Does performing a one- or two-stage revision for cases of prosthetic surgical site infections impact the recurrence rate of surgical site infections?

Two-stage revision is safer

Both one-stage and two-stage revisions in periprosthetic infections are current concepts which both exhibit clinical results justifying their application. There are actually no substantial and evidence-based data which can reveal the advantage of one of these methods. Usually the treatment is based on personal experience and bias.

One-stage revision, if successful, provides the most advantages for the patient and health economics. The risk of re-infection is higher when the microorganism has not been identified before surgery. Usually one-stage revision is performed using a cemented revision implant with antibiotic-laden cement. The disadvantage in case of a re-infection is the necessity not only to remove the implant, but also the cement which compromises the bone stock.

I carry out a two-stage revision using cementless revision implants after placing an antibiotic-containing spacer for six to eight weeks. During the first procedure, I take a specimen for culture from at least three locations either to confirm results detected by a previous aspiration or to detect other pathogen organisms. Systemic antibiotic treatment is then specified and performed for at least six weeks.

In my experience, the recurrence rate is not determined by the method used, but by the strictness and accuracy of performing the applied concept. The main influencing factor is the individual pathologenicity, which is mainly affected by the pathology of the organisms, the duration and spreading of the infection, the local conditions of the implant bed, including blood perfusion and bone quality, as well as by the comorbidity of the patient. This is the main reason why different concepts described so far cannot be compared. However, the individual approach has to be performed meticulously. In my opinion, two-stage revision is safer in most of the cases unless it is more challenging for both the patient and surgeon.

Georg Köster, MD, is the head of the Department Orthopaedic and Trauma Surgery Clinic for Orthopaedic Surgery Lorsch, Germany and an associate professor at the University of Göttingen, Germany.

Recurrence rates depend more on patient selection

For years, we have followed a strict algorithm to treat prosthetic surgical site infections with our infectiologist partners. The recurrence rate depends more on the careful selection of adequate patients for one- or two-stage revision. There are many different situations of prosthetic joint infections. Therefore, it does not make sense to treat all the same way. In some early infections, you even can try with success to cure the infection with debridement and antibiotics without an exchange.

One-stage revision is feasible, if the following prerequisites are accomplished:

• susceptibility to antimicrobial agents with activity against surface-adhering microorganisms; and
• soft tissues intact or only slightly damaged.

Under these conditions we can expect healing rates of over 90%.

If adequate antibiotics are not available and/or if there is a chronic sinus or in presence of deep abscess formation, we choose a two-stage revision. The interval between removal of the prosthesis and re-implantation varies between 2 and 8 weeks. Two weeks seems adequate in difficult soft tissue situation alone; 8 weeks seems adequate for bacteria that are difficult to treat. If we respect these rules, choosing two-stage revision for cases with difficult situations ends with a comparable healing rate over 90%.

It is natural that defenders of two-stage revision in all cases can produce positive results. On the other hand, patients can also be safely treated with a one-stage procedure if they are carefully selected according to a controlled algorithm. The treatment is then more economic, shorter and more comfortable for the patient.

Peter E. Ochsner, MD, is an orthopaedic surgeon and professor emeritus at the University of Basel in Frenkendorf, Switzerland.