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Two-Stage Exchange for Prosthetic Joint Infections:

The Gold Standard

John A. Abraham MD Orthopedic Oncology and Adult Reconstruction

Rothman Institute

Philadelphia, PA

Disclosures

• No financial disclosures relevant to this talk.

Why use a two stage exchange?

• #1: Because it works!

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The Gold Standard• Extensive support in literature over many

decades for two-stage approach to PJI management

• Overall eradication of infection reported after two-stage revisions:– between 80 and 100% success reported

– generally higher success rates than one-stage studies

– Difference may not be large but it exists!

Benefits of Two Stage

• Can be used in all infected patients

• Preferred technique in septic patients

• Reimplantation can be performed after patient parameters are optimized

• Effective for all organisms

• Useful when no organism is identified

• Useful in patients with a sinus tract

• Spacer Exchange can be used if infection is not cleared with first round of Abx

• Engesæter LB, Dale H, Schrama JC, Hallan G, Lie SA. Surgical procedures in the treatment of 784 infected THAs reported to the Norwegian Arthroplasty Register. Acta Orthopaedica 2011;82:530–7. doi:10.3109/17453674.2011.623572.

• Cooper HJ, Della Valle CJ. The two-stage standard in revision total hip replacement. The Bone & Joint Journal 2013;95-B:84–7. doi:10.1302/0301-620X.95B11.32906.

• Azzam K, McHale K, Austin M, Purtill JJ, Parvizi J. Outcome of a second two-stage reimplantation for periprosthetic knee infection. Clinical Orthopaedics and Related Research 2009;467:1706–14. doi:10.1007/s11999-009-0739-4.

• Haleem AA, Berry DJ, Hanssen AD. Mid-term to long-term followup of two-stage reimplantation for infected total knee arthroplasty. Clinical Orthopaedics and Related Research 2004:35–9. 494

• 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;13:224–31. doi:10.1007/s11420-017-9550-z.

• Kunutsor SK, Whitehouse MR, Blom AW, Beswick AD, INFORM Team. Re-Infection Outcomes following One- and Two-Stage Surgical Revision of Infected Hip Prosthesis: A Systematic Review and Meta-Analysis. PLoS ONE 2015;10:e0139166. doi:10.1371/journal.pone.0139166.

• Kunutsor SK, Whitehouse MR, Lenguerrand E, Blom AW, Beswick AD, INFORM Team. Re-Infection Outcomes Following One- And Two-Stage Surgical Revision of Infected Knee Prosthesis: A Systematic Review and Meta-Analysis. PLOS ONE 2016;11:e0151537. doi:10.1371/journal.pone.0151537.

• Kim YH, Kim JS, Park JW, Joo JH. Cementless revision for infected total hip replacements. J Bone Joint Surg [Br] 2011;93-B:19–26

• DeMan FH, Sendi P, Zimmerli W, et al.Infectiological, functional, and radiographic outcome after revision for prosthetic hip infection according to a strict algorithm. Acta Orthop 2011;82:27–34

• Oussedik SI, Dodd MB, Haddad FS. Outcomes of revision total hip replacement for infection after grading according to a standard protocol. J Bone Joint Surg [Br] 2010;92-B:1222–1226

• D’Angelo F, Negri L, Binda T, Zatti G, Cherubino P. The use of a preformed spacer in two-stage revision of infected hip arthroplasties. Musculoskelet Surg 2011;95:115–120

The Gold Standard

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Why use a two stage exchange?

• #2: Because it can be used in all situations

Contraindications to One StageFrom Philadelphia International Consensus Meeting 2018:

Relative Contraindication to One-stage

• Severe damage of soft tissues where the direct closure of the joint and the wound is not possible

• A complex sinus tract which cannot be excised along with the old scar.

• Culture-negative PJI, where the causative organism and its susceptibility are not known.

• Systemic sepsis

• Immunocompromised host

• No radical debridement of infected soft tissues or bone is possible (for whatever reason).

• No local antimicrobial treatment is possible (for whatever reason).

• No proper bone stock exists for the fixation of the new implant.

Why use a two stage exchange?

• #3: Because functional outcomes are equivalent

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Functional outcomes• KNEE

– Kunutsor SK, Whitehouse MR, Lenguerrand E, Blom AW, Beswick AD, INFORM Team. Re-Infection Outcomes Following One- And Two-Stage Surgical Revision of Infected Knee Prosthesis: A Systematic Review and Meta-Analysis. PLoS ONE 2016;11:e0151537

– No difference in Knee Society Knee Scores or Knee Society Function scores

• HIP– De Man FHR, Sendi P, Zimmerli W, Maurer TB, Ochsner PE, Ilchmann T.

Infectiological, functional, and radiographic outcome after revision for prosthetic hip infection according to a strict algorithm. Acta Orthop 2011;82:27–34.

– Harris Hip Scores 80-87 points following reimplantation, no difference between groups

– Two other studies support these data (Choi et al, Klouche et al)

Why use a two stage exchange?

• #4: Because it doesn’t depend on technique

Cemented Technique• Bucholz original description of One Stage Exchange used a

cemented reimplantation technique:– Buchholz HW, Elson RA, Engelbrecht E, Lodenkämper H, Röttger J,

Siegel A. Management of deep infection of total hip replacement. The Journal of Bone and Joint Surgery British Volume 1981;63-B:342–53.

• Much of the data available for one-stage is from European studies relying on a similar cemented reimplantation technique with high dose antibiotic cement

• Cemented technique not commonly used in the United States and does have a learning curve…results may not necessarily be translatable to an uncemented technique

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Uncemented Technique?• Hansen E, Tetreault M, Zmistowski B, Della Valle CJ, Parvizi J, Haddad FS, et al.

Outcome of one-stage cementless exchange for acute postoperative periprosthetic hip infection. Clin Orthop Relat Res 2013;471:3214–22

– 27 patients, retrospective, mean follow up 50 months

– Isolated one-stage exchange successful in only 15/27 (56%)

• Wolf M, Clar H, Friesenbichler J, Schwantzer G, Bernhardt G, Gruber G, et al. Prosthetic joint infection following total hip replacement: results of one-stage versus two-stage exchange. Int Orthop 2014;38:1363–8.

– 92 patients, retrospective, Two year follow up

– 94.5% success rate with two-stage (n=52),

– 56.8% one-stage exchange, uncemented technique (n=21); p<0.001

Why use a two stage exchange?

• #5: Because comparison studies have failed to demonstrate superiority of a One Stage technique

Comparison Data• No Randomized Controlled Trials to compare One vs. Two

Stage exchange

• Majority of Comparison studies show an advantage to two stage exchange (although minimal in most)

• Meta-analyses comparing outcomes: – Limited by the quality of the studies included in the meta-analyses

– Contain relative paucity of studies evaluating one-stage protocols

– Show no statistically significant difference in success rates

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Comparison Studies• Klouche S, Leonard P, Zeller V, Lhotellier L, Graff W, Leclerc P, et al. Infected total

hip arthroplasty revision: One- or two-stage procedure? Orthopaedics & Traumatology: Surgery & Research 2012;98:144–50.

• Choi H-R, Kwon Y-M, Freiberg AA, Malchau H. Comparison of One-Stage Revision With Antibiotic Cement Versus Two-Stage Revision Results for Infected Total Hip Arthroplasty. The Journal of Arthroplasty 2013;28:66–70.

• Wolf M, Clar H, Friesenbichler J, Schwantzer G, Bernhardt G, Gruber G, et al. Prosthetic joint infection following total hip replacement: results of one-stage versus two-stage exchange. International Orthopaedics 2014;38:1363–8..

• 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;24:3106–14.

• Wolf CF, Gu NY, Doctor JN, Manner PA, Leopold SS. Comparison of One and Two-Stage Revision of Total Hip Arthroplasty Complicated by Infection: A Markov Expected-Utility Decision Analysis. The Journal of Bone and Joint Surgery-American Volume 2011;93:631–9.

Why use a two stage exchange?

• #6: Because a failed one stage exchange may compromise the results of a subsequent two stage exchange

Failed initial management• Although no studies address this question directly:

– There are data to suggest that a failed DAIR procedure may compromise the results of a subsequent Two Stage Exchange

• Sherrell, J.C., et al., The Chitranjan Ranawat Award: fate of two-stage reimplantation after failed irrigation and debridement for periprosthetic knee infection. Clin Orthop Relat Res, 2011. 469(1): p. 18-25.

– Of the 83 knees that had undergone prior I&D, 28 (34%) failed subsequent two stage revision and required reoperation for persistent infection.

• Rajgopal, A., et al., Does Prior Failed Debridement Compromise the Outcome of Subsequent Two-Stage Revision Done for Periprosthetic Joint Infection Following Total Knee Arthroplasty? J Arthroplasty, 2018.

– 23.86% (21/88) failure rate after two stage exchange following failed I&D compared to 15.62% (15/96) after direct two stage exchange

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Why use a two stage exchange?

• #7: Because some things are just better done in two steps

Get Rid of the Infection.Even if it means doing it

in Two Stages

Just Stage It

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Thank you!