Single-stage exchange revision for chronic PJI in selected patients | advanced
Surgical Imaging
The trap: Attempting one-stage revision when a sinus tract is present — the tract indicates chronic fistulous communication with skin flora and guarantees polymicrobial or resistant contamination.
The fix: Any sinus tract mandates two-stage exchange or, at minimum, excision of the tract with temporary spacer before considering reimplantation. One-stage protocols explicitly exclude sinus tracts.
The trap: Proceeding to one-stage exchange without a preoperative culture identifying a susceptible organism — you cannot select appropriate local and systemic antibiotics.
The fix: Preoperative aspiration or biopsy with organism identification and susceptibility testing is mandatory. Resistant organisms (MRSA, VRE, fungi, MDR Gram-negatives) are managed with two-stage protocols or suppressive therapy.
The trap: Offering one-stage revision to patients on chemotherapy, high-dose steroids, biologics, or with uncontrolled diabetes, HIV, or dialysis dependence — host immunity is insufficient to clear residual biofilm.
The fix: These patients require two-stage exchange with prolonged antibiotic holiday and optimisation; one-stage success rates drop dramatically in immunocompromised hosts.
The trap: Assuming immediate reimplantation is feasible when major bone loss or poor soft-tissue coverage exists — the new implant will have no stable fixation or coverage.
The fix: Assess bone defects with CT; if Paprosky type III or greater femoral/acetabular loss or significant soft-tissue deficiency, convert to two-stage with spacer and plan for augments or flaps at reimplantation.
The trap: Completing debridement and immediately reimplanting with the same drapes and instruments — this recontaminates the new prosthesis with residual bacteria from the infected field.
The fix: After explantation and thorough debridement, remove all drapes, re-scrub, re-gown, apply completely new drapes, and open an entirely new sterile instrument set before reimplantation. This step is the hallmark of a true one-stage protocol.
The trap: Confusing one-stage exchange with DAIR — DAIR retains the original implants and is indicated only for acute postoperative or haematogenous infections within 3-4 weeks of symptoms.
The fix: One-stage exchange is for chronic PJI (greater than 4 weeks of symptoms) with known organism; it always involves complete explantation and reimplantation. DAIR leaves the implants in situ.
S.E.L.E.C.T.SELECT — One-Stage Patient Selection Criteria
S.T.E.P.S.STEPS — One-Stage Operative Sequence
O.U.T.C.O.M.E.OUTCOME — Evidence and Limitations
Surgical Indications for One-Stage Revision
Absolute Indications (Endo-Klinik Criteria)
- Chronic periprosthetic joint infection (symptoms greater than 4 weeks) with a single, known, susceptible organism identified on preoperative aspiration or biopsy
- Immunocompetent host with well-controlled comorbidities and no active systemic infection
- Healthy soft-tissue envelope without sinus tract, abscess, or significant scarring
- Adequate bone stock permitting immediate stable reimplantation without major structural augments
- Organism susceptible to biofilm-active antibiotics that can be delivered both locally in cement and systemically
Relative Indications
- Patient preference for single anaesthetic exposure after informed discussion of success rates versus two-stage
- Low-virulence organisms (coagulase-negative staphylococci, Cutibacterium, streptococci) with proven susceptibility
- Well-fixed implants with minimal bone loss on preoperative imaging
Contraindications
Absolute:
- Presence of sinus tract or fistulous communication
- Unknown organism or culture-negative PJI
- Resistant or difficult-to-treat organisms (MRSA, VRE, fungi, MDR Gram-negatives, rifampicin-resistant staphylococci)
- Immunocompromised state (chemotherapy, biologics, uncontrolled diabetes with HbA1c greater than 8 percent, dialysis, HIV with low CD4)
- Significant soft-tissue deficiency requiring flap coverage
- Major bone defects (Paprosky III or greater) precluding immediate stable fixation
Relative:
- Acute postoperative or haematogenous PJI (these are DAIR indications)
- Previous failed one-stage revision
- Patient unable to comply with prolonged postoperative antibiotic course or follow-up
Evidence Comparing One-Stage versus Two-Stage Exchange
One-stage exchange has been performed at the Endo-Klinik since the 1980s with published success rates supporting its use in selected patients. Modern series report reinfection rates of 5-15 percent at 5-10 years when strict selection criteria are applied, comparable to two-stage exchange in appropriately chosen cohorts.
Advantages of one-stage revision include single anaesthetic exposure, shorter total hospital stay, lower cumulative cost, faster return to function, and avoidance of spacer-related complications (spacer dislocation, fracture, or prolonged immobilisation).
Limitations include the requirement for known susceptible organism preoperatively, the technical demand of radical debridement in a single sitting, and the inability to confirm clearance of infection before reimplantation.
One-Stage versus Two-Stage Exchange — Decision Framework
Key Evidence
One-Stage Revision for Infected Total Hip Arthroplasty
One- and two-stage surgical revision of peri-prosthetic joint infection of the hip: a pooled individual participant data analysis of 44 cohort studies
Re-Infection Outcomes Following One- And Two-Stage Surgical Revision of Infected Knee Prosthesis: A Systematic Review and Meta-Analysis
One- and two-stage surgical revision of infected shoulder prostheses following arthroplasty surgery: A systematic review and meta-analysis
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“A 68-year-old man with a well-fixed cemented total hip arthroplasty presents with insidious groin pain 4 years after index surgery. CRP is 35 mg/L, ESR 45 mm/hr. Aspiration grows coagulase-negative Staphylococcus sensitive to vancomycin and rifampicin. There is no sinus tract, he is immunocompetent, and CT shows only minor osteolysis around the cup. Is he a candidate for one-stage revision, and what are the key technical steps you would emphasise?”
“You are planning a one-stage revision for an infected total knee arthroplasty. The patient has a known methicillin-sensitive Staphylococcus aureus (MSSA) on preoperative aspiration. During the case, after radical debridement and explantation, you notice that the medial collateral ligament has been compromised by the infectious process. How do you proceed?”
“A 72-year-old woman with an infected total hip arthroplasty has a sinus tract communicating with the joint. Aspiration grows a fully susceptible coagulase-negative Staphylococcus. She is otherwise fit and the bone stock is good. Why is one-stage revision contraindicated, and what is the correct management?”