprosthetic joint infection in 2017

Patients considered suitable for total hip resurfacing arthroplasty often have bilateral disease. The peri-operative complications, transfusion requirements, hospital stay, outcome and costs in patients undergoing one-stage bilateral total hip resurfacing were compared with a group of patients undergoing a two-stage procedure. A total of 92 patients were included in the study, of which 37 (40%) had a one-stage and 55 (60%) had a two-stage resurfacing. There were no significant differences in age, gender, or American Society of Anaesthesiologists grade between the groups (p = 0.31, p = 0.23, p = 0.13, respectively). There were three systemic complications in the one-stage group (8.1%) and one in the two-stage group (1.8% of patients; 0.9% of procedures). There was no significant difference in the complication rate (p = 0.72) or the transfusion requirements (p = 0.32) between the two groups. The one-stage group had a reduced total hospital stay of five days (95% confidence interval 4.0 to 6.9; p < 0.001), reduced length of time to completion of all surgery of five months (95% confidence interval 2.6 to 8.3; p < 0.001), and the reduced cost was 35% less than that of a two-stage procedure. However, the total anaesthetic time was significantly longer for the one-stage group (p < 0.001; 95% confidence interval 31 to 52). This study demonstrates that consideration should be given to one-stage surgery for patients with bilateral symptomatic disease suitable for metal-on-metal hip resurfacing. A one-stage procedure appears to have benefits for both the patient and the hospital without additional complications

Introduction. Debridement, antibiotics, and implant retention (DAIR) for acute prosthetic hip infection is a popular low morbidity option despite less than optimal success rates. We theorized that the delay between DAIR and explantation in failed cases may complicate eradication due to biofilm maturation and entrenchment of bacteria in periprosthetic bone. We ask, what are the results of two-stage reimplantation after a failed DAIR versus an initial two-stage procedure?. Methods. 114 patients were treated with 2-stage exchange for periprosthetic hip infection. 65 were treated initially with a 2-stage exchange, while 49 underwent an antecedent DAIR prior to a 2-stage exchange. Patients were classified according to MSIS host criteria. Failure was defined as return to the OR for infection, a draining sinus, or systemic infection. Results. Treatment failure occurred in 42.9% (21 of 49) of patients treated with an antecedent DAIR. In contrast, treatment failure occurred in only 12.3% (8 of 65) of initial 2-stage procedures (p< 0.001). Relative Risk of return to the OR after a 2-stage reimplantation with an antecedent DAIR compared to initial resection was 4.52 (95% CI 1.71, 11.9). MSIS host grading was similar between groups and did not influence the rate of failure. The DAIR cohort had increased hospitalization length and greater number of operative procedures (p< 0.001). Conclusion. We have shown that if irrigation and debridement fails to treat acute prosthetic hip infection, subsequent attempts at two-stage reimplantation may be compromised. Additionally, in the antecedent DAIR group, the average number of infection-related procedures (5) was nearly twice that of those initially resected (2.7). This by nature implies a significantly greater burden to the patient and cost to the healthcare system

Introduction. Despite several studies, controversies prevailed about the rate of complications following one-stage and two-stage bilateral total hip arthroplasty (THA). In current prospective study, we compared the complications and functional outcomes of one-stage and two-stage procedures. Methods. One hundred and eighty patients (ASA class I or II) with bilateral hip osteoarthritis were assigned randomly to two equal groups. Two groups were matched in term of age and sex. All of the surgeries were performed through the Harding approach using uncemented implants. In two-stage procedures, surgeries were performed with 6 months to one year interval. All patients were evaluated one year postoperatively. Results. The Harris hip score averaged 84.1±12.6 and 82.6±15.3 in one-stage and two-stage groups, respectively (p=0.528). The hospital stay was significantly longer in two-stage group (9.8±1.1 versus 4.9±0.8 days). The cumulative hemoglobin drop and number of transfused blood units were the same. One patient in each group developed symptomatic deep venous thrombosis and managed successfully. There was no patient with perioperative death, pulmonary embolism, infection, dislocation, periprosthetic fracture or heterotrophic ossification. No patient required reoperation. Two patients in one-stage group developed unilateral temporary peroneal nerve palsy resolved after 3 and 4 months. Conclusion. The current study showed that one-stage bilateral THA can be used successfully for patients who require bilateral hip arthroplasty without increased rate of complications. The functional and clinical outcomes are comparable and hospital stay is significantly shorter. However, the authors recommend to perform one-stage bilateral THA for healthy patients with ASA class I or II

Aim. Due to medical and organizational factors, it occurs in everyday practice that spacers are left in place longer than originally planned during a two-stage prosthesis exchange in the case of prosthetic joint infections. Patients are severely restricted in their mobility and, after initial antibiotic administration, the spacer itself only acts as a foreign body. The aim of this study is to analyze whether the duration of the spacer in situ has an influence on the long-term success of treatment and mortality. Method. We retrospectively studied all 204 two-stage prosthesis replacements of the hip and knee from 2012 to 2016 with a minimum follow-up of two years at an arthroplasty center with 3 main surgeons. The duration of the spacer interval was divided into two groups. Patients replanted within ten weeks (as is standard in multiple algorithms) after systemic antibiotic treatment were assigned to the ‘Regular Spacer Interval (< 70 days)’ group. If the spacer interval was longer, they were assigned to the ‘Long Spacer Interval (≥ 70 days)’ group. Results. Patients were on average 67.69 years old (SD 12.3). The mean duration of the spacer-interval was 100.9 days (range: 423.0; SD, 60.0). In 62 patients reimplantation could be performed within 70 days after explantation, in 142 patients this took longer (max. 438 days). In 26 patients, the spacer had to be changed at least once during this period (11 patients in the hip group, and 15 patients in the knee group). In the remaining cases, other medical or organizational reasons delayed replantation. Both groups were comparable concerning Charlson Comorbity Index, age, number of previous surgeries and laboratory infection markers. There was no statistically significant influence of the duration of the spacer interval on the infection free survival (n=204, p=0.32). There was also no influence on mortality (n=204, p=0.35) and aseptic implant failure (n=204, p=0.15). Conclusions. The timely replantation of a knee or hip prosthesis seems to be reasonable in general because the patients are strongly limited in their mobility and daily activities by the spacer. However, there does not seem to be a negative influence on infection eradication and survival due to a long spacer interval

Aim. Periprosthetic joint infections (PJI) are a severe complications after hip arthroplasty. The infections rate ranges from 0.7 to 1.3 depending on different reports. The aim of the present study is to evaluate the radiological and clinical outcome of patients that underwent two-stage revision for the treatment of periprosthetic joint infection of the hip when an extended trochanteric osteotomy (ETO) was necessary to remove the femoral stem. Methods. We retrospectively analyzed data from 84 patients that underwent two-stage revision of the hip between January 2006 and December 2010 at our institution. In forty-nine patients (Group A, 58.3%), the femoral stem was removed without an ETO, while in the remaining thirty-five patients (Group B, 41.7%) an ETO was necessary. In each case a metallic cerclage was used to closure of the flap. The average age for patients in group A was 64.3 years, while the average age in patients in group B was 66.4 years. The mean follow-up was respectively 117 months in group A and 122 months in group B. Eight patients died before the last follow-up, and data from six patients were incomplete. Complications, radiological and clinical outcome were. Mann Whitney U Test and Chi Square Test were used respectively to analyze continues and categorical variables. Cumulative survival of the implants was calculated for reinfection and mechanical complications with Kaplan-Meyer curves. Results. The mean follow-up was 118 months. The cumulative incidence of reinfection was 4.7% at 1 years and 10.7 at last follow-up. No statistically significant (p-value > 0.05) differences were observed in the two groups neither at 1 year nor at last follow up. The cumulative incidence of mechanical complication was 3.6% at 1 year and 8.3% at last follow-up. No statistically significant differences (p-value > 0.05) were observed in the two groups neither at 1 year nor at last follow up. All the patients had the healing of the ETO at six months (mean 11.4 weeks). The mean Harris Hip Score was 77.5. No statistically significant (p-value > 0.05) differences were observed in the two groups. Discussion. The results obtained in this retrospective study demonstrates that there is no difference in terms of reinfection-rate, mechanical complications and clinical outcome in patients that underwent two-stage revision with or without an ETO. In presence of a well-fixed femoral stem, performing an ETO could be helpful to expose the femoral canal facilitating the femoral stem's removal avoiding intra-operative femoral fracture

Background. The two-stage revision strategy has been claimed as being the “gold standard” for treating prosthetic joint infection. The one-stage revision strategy remains an attractive alternative option, however, its effectiveness in comparison to the two-stage strategy remains uncertain. A systematic review and meta-analysis was conducted to compare the effectiveness of one- and two-stage revision strategies to prevent re-infection after prosthetic hip infection. Methods. Cohort studies (prospective or retrospective) conducted in unselected patients with infection treated exclusively by one- or two-stage revision and reporting re-infection outcomes within two years of revision were retrieved from MEDLINE, EMBASE, Web of Science, Cochrane databases, manual search of bibliographies to March 2015, and email contact with investigators. Data were extracted by two independent investigators and a consensus was reached with involvement of a third. Rates of re-infection were aggregated using random-effect models after arcsine transformation, and were grouped by study and population level characteristics. Results. In 38 one-stage studies, the rate (95% confidence intervals) of re-infection was 8.2% (6.0–10.8). The corresponding re-infection rate for 60 two-stage studies was 7.9% (6.2–9.7). Re-infection rates remained generally similar when grouped by several study and population level characteristics. There was no evidence of publication bias among contributing studies. Conclusion. Among unselected populations, evidence from aggregate published data suggest similar re-infection rates after one- or two-stage revision. More detailed analyses under a broader range of circumstances and exploration of other sources of heterogeneity will require collaborative pooling of individual participant data, which is ongoing within our Global Infection Orthopaedic Management (INFORM) collaboration. Level of evidence. Level 2a - Systematic reviews of cohort studies. Funding statement. This abstract presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (grant number: RP-PG-1210-12005). The views expressed in this abstract are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health

While frequently discussed as a standard treatment for the management of an infected shoulder replacement, there is little information on the outcome of two-stage re-implantation. We examined the outcome of 17 consecutive patients (19 shoulders) who were treated between 1995 and 2004 with a two-stage re-implantation for the treatment of a deep-infection after shoulder replacement. All 19 shoulders were followed for a minimum of two years or until the time of further revision surgery. The mean clinical follow-up was for 35 months (24 to 80). The mean radiological follow-up was 27 months (7 to 80). There were two excellent results, four satisfactory and 13 unsatisfactory. In 12 of the 19 shoulders (63%) infection was considered to be eradicated. The mean pain score improved from 4.2 (3 to 5 (out of 5)) to 1.8 (1 to 4). The mean elevation improved from 42° (0° to 140°) to 89° (0° to 165°), mean external rotation from 30° (0° to 90°) to 43° (0° to 90°), and mean internal rotation from the sacrum to L5. There were 14 complications. Our study suggests that two-stage re-implantation for an infected shoulder replacement is associated with a high rate of unsatisfactory results, marginal success at eradicating infection and a high complication rate

Abstract. Introduction. The prevalence of recurrent infection following two-stage exchange arthroplasty following failure of a total knee arthroplasty (TKA) has been reported to be 10% to 25%. There is limited literature available on repeat two stage revisions for TKA infection with only small cohorts and variable success rates. Methodology. A retrospective cohort study investigating the outcome of two stage revision arthroplasty for treatment of TKA infection was conducted with the aim of identifying factors linked to recurrence of infection. A consecutive cohort of all microbiology intra-operative periprosthetic knee samples from a single revision arthroplasty centre between January 2010 and December 2016 was identified. The final cohort consisted of 658 samples taken during 64 patients undergoing two stage revision knee surgery for infection. Patient demographics, medical and orthopaedic history data including post-operative outcomes and subsequent treatment was obtained from the electronic records system and medical notes. Results. 65.6% of the cohort (N=42) had successful eradication of their infection. For the twenty-two patients that had failure of their two stage revision, twenty patients had samples available from further surgical intervention. Sixteen patients (80%) had different organisms isolated when they had repeat surgical samples taken when compared to their first stage samples. Overall, for subsequent treatments there was a success rate of 75% if the same organism was identified and 62.5% if there were new isolated organisms. Conclusion. These findings may have implications for the treatment strategies chosen for re-infection after two stage TKA revisions if new causative organisms are isolated

Introduction. Two-stage reimplantation for prosthetic joint infection (PJI) of the hip is the standard of care with a 5–10% recurrence at a minimum two-year follow-up. Compiling outcomes data for this standard of care is necessary in order to characterize long-term reinfection risk and the culpable microbiology. The purpose of this study was to determine the long-term success of two-stage reimplantation and identify the factors that affected the success. Methods. We performed a systematic review of randomized control trials, cohort studies, and case series through May 2019, searching Embase, Medline via PubMed, and Cochrane Library for the concept of two-stage reimplantation for the treatment of hip and knee PJIs, yielding 464 unique citations for abstract review, of which 135 were reviewed in full. Our parameters of interest included: reinfection and mortality events following successful reimplantation, the timing of these events, and the microbiology of index and recurrent infections. Results. Meeting our criteria were 59 studies with 4,494 patients (1,842 hips) who had completed reimplantation. Among successfully reimplanted hips, 4.76% (95% CI, 2.00–8.41) were reinfected by 24 months, 6.84% (4.92–9.02) were reinfected by final follow-up, 1.6% (0.32–3.52) were reinfected with an identical organism(s) with identical resistance, and 2.55% (0.77–5.03) were reinfected with a novel organism(s) or novel resistance. In 24 studies with reinfected patients and sufficient data, 8 studies reported an average interval from reimplantation to reinfection greater than 24 months, and 14 reported at least 1 patient with a reinfection event greater than 48 months following reimplantation. Conclusion. The results from this review determined that the host of an index PJI faces ongoing risk of recurrent infection years into the post-operative period despite initial eradication and that novel microbiology is the cause of a significant proportion of failures. For any tables or figures, please contact the authors directly

Patients with knee prosthetic joint infection (PJI) frequently receive one- or two-stage revision. To explore the feasibility of a randomised controlled trial (RCT) comparing methods, we analysed a UK registry, interviewed patients and surgeons, systematically reviewed literature, held a consensus meeting, and assessed progress of an RCT in hip PJI. In 2014, in England and Wales, knee PJI was treated with one- or two-stage procedures in 19% and 71% of patients respectively. Between 2007 and 2014, use of one-stage procedures doubled and, in major centres, up to 42% of treatments were one-stage. We conducted in-depth interviews with 16 patients with knee PJI and 11 surgeons performing one- or two-stage revision. Patients considered randomisation acceptable with appropriate counselling and, depending on infecting organisms and health status, surgeons would randomise treatments. In meta-analysis, two-year re-infection rates in 10 one-stage series (423 patients) and 108 two-stage series (5,129 patients) were 7.6% (95%CI 3.4,13.1) and 8.8% (7.2,10.6) respectively. In a series of patients with knee PJI, surgeons from 2 major centres considered 6/15 patients eligible for either treatment, with 4 more potentially eligible after treatment of soft tissue infection. In an ongoing RCT of surgical treatment of hip PJI, 116 patients have been randomised at 14 centres in 3 years. Randomising patients with PJI is feasible but, as knee PJI is uncommon, a multicentre RCT would be required. Based on WOMAC score outcome and appropriate assumptions on eligibility and acceptability, 170 patients would need to be randomised over 4 years at 14 major centres