Systematic review and meta-analysis of single-stage versus two-stage revision for periprosthetic joint infection after knee arthroplasty: a call for a randomised trial

in EFORT Open Reviews
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Chengxin Xie Department of Orthopedics, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China

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Wenjun Pan Department of Orthopedics, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China

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Shouli Wang Department of Orthopedics, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China

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Xueli Yan Department of Orthopedics, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China

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Hua Luo Department of Orthopedics, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China

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Correspondence should be addressed to H Luo; Email: luoh5367@enzemed.com

*(C Xie, W Pan and S Wang contributed equally to this work).

Open access

Purpose

  • Knee arthroplasty is an effective treatment for severe knee degeneration; however, periprosthetic joint infection (PJI) is one of its serious complications. Single- and two-stage revision are common treatments, but few studies have compared single- and two-stage revision for PJI after knee arthroplasty. This study aimed to compare the reinfection and reoperation rates of single- and two-stage revision through meta-analysis.

Methods

  • The review process was conducted according to the PRISMA guidelines. We searched the PubMed, Medline, Embase and Cochrane Central Register of Controlled Trials databases for trials comparing single- and two-stage revision for PJI after knee arthroplasty from the respective inception dates to April 2023. Two researchers individually screened the studies, performed the literature quality evaluation and data extraction and used Stata 17 software for data analysis.

Results

  • The meta-analysis showed that the reinfection rate was significantly lower in the single-stage revision group than in the two-stage revision group. While the reoperation rates demonstrated no statistically significant difference between the two groups. We presented descriptive results because the discrepancies in the knee function scores and data reported in the studies meant that these data could not be combined in the meta-analysis.

Conclusion

  • Based on the available research, single-stage revision is a reliable option for PJI after knee arthroplasty. However, when developing the best treatment strategy, it is still necessary to consider the individual circumstances and needs of the patient, as well as the risks of postoperative rehabilitation and complications.

Abstract

Purpose

  • Knee arthroplasty is an effective treatment for severe knee degeneration; however, periprosthetic joint infection (PJI) is one of its serious complications. Single- and two-stage revision are common treatments, but few studies have compared single- and two-stage revision for PJI after knee arthroplasty. This study aimed to compare the reinfection and reoperation rates of single- and two-stage revision through meta-analysis.

Methods

  • The review process was conducted according to the PRISMA guidelines. We searched the PubMed, Medline, Embase and Cochrane Central Register of Controlled Trials databases for trials comparing single- and two-stage revision for PJI after knee arthroplasty from the respective inception dates to April 2023. Two researchers individually screened the studies, performed the literature quality evaluation and data extraction and used Stata 17 software for data analysis.

Results

  • The meta-analysis showed that the reinfection rate was significantly lower in the single-stage revision group than in the two-stage revision group. While the reoperation rates demonstrated no statistically significant difference between the two groups. We presented descriptive results because the discrepancies in the knee function scores and data reported in the studies meant that these data could not be combined in the meta-analysis.

Conclusion

  • Based on the available research, single-stage revision is a reliable option for PJI after knee arthroplasty. However, when developing the best treatment strategy, it is still necessary to consider the individual circumstances and needs of the patient, as well as the risks of postoperative rehabilitation and complications.

Introduction

Knee arthroplasty is widely used to treat severe knee degeneration and is considered an effective measure that improves the quality of life and restores the mobility of patients (1, 2). However, despite the excellent performance of knee arthroplasty in most patients, postoperative periprosthetic joint infection (PJI) (an infection that occurs in joint replacement) remains concerning as a rare but serious complication (3). PJI is identified if: there is a sinus tract linked to the prosthesis, a pathogen is isolated from two separate joint samples, or four out of six specific criteria are met, including elevated blood markers, increased joint fluid cell counts, presence of joint purulence or positive culture or histologic findings from joint tissue (4). Infection can lead to prosthesis loosening, bone defects and even life-threatening conditions in severe cases (5). With advances in surgical techniques and improvements in surgical conditions, PJI currently occurs in less than 1% of patients with knee arthroplasty (6).

For patients with PJI after knee arthroplasty, it is critical to choose the most appropriate treatment strategy. Two-stage revision surgery was previously considered the gold standard for PJI (2); however, the ideal time interval between surgeries, choice of antimicrobial agent and timing of treatment remain controversial. Furthermore, the recurrence rate of PJI varies widely, and some patients are medically ill and may not tolerate a second surgery. In recent years, the single-stage revision technique has received widespread attention worldwide, and its application is increasing (7, 8). The shortcomings of two-stage revision can be avoided by performing single-stage revision, which is more conducive to the functional recovery of the affected limb, reduces the occurrence of complications, overall cost and surgical trauma, and improves the level of patient satisfaction (9). Blom et al. highlighted that single-stage revision showed cost-effectiveness over an 18-month follow-up period and is increasingly being adopted (10). Additionally, some centres report that single-stage revision has a success rate comparable to two-stage revision (11, 12, 13). However, there is a lack of clear evidence to identify the superior surgical modality between single- and two-stage revision for PJI after knee arthroplasty. Although some small clinical studies have explored this issue, their conclusions are inconsistent and limited by small sample sizes. Therefore, this review aimed to systematically pool and synthesise existing clinical research data by conducting a comprehensive meta-analysis to compare the efficacy of single- and two-stage revision for PJI after knee arthroplasty. Through this comprehensive analysis, we hope to provide more accurate and effective treatment recommendations for medical teams to optimise treatment strategies for patients with PJI after knee replacement, and contribute to the recovery and health improvement of patients.

Materials and methods

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, this meta-analysis was performed in agreement. (14) The protocol for this meta-analysis was registered on PROSPERO (Registration No: CRD 42022384299).

Inclusion criteria

(i) Study type: randomised controlled trial, cohort study or case–control study. (ii) Study population: patients with infected knee arthroplasty. (iii) Intervention and control: single-stage in the treatment group and two-stage in the control group. (iv) Outcome index: reinfection rate, reoperation rate and knee function.

Exclusion criteria

(i) Letters, meetings, case reports, reviews or republished studies; (ii) studies lacking a control group; (iii) patients with septic arthritis or tuberculous arthritis; (iv) patients did not undergo second-stage in the two-stage group.

Outcomes

The primary outcome was the incidence of reinfection. A secondary outcome was the incidence of reoperation and knee function.

Search strategy

Two of the authors performed the search in PubMed, Medline, EMBASE and the Cochrane Central Register of Controlled Trials from the inception dates to April 30, 2023, using the keywords ‘(periprosthetic joint infection or prosthetic joint infection) and (Two-stage or 2-stage or two stage or second-stage or double-stage) and (Single-stage or one-stage or 1-stage) and knee and (unhealed or infection or reoperate* or revise or function or knee score or range of motion)’. No language restrictions were applied during the search.

Study selection

Two researchers screened the retrieved literature strictly and individually against inclusion and exclusion criteria. In cases where two researchers do not agree during the literature screening process, it will be left to the senior researcher.

Data collection process

Data on relevant outcome measures were extracted from the literature that met the inclusion criteria, including author year, country, age, study design, follow-up and outcomes by two researchers individually. If two researchers do not agree during the data collection, it will be left to the senior researcher.

Assessment of risk of bias and quality of evidence

Two researchers independently assessed the quality of all included trials based on Cochrane risk-of-bias criteria (15). The Newcastle–Ottawa scale (NOS) was used to evaluate the literature quality of the retrospective studies (16). We also examined the quality of evidence for outcomes using the grading of recommendations assessment, development, and evaluation (GRADE) approach (17).

Data synthesis

The meta-analysis was performed using Stata (version 17; StataCorp, 2021) software. Heterogeneity was assessed by using the Q test and I2 value calculation. If heterogeneity was not present (P > 0.1 and I2 < 50%), the data were combined using a fixed-effect model. The random-effects model was used if heterogeneity was present (P < 0.1 or I2 > 50%). In the investigation of potential publication bias, the Harbord test was employed to assess the presence of a small-study effect. Odds ratio (OR) (method of Mantel–Haenszel heterogeneity) and their associated 95% CIs were used to assess outcomes, with a P-value less than 0.05 indicating a statistically significant difference.

Sensitivity analyses

We performed a sensitivity analysis on a case-by-case exclusion basis.

Results

After identifying total of 279 studies, 142 duplicates were removed, and 99 irrelevant studies were excluded based on the titles and abstracts. The full text of 38 articles was read, and 27 retrospective studies were included in the systematic review (8, 11, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42). Due to six studies discussing hip and knee replacements (38, 38, 39, 40, 41, 42), we were unable to separate and extract knee-specific data for inclusion in our article. Consequently, we only included them in the systematic review, resulting in a final meta-analysis comprising 21 studies (8, 11, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36). The literature screening process is shown in Fig. 1. All included studies had NOS scores of greater than or equal to 6 points, indicating that they are high-quality studies. The basic characteristics of the included studies are shown in Table 1.

Figure 1
Figure 1

Flow diagram for search and selection of included studies.

Citation: EFORT Open Reviews 9, 6; 10.1530/EOR-23-0147

Table 1

Characteristics of included studies.

Study Country Date range Design FU Age* Subjects, n Outcomes NOS score
One stage Two stage One stage Two stage
Baker et al. (18) UK 2008–2010 RCS 6–12 m 69.4 ± 10.7 70.3 ± 8.9 33 89 Reoperation, knee score, satisfaction, complications 8
Bauer et al. (19) France NA RCS 2 Y 71.8 68.3 30 77 Reinfection rate, knee score 8
Capuano et al. (20) Italy 2013–2015 RCS 29.3 M - - 17 17 Reinfection, length of hospital stay, KSS 9
Chalmers et al. (21) USA 2009–2017 RCS 1–9 Y 51–87 1 4 Reinfection, reoperation 9
Crego et al. (22) Germany NA RCS NA NA NA 20 45 Reinfection 9
Cury et al. (23) Brazil 2008–2010 RCS NA NA NA 6 7 Reinfection, functionality score, life scores 6
Haddad et al. (24) UK 2004–2009 RCS 3–9 Y 63 (48–87) 68 (45–85) 28 74 Reinfection, reoperation, knee score, 7
Kheir et al. (25) USA 1991–2014 RCS 12 M 66.3 (39–85) 2 36 Failure rate 9
Klemt et al. (26) USA 2015–2018 RCS NA 64.9 ± 9.2 65.4 ± 8.6 44 88 Reinfection, reoperation, readmission, PROM 8
Laffer et al. (27) Switzerland 1988–2003 RCS 2–193 M 70.1 (43.5–90.1) 2 13 Success rate 8
Lenguerrand et al. (8) Multicentre 2003–2014 RCS NA 68 ± 10 69 ± 9 489 2377 Reoperation 9
Leta et al. (28) Norway 1994–2016 RCS 1 Y 69 ± 9.5 69 ± 9.7 72 243 Reinfection, reoperation, survival rate, mortality rate 9
Li et al. (29) China 2003–2014 RCS 12–158 M 64.4 ± 9.5 22 87 Reinfection, complication 9
Massin et al. (30) France 2005–2010 RCS 2 Y 71 (63–76) 67 (59–73) 108 177 Reinfection, reoperation, knee score 8
Matar et al. (11) UK 2003–2018 RCS 2.0–17.6 Y 71.8 ± 9.8 70.5 ± 10.2 82 161 Success rate, survivorship rate 8
Ribes et al. (31) France 2009–2014 RCS 1 Y 72.6 ± 9.2 69.5 ± 9.1 21 41 Reinfection, knee score 9
Ritter and Farris (32) Indiana 1969–2004 RCS 1 Y 65.4 ± 12.2 3 51 Success rate 9
Shanmugasundaram et al. (33) Multicentre 2008–2011 RCS NA NA NA 5 16 Success rate 6
Siddiqi et al. (34) USA 2012–2017 RCS 2 Y NA NA 57 137 Reinfection, reimplantation, reoperation rates, success rate, ROM 9
Tuecking et al. (35) Germany 2013–2019 RCS 18–92 M 65.0 ± 10.2 69.3 ± 11.1 15 48 Reinfection, reoperation, implant survival 9
Van den Kieboom et al. (36) USA 2010–2018 RCS 2.5–22.9 Y 67.9 ± 10.6 65.0 ± 11.0 18 48 Reinfection, reoperation, amputation, readmission, mortality, hospital stay 9

*Data are mean ± s.d. or range; Mean value.

NOS, Newcastle–Ottawa scale; FU, follow-up; M, month; Y, year; NA, not applicable; RCS, retrospective cohort study; KSS, knee society scores; PROM, patient-reported outcome measures; ROM, range of motion.

Reinfection rate

The 18 trials included in this study reported the reinfection rates after the two surgical regimens (11, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36). As there was no heterogeneity between the results (I 2 = 0%), the fixed-effect model was used to pool the results. The reinfection rate was significantly lower after single-stage revision than two-stage revision (OR = 0.72, 95% CI: 0.55–0.96, P = 0.023, Fig. 2).

Figure 2
Figure 2

Reinfection rate in included studies.

Citation: EFORT Open Reviews 9, 6; 10.1530/EOR-23-0147

Reoperation rate

A total of 10 studies reported the reoperation rates (8, 18, 21, 24, 26, 28, 30, 34, 35, 36). As there was no heterogeneity between study results (I2 = 0%), the fixed-effect model was used to pool the results. There was no statistically significant difference in the rate of reoperation after single-stage revision compared with two-stage revision (OR = 0.95, 95% CI: 0.77–1.17, P = 0.240, Fig. 3).

Figure 3
Figure 3

Reoperation rate in included studies.

Citation: EFORT Open Reviews 9, 6; 10.1530/EOR-23-0147

Knee function

Seven studies reported the postoperative knee function (18, 19, 20, 24, 30, 31, 34). The findings regarding the effects of single- and two-stage revision on knee function scores were heterogeneous and inconsistent and could not be combined in a meta-analysis. Therefore, we have presented the results descriptively and provided a brief summary of the study findings. Baker et al. found that the Oxford Knee Score did not significantly differ between the two groups (18). Bauer et al. also reported no significant difference between the two groups in the knee score but did not report the s.d. and CIs (19). Capuano et al. found no difference in Knee Society Scores (KSS) between the two groups at the final follow-up (20). Haddad et al. showed that the knee function was better after single-stage revision than after two-stage revision based on the KSS but only showed the mean and range (24). Massin et al. reported that international KSS were similar between the two groups (30). Ribes et al. found that the international KSS and Knee Injury and Osteoarthritis Outcome Score were better in the single-stage revision group than the two-stage revision group (31). Siddiqi et al. showed that the postoperative knee range of motion did not significantly differ between the two groups (34). The detail of knee joint function scores for each study are shown in Table 2.

Table 2

The results of the studies about knee function. Data are presented mean ± s.d. or as mean (range).

Study
(18) (19) (20) (24) (30) (31) (34)
OKS
 One stage 24.9 ± 13.1
 Two stage 22.8 ± 12.4
KSS
 One stage 75.5 78 ± 6.1 88 (38–97)
 Two stage 74.8 77.3 ± 6.4 76 (29–93)
IKS
 One stage 88.6 ± 9.4 51.05
 Two stage 89.7 ± 2 39.75
KOOS
 One stage 10
 Two stage 8.75
SF-12
 One stage 39.1
 Two stage 34.41
Flexion range
 One stage 92.5 (10–125) 97 ± 18 106.6 ± 23.2
 Two stage 93 (20–125) 91 ± 24 104.0 ± 18.1

OKS, Oxford Knee Score; IKS, International Knee Society; KSS, Knee Society Score; KOOS, Knee Injury and Osteoarthritis Outcome Score; SF-12, Short form-12 questionnaire.

Sensitivity analysis

The remaining studies were combined using the OR values when any individual study was excluded. No individual study had a significant impact on the results (Fig. 4).

Figure 4
Figure 4

The result of sensitivity analysis of reinfection (A) and reoperation (B).

Citation: EFORT Open Reviews 9, 6; 10.1530/EOR-23-0147

Risk of bias

As shown in Fig. 5, the funnel plots showed some asymmetry, which may suggest the presence of publication bias. However, the Harbord test showed no evidence of a small study effect regarding reinfection (P = 0.66) and reoperation (P = 0.24).

Figure 5
Figure 5

Funnel plot of the included studies in this meta-analysis for the incidence of reinfection (A) and reoperation (B).

Citation: EFORT Open Reviews 9, 6; 10.1530/EOR-23-0147

Discussion

Our meta-analysis results suggest that the reinfection rate is significantly lower after single-stage revision than after two-stage revision for PJI after knee arthroplasty. Two-stage revision has long been considered the gold standard for PJI, but it significantly reduces the activity time of patients, predisposing them to bone degeneration and periprosthetic fractures (43). Our results suggest that single-stage revision is no less effective than two-stage revision and has a lower rate of infection recurrence. However, the studies included in our review were retrospective studies with some bias in the process of patient allocation, as the decision whether to perform single- or two-stage revision is made at the discretion of the surgeon after considering all the details of the patient and the surgical site. The need for larger-scale, randomised clinical trials to validate our conclusions and to comprehensively address potential biases in future investigations. Besides, single-stage revision can avoid the shortcomings of two-stage revision, reduce the hospitalisation time and cost, reduce the number of surgeries and improve patient satisfaction and quality of life (44, 45). Although recurrent infection seriously decreases quality of life, not all recurrent infections require reoperation; mild infections can be improved with anti-infective treatment. Our analysis found no difference in the reoperation rate after the two treatment modalities. Due to differences in reporting across studies, we were unable to pool the knee function data; therefore, we could only describe the results. Although descriptive results are still useful to understand trends in knee function scores in the single- and two-revision groups, future studies should increase the sample sizes and add data from more independent studies to fully assess the knee function of patients with PJI after knee arthroplasty.

Previous meta-analyses of single- and two-stage revision for PJI after knee arthroplasty have been reported, but most have been single-arm meta-analyses that systematically reviewed the recurrence of infection after both surgical modalities (46, 47, 48). In contrast, we included studies that compared single- versus two-stage revision, providing more specific and reliable estimates of the outcomes of single- and two-stage revision for PJI after knee arthroplasty. Nagra et al. also compared the efficacy of single- and two-stage revision in the treatment of PJI in 2015 (49), but their study included only five cohort studies of 231 patients. Based on the included studies, their conclusion was that there was no difference in the re-infection rates between single-stage and two-stage revisions. However, their subgroup analysis revealed a divergence: among studies published before 2000 (including two studies), no difference was observed between single-stage and two-stage revisions. Contrastingly, among studies published after 2000 (comprising three studies), the re-infection rate was significantly lower in single-stage revisions compared to two-stage revisions. Since then, more studies comparing single- and two-stage revision have been published. As our results are based on a larger number of studies (21 studies, 4911 patients), our conclusion indicates that the re-infection rate in single-stage revisions is significantly lower than in two-stage revisions. Our study possesses stronger statistical power, robustly demonstrating these findings. Technological advancements, accumulated expertise and further optimisation of surgical techniques might contribute to the increased success rates in single-stage revisions. Additionally, we conducted a comparative analysis of reoperation rates between the two procedures, which was not performed in the study by Nagra et al.

Strengths and limitations

The present study has some strengths. First, we included a large number of studies (four times more than were included in the previous meta-analysis (49)) and compared the effectiveness of single- and two-stage revision in more detail. Secondly, in contrast to previous reviews (46, 47, 48), we used a two-arm meta-analysis approach that enabled the use of quantitative estimates to compare the effectiveness of the two revision strategies. Thirdly, our results remained robust in several sensitivity analyses.

Our study also had certain limitations. First, there was bias in the selection of the revision strategy. Capuano et al. used implants coated with an antibiotic-loaded hydrogel for single-stage revision but used uncoated implants for two-stage revision (20). Li et al. performed single-stage revision in cases with negative cultures and performed two-stage revision in cases with positive cultures (29). Secondly, the included studies were retrospective, and there was a lack of randomised controlled trials with large samples, resulting in reduced confidence in the study results. Thirdly, when discussing the advantages and disadvantages of single- and two-stage revisions, we only considered reinfection rates, reoperation rates and knee function scores, and did not perform a comprehensive analysis of other relevant indicators such as patient satisfaction, quality of life and complication rates. Future studies should consider more factors to fully assess the advantages and disadvantages of the two surgical modalities.

Conclusion

The existing research suggests that single-stage revision surgery is a reliable option for PJI after knee arthroplasty. In clinical practice, medical professionals should carefully select the appropriate surgical method based on factors such as the individual characteristics of the patient, severity of infection and available surgical technology. We hope that our results will provide useful guidance for clinical decision-making and contribute to further improving the treatment outcomes and quality of life of patients with PJI after knee arthroplasty. Through continuous in-depth research, we have the potential to provide patients with safer and more effective treatment options, thereby promoting their recovery and wellbeing.

ICMJE Conflict of Interest Statement

The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the study reported.

Funding Statement

This work did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

Author contribution statement

CX and HL collected data, performed data analysis, interpreted results, and wrote the first draft of the manuscript. WP and SW reviewed the protocol, screened articles, extracted data, and reviewed the results and manuscript. XY and HL contributed to the systematic review protocol and critically reviewed the results and manuscript. HL contributed to the protocol development and reviewed the manuscript. All authors contributed to the conception and design of the study and reviewed all documents and materials.

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    Baker P, Petheram TG, Kurtz S, Konttinen YT, Gregg P, & Deehan D. Patient reported outcome measures after revision of the infected TKR: comparison of single versus two-stage revision. Knee Surgery, Sports Traumatology, Arthroscopy 2013 21 27132720. (https://doi.org/10.1007/s00167-012-2090-7)

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  • 19

    Bauer T, Piriou P, Lhotellier L, Leclerc P, Mamoudy P, & Lortat-Jacob A. Results of reimplantation for infected total knee arthroplasty: 107 cases. Revue de Chirurgie Orthopédique et Reparatrice de l’Appareil Moteur 2006 92 692700. (https://doi.org/10.1016/s0035-1040(0675930-x)

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  • 20

    Capuano N, Logoluso N, Gallazzi E, Drago L, & Romanò CL. One-stage exchange with antibacterial hydrogel coated implants provides similar results to two-stage revision, without the coating, for the treatment of peri-prosthetic infection. Knee Surgery, Sports Traumatology, Arthroscopy 2018 26 33623367. (https://doi.org/10.1007/s00167-018-4896-4)

    • PubMed
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    • Export Citation
  • 21

    Chalmers BP, Kapadia M, Chiu YF, Henry MW, Miller AO, & Carli AV. Treatment and outcome of periprosthetic joint infection in unicompartmental knee arthroplasty. Journal of Arthroplasty 2020 35 19171923. (https://doi.org/10.1016/j.arth.2020.02.036)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Crego-Vita D, Sánchez-Pérez C, Espigares-Correa A, & Aedo-Martín D. Total knee arthroplasty infection, what is the best strategy for better functional outcomes?. Acta Ortopédica Mexicana 2019 33 297302. (https://doi.org/10.35366/OR195G).

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Cury Rde P, Cinagawa EH, Camargo OP, Honda EK, Klautau GB, & Salles MJ. Treatment of infection after total knee arthroplasty. Acta Ortopédica Brasileira 2015 23 239243. (https://doi.org/10.1590/1413-785220152305138774)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Haddad FS, Sukeik M, & Alazzawi S. Is single-stage revision according to a strict protocol effective in treatment of chronic knee arthroplasty infections? Clinical Orthopaedics and Related Research 2015 473 814. (https://doi.org/10.1007/s11999-014-3721-8)

    • PubMed
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    • Export Citation
  • 25

    Kheir MM, Tan TL, Higuera C, George J, Della Valle CJ, Shen M, & Parvizi J. Periprosthetic joint infections caused by enterococci have poor outcomes. Journal of Arthroplasty 2017 32 933947. (https://doi.org/10.1016/j.arth.2016.09.017)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Klemt C, Tirumala V, Oganesyan R, Xiong L, van den Kieboom J, & Kwon YM. Single-stage revision of the infected total knee arthroplasty is associated with improved functional outcomes: a propensity score-matched cohort study. Journal of Arthroplasty 2021 36 298304. (https://doi.org/10.1016/j.arth.2020.07.012)

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    • Export Citation
  • 27

    Laffer RR, Graber P, Ochsner PE, & Zimmerli W. Outcome of prosthetic knee-associated infection: evaluation of 40 consecutive episodes at a single centre. Clinical Microbiology and Infection 2006 12 433439. (https://doi.org/10.1111/j.1469-0691.2006.01378.x)

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  • 28

    Leta TH, Lygre SHL, Schrama JC, Hallan G, Gjertsen JE, Dale H, & Furnes O. Outcome of revision surgery for infection after total knee arthroplasty: results of 3 surgical strategies. JBJS Reviews 2019 7 e4. (https://doi.org/10.2106/JBJS.RVW.18.00084)

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  • 29

    Li H, Ni M, Li X, Zhang Q, Li X, & Chen J. Two-stage revisions for culture-negative infected total knee arthroplasties: a five-year outcome in comparison with one-stage and two-stage revisions for culture-positive cases. Journal of Orthopaedic Science 2017 22 306312. (https://doi.org/10.1016/j.jos.2016.11.008)

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  • 30

    Massin P, Delory T, Lhotellier L, Pasquier G, Roche O, Cazenave A, Estellat C, & Jenny JY. Infection recurrence factors in one- and two-stage total knee prosthesis exchanges. Knee Surgery, Sports Traumatology, Arthroscopy 2016 24 31313139. (https://doi.org/10.1007/s00167-015-3884-1)

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  • 31

    Ribes C, Masquefa T, Dutronc H, De Seynes C, Dupon M, Fabre T, & Dauchy FA. One-stage versus two-stage prosthesis replacement for prosthetic knee infections. Médecine et Maladies Infectieuses 2019 49 519526. (https://doi.org/10.1016/j.medmal.2019.01.013)

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  • 32

    Ritter MA, & Farris A. Outcome of infected total joint replacement. Orthopedics 2010 33. (https://doi.org/10.3928/01477447-20100129-09)

  • 33

    Shanmugasundaram S, Ricciardi BF, Briggs TW, Sussmann PS, & Bostrom MP. Evaluation and management of periprosthetic joint infection-an international, multicenter study. HSS Journal 2014 10 3644. (https://doi.org/10.1007/s11420-013-9366-4)

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  • 34

    Siddiqi A, Nace J, George NE, Buxbaum EJ, Ong AC, Orozco FR, Ponzio DY, & Post ZD. Primary total knee arthroplasty implants as functional prosthetic spacers for definitive management of periprosthetic joint infection: a multicenter study. Journal of Arthroplasty 2019 34 30403047. (https://doi.org/10.1016/j.arth.2019.07.007)

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  • 35

    Tuecking LR, Silligmann J, Savov P, Omar M, Windhagen H, & Ettinger M. Detailed revision risk analysis after single- vs. two-Stage Revision total knee arthroplasty in periprosthetic joint infection: a retrospective tertiary center analysis. Antibiotics 2021 10. (https://doi.org/10.3390/antibiotics10101177)

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  • 36

    van den Kieboom J, Tirumala V, Box H, Oganesyan R, Klemt C, & Kwon YM. One-stage revision is as effective as two-stage revision for chronic culture-negative periprosthetic joint infection after total hip and knee arthroplasty. Bone and Joint Journal 2021 103–B 515521. (https://doi.org/10.1302/0301-620X.103B.BJJ-2020-1480.R2)

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  • 37

    Betsch BY, Eggli S, Siebenrock KA, Täuber MG, & Mühlemann K. Treatment of joint prosthesis infection in accordance with current recommendations improves outcome. Clinical Infectious Diseases 2008 46 12211226. (https://doi.org/10.1086/529436)

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    • Export Citation
  • 38

    Castellani L, Daneman N, Mubareka S, & Jenkinson R. Factors associated with choice and success of one- versus two-stage revision arthroplasty for infected hip and knee prostheses. HSS Journal 2017 13 224231. (https://doi.org/10.1007/s11420-017-9550-z)

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    • Export Citation
  • 39

    Mahieu R, Dubée V, Seegers V, Lemarié C, Ansart S, Bernard L, Le Moal G, Asseray N, Arvieux C, Ramanantsoa C, et al.The prognosis of streptococcal prosthetic bone and joint infections depends on surgical management-A multicenter retrospective study. International Journal of Infectious Diseases 2019 85 175181. (https://doi.org/10.1016/j.ijid.2019.06.012)

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  • 40

    Masood K, Redfern RE, Duggan JM, Georgiadis GM, & Suleyman G. Clinical characteristics and outcomes of Staphylococcus lugdunensis prosthetic joint infections: a multicenter retrospective analysis. Orthopedics 2020 43 345350. (https://doi.org/10.3928/01477447-20200923-03)

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  • 43

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    Okafor CE, Nghiem S, & Byrnes J. Is 2-stage septic revision worth the money? A cost-utility analysis of a 1-stage versus 2-stage septic revision of total knee arthroplasty. Journal of Arthroplasty 2023 38 347354. (https://doi.org/10.1016/j.arth.2022.09.003)

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  • 46

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  • 47

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  • 48

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    Nagra NS, Hamilton TW, Ganatra S, Murray DW, & Pandit H. One-stage versus two-stage exchange arthroplasty for infected total knee arthroplasty: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy 2016 24 31063114. (https://doi.org/10.1007/s00167-015-3780-8)

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  • Collapse
  • Expand
  • Figure 1

    Flow diagram for search and selection of included studies.

  • Figure 2

    Reinfection rate in included studies.

  • Figure 3

    Reoperation rate in included studies.

  • Figure 4

    The result of sensitivity analysis of reinfection (A) and reoperation (B).

  • Figure 5

    Funnel plot of the included studies in this meta-analysis for the incidence of reinfection (A) and reoperation (B).

  • 1

    Garner AJ, Dandridge OW, van Arkel RJ, & Cobb JP. The compartmental approach to revision of partial knee arthroplasty results in nearer-normal gait and improved patient reported outcomes compared to total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy 2023 31 11431152. (https://doi.org/10.1007/s00167-021-06691-9)

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    Chuang CA, Lee SH, Chang CH, Hu CC, Shih HN, Ueng SWN, & Chang Y. Application of structural allogenous bone graft in two-stage exchange arthroplasty for knee periprosthetic joint infection: a case control study. BMC Musculoskeletal Disorders 2022 23 325. (https://doi.org/10.1186/s12891-022-05228-6)

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    Li Y, Zhang X, Ji B, Wulamu W, Yushan N, Guo X, & Cao L. One-stage revision using intra-articular carbapenem infusion effectively treats chronic periprosthetic joint infection caused by Gram-negative organisms. Bone and Joint Journal 2023 105–B 284293. (https://doi.org/10.1302/0301-620X.105B3.BJJ-2022-0926.R1)

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    Matar HE, Bloch BV, Snape SE, & James PJ. Outcomes of single- and two-stage revision total knee arthroplasty for chronic periprosthetic joint infection: long-term outcomes of changing clinical practice in a specialist centre. Bone and Joint Journal 2021 103–B 13731379. (https://doi.org/10.1302/0301-620X.103B8.BJJ-2021-0224.R1)

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  • 13

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  • 18

    Baker P, Petheram TG, Kurtz S, Konttinen YT, Gregg P, & Deehan D. Patient reported outcome measures after revision of the infected TKR: comparison of single versus two-stage revision. Knee Surgery, Sports Traumatology, Arthroscopy 2013 21 27132720. (https://doi.org/10.1007/s00167-012-2090-7)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Bauer T, Piriou P, Lhotellier L, Leclerc P, Mamoudy P, & Lortat-Jacob A. Results of reimplantation for infected total knee arthroplasty: 107 cases. Revue de Chirurgie Orthopédique et Reparatrice de l’Appareil Moteur 2006 92 692700. (https://doi.org/10.1016/s0035-1040(0675930-x)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Capuano N, Logoluso N, Gallazzi E, Drago L, & Romanò CL. One-stage exchange with antibacterial hydrogel coated implants provides similar results to two-stage revision, without the coating, for the treatment of peri-prosthetic infection. Knee Surgery, Sports Traumatology, Arthroscopy 2018 26 33623367. (https://doi.org/10.1007/s00167-018-4896-4)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Chalmers BP, Kapadia M, Chiu YF, Henry MW, Miller AO, & Carli AV. Treatment and outcome of periprosthetic joint infection in unicompartmental knee arthroplasty. Journal of Arthroplasty 2020 35 19171923. (https://doi.org/10.1016/j.arth.2020.02.036)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Crego-Vita D, Sánchez-Pérez C, Espigares-Correa A, & Aedo-Martín D. Total knee arthroplasty infection, what is the best strategy for better functional outcomes?. Acta Ortopédica Mexicana 2019 33 297302. (https://doi.org/10.35366/OR195G).

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Cury Rde P, Cinagawa EH, Camargo OP, Honda EK, Klautau GB, & Salles MJ. Treatment of infection after total knee arthroplasty. Acta Ortopédica Brasileira 2015 23 239243. (https://doi.org/10.1590/1413-785220152305138774)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Haddad FS, Sukeik M, & Alazzawi S. Is single-stage revision according to a strict protocol effective in treatment of chronic knee arthroplasty infections? Clinical Orthopaedics and Related Research 2015 473 814. (https://doi.org/10.1007/s11999-014-3721-8)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Kheir MM, Tan TL, Higuera C, George J, Della Valle CJ, Shen M, & Parvizi J. Periprosthetic joint infections caused by enterococci have poor outcomes. Journal of Arthroplasty 2017 32 933947. (https://doi.org/10.1016/j.arth.2016.09.017)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Klemt C, Tirumala V, Oganesyan R, Xiong L, van den Kieboom J, & Kwon YM. Single-stage revision of the infected total knee arthroplasty is associated with improved functional outcomes: a propensity score-matched cohort study. Journal of Arthroplasty 2021 36 298304. (https://doi.org/10.1016/j.arth.2020.07.012)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Laffer RR, Graber P, Ochsner PE, & Zimmerli W. Outcome of prosthetic knee-associated infection: evaluation of 40 consecutive episodes at a single centre. Clinical Microbiology and Infection 2006 12 433439. (https://doi.org/10.1111/j.1469-0691.2006.01378.x)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Leta TH, Lygre SHL, Schrama JC, Hallan G, Gjertsen JE, Dale H, & Furnes O. Outcome of revision surgery for infection after total knee arthroplasty: results of 3 surgical strategies. JBJS Reviews 2019 7 e4. (https://doi.org/10.2106/JBJS.RVW.18.00084)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Li H, Ni M, Li X, Zhang Q, Li X, & Chen J. Two-stage revisions for culture-negative infected total knee arthroplasties: a five-year outcome in comparison with one-stage and two-stage revisions for culture-positive cases. Journal of Orthopaedic Science 2017 22 306312. (https://doi.org/10.1016/j.jos.2016.11.008)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Massin P, Delory T, Lhotellier L, Pasquier G, Roche O, Cazenave A, Estellat C, & Jenny JY. Infection recurrence factors in one- and two-stage total knee prosthesis exchanges. Knee Surgery, Sports Traumatology, Arthroscopy 2016 24 31313139. (https://doi.org/10.1007/s00167-015-3884-1)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Ribes C, Masquefa T, Dutronc H, De Seynes C, Dupon M, Fabre T, & Dauchy FA. One-stage versus two-stage prosthesis replacement for prosthetic knee infections. Médecine et Maladies Infectieuses 2019 49 519526. (https://doi.org/10.1016/j.medmal.2019.01.013)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Ritter MA, & Farris A. Outcome of infected total joint replacement. Orthopedics 2010 33. (https://doi.org/10.3928/01477447-20100129-09)

  • 33

    Shanmugasundaram S, Ricciardi BF, Briggs TW, Sussmann PS, & Bostrom MP. Evaluation and management of periprosthetic joint infection-an international, multicenter study. HSS Journal 2014 10 3644. (https://doi.org/10.1007/s11420-013-9366-4)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Siddiqi A, Nace J, George NE, Buxbaum EJ, Ong AC, Orozco FR, Ponzio DY, & Post ZD. Primary total knee arthroplasty implants as functional prosthetic spacers for definitive management of periprosthetic joint infection: a multicenter study. Journal of Arthroplasty 2019 34 30403047. (https://doi.org/10.1016/j.arth.2019.07.007)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Tuecking LR, Silligmann J, Savov P, Omar M, Windhagen H, & Ettinger M. Detailed revision risk analysis after single- vs. two-Stage Revision total knee arthroplasty in periprosthetic joint infection: a retrospective tertiary center analysis. Antibiotics 2021 10. (https://doi.org/10.3390/antibiotics10101177)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    van den Kieboom J, Tirumala V, Box H, Oganesyan R, Klemt C, & Kwon YM. One-stage revision is as effective as two-stage revision for chronic culture-negative periprosthetic joint infection after total hip and knee arthroplasty. Bone and Joint Journal 2021 103–B 515521. (https://doi.org/10.1302/0301-620X.103B.BJJ-2020-1480.R2)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Betsch BY, Eggli S, Siebenrock KA, Täuber MG, & Mühlemann K. Treatment of joint prosthesis infection in accordance with current recommendations improves outcome. Clinical Infectious Diseases 2008 46 12211226. (https://doi.org/10.1086/529436)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Castellani L, Daneman N, Mubareka S, & Jenkinson R. Factors associated with choice and success of one- versus two-stage revision arthroplasty for infected hip and knee prostheses. HSS Journal 2017 13 224231. (https://doi.org/10.1007/s11420-017-9550-z)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Mahieu R, Dubée V, Seegers V, Lemarié C, Ansart S, Bernard L, Le Moal G, Asseray N, Arvieux C, Ramanantsoa C, et al.The prognosis of streptococcal prosthetic bone and joint infections depends on surgical management-A multicenter retrospective study. International Journal of Infectious Diseases 2019 85 175181. (https://doi.org/10.1016/j.ijid.2019.06.012)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

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