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One-stage exchange may yield better outcomes vs two-stage exchange in TJA
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WAIKOLOA, Hawaii — Despite two-stage exchange being the traditional treatment method in North America for infected total joints, a presenter at Orthopedics Today Hawaii noted that one-stage exchange may be easier for patients and may result in better functional outcomes.
In a review of two-stage exchange, Wayne G. Paprosky, MD, FACS, noted it includes a protocol of radical debridement of all components and use of 3 grams of vancomycin.
“We try to use spacers, either articulating spacers or a static spacer depending on the bone loss, maintain soft-tissue tension and we are able to deliver fairly high doses of antibiotic cement,” Paprosky said in his presentation here.
However, he noted previously published research has shown a cure rate between 80% to 95% for two-stage exchange, as well as 12% of patients requiring interim spacer exchange, 17% never being re-implanted and a mortality rate of 7%.
In comparison, indication for one-stage exchange includes patients who do not need bone grafting, the ability to perform aggressive debridement of all infected tissue, the presence of good soft tissue envelope for closure, absence of difficult to treat microorganisms and bacteria that is sensitive to antibiotic cement, according to Paprosky. He added research has shown a success rate of 95% for one-stage exchange.
“If we go by what is done in Europe, there is a complete re-draping, re-prepping, [one-stage exchange technique is] like two different operations,” Paprosky said. “[There is] massive debridement, and most of these patients get all cemented components in their hips.”
Overall, he noted multicenter analyses, patient selection criteria, surgical technique and antibiotic management to optimize outcomes are needed for one- and two-stage exchange.
“Future studies are currently now involved [at] our institution, as well as these other institutions, trying to determine indications [and] specific selection criteria,” Paprosky said. – by Casey Tingle
Reference:
Paprosky WG. The infected total joint: Two-stage and when not to two-stage. Presented at: Orthopedics Today Hawaii; Jan. 13-17, 2019; Waikoloa, Hawaii.
Disclosure: Paprosky reports he receives royalties from Zimmer and Stryker; is a consultant for Zimmer, Medtronic-Salient, Stryker, Inellijoint and CeramTec; and provided medical education for DePuy.