Partial 2-stage exchange for chronic periprosthetic joint infection after total hip arthroplasty: a comprehensive meta-analysis

Abstract

Background:

Periprosthetic joint infection (PJI) is a devastating complication of total hip arthroplasty (THA) that has major clinical and financial implications. Despite CDCR being the accepted gold standard for chronic PJI, serious complications, such as extensive bone loss and protracted rehabilitation, have led to the investigation of PTCR as an alternative treatment strategy for chronic PJI.

Methods:

According to the PICOS framework, a systematic review and meta-analysis were performed to assess the clinical efficacy of partial 2-stage exchange in chronic PJI with a stable femoral component. There were no time or language limits during the search for relevant articles in PubMed, Embase, Scopus, and Cochrane Library databases. Data extraction and quality assessment were performed according to the MINORS criteria by 2 independent reviewers. Statistical analysis, including heterogeneity and sensitivity analyses, was performed using R Studio software with the appropriate meta-analytical packages.

Results:

13 studies, including 239 patients, were analysed. When the data were pooled, MDCT showed an 88% rate of complete eradication with homogeneity (I² = 0%). Secondary traits included 12% re-operations, 8% deaths, and 1% fractures. Infectious and systemic complications were observed in 13% and 3% of patients, respectively. Implant stability was present in 89% of cases, with significant functional improvement, with a mean Harris Hip Score of 37.77 at the final follow-up. Treatment failure, defined as infection recurrence or the need for chronic antibiotic suppression, was observed in 14% of cases, and sensitivity analysis excluding zero-event studies showed a 17% failure rate.

Conclusions:

Partial 2-stage exchange results in favorable eradication of infection, may reduce bone stock loss, and optimises functional outcomes. However, concerns remain regarding its efficacy against resistant strains and proper patient selection criteria. Well-designed comparative studies with longer follow-up periods are needed to establish treatment algorithms and confirm long-term clinical results.

PROSPERO registration number CRD42024599183.

Keywords

Meta-analysis partial two-stage exchange prosthetic joint infection revision arthroplasty total hip arthroplasty

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References

Tande

Patel

Prosthetic joint infection. Clin Microbiol Rev 2014; 27: 302–345.

Learmonth

Young

Rorabeck

The operation of the century: total hip replacement. Lancet 2007; 370: 1508–1519.

Kapadia

Banerjee

Cherian

, et al. The economic impact of periprosthetic infections after total hip arthroplasty at a specialized tertiary-care center. J Arthroplasty 2016; 31: 1422–1426.

Aggarwal

Rasouli

Parvizi

Periprosthetic joint infection: current concept. Indian J Orthop 2013; 47: 10–17.

Bozic

Ries

MD.

The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization. J Bone Joint Surg Am 2005; 87: 1746–1751.

Osmon

Berbari

Berendt

, et al. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the infectious diseases society of Americaa. Clin Infect Dis 2013; 56: e1–e25.

Zimmerli

Trampuz

Ochsner

PE.

Prosthetic-joint infections. N Engl J Med 2004; 351: 1645–1654.

Cooper

Della Valle

CJ.

The two-stage standard in revision total hip replacement. Bone Joint J 2013; 95-B(Suppl. A): 84–87.

Hsieh

Shih

Chang

, et al. Two-stage revision hip arthroplasty for infection. J Bone Joint Surg Am 2004; 86: 1989–1997.

10.

Ekpo

Berend

Morris

, et al. Partial two-stage exchange for infected total hip arthroplasty: a preliminary report. Clin Orthop Relat Res 2014; 472: 437–448.

11.

Berend

Lombardi

Jr Morris

, et al. Two-stage treatment of hip periprosthetic joint infection is associated with a high rate of infection control but high mortality. Clin Orthop Relat Res 2013; 471: 510–518.

12.

Anagnostakos

Jung

Kelm

, et al. Two-stage treatment protocol for isolated septic acetabular cup loosening. Hip Int 2010; 20: 320–326.

13.

Lee

Nho

, et al. Retaining well-fixed cementless stem in the treatment of infected hip arthroplasty. Acta Orthop 2013; 84: 260–264.

14.

Faroug

Shah

Mccarthy

MJH

, et al. Two stage one component revision in infected total hip replacements - two case reports and literature review. Hip Int 2009; 19: 292–298.

15.

Liebs

TR.

CORR Insights(®): the role of highly selective implant retention in the infected hip arthroplasty. Clin Orthop Relat Res 2016; 474: 2164–2167.

16.

Anil

Singh

Schwarzkopf

Diagnosis and detection of subtle aseptic loosening in total hip arthroplasty. J Arthroplasty 2022; 37: 1494–1500.

17.

Slim

Nini

Forestier

, et al. Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg 73: 712–716.

18.

DerSimonian

Laird

Meta-analysis in clinical trials. Control Clin Trials 1986; 7: 177–188.

19.

Triantafyllopoulos

Memtsoudis

Zhang

, et al. Periprosthetic infection recurrence after 2-stage exchange arthroplasty: failure or fate? J Arthroplasty 2017; 32: 526–531.

20.

Shon

Santhanam

Choi

JW.

Acetabular reconstruction in total hip arthroplasty. Hip Pelvis 2016; 28: 1–14.

21.

Hsieh

Shih

Chang

, et al. Treatment of deep infection of the hip associated with massive bone loss. J Bone Joint Surg Br 2005; 87: 770–775.

22.

Lombardi

Jr Berend

Adams

JB.

Partial two-stage exchange of the infected total hip replacement using disposable spacer moulds. Bone Joint J 2014; 96-B: 66–69.

23.

Bozic

Ries

MD.

The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization. J Bone Joint Surg Am 2005; 87: 1746–1751.

24.

McPherson

Woodson

Holtom

, et al. Periprosthetic total hip infection. Clin Orthop Relat Res 2002; 403: 8–15.

25.

Guo

, et al. Retention of the well-fixed implant in the single-stage exchange for chronic infected total hip arthroplasty: an average of five years of follow-up. Int Orthop 2016; 41: 901–909.

26.

El-Husseiny

Haddad

FS.

The role of highly selective implant retention in the infected hip arthroplasty. Clin Orthop Relat Res 2016; 474: 2157–2163.

27.

Hsieh

Chen

, et al. Two-stage revision hip arthroplasty for infection with a custom-made, antibiotic-loaded, cement prosthesis as an interim spacer. J Trauma 2004; 56: 1247–1252.

28.

Moreno-Romero

Ordas-Bayon

Gomez-Rice

, et al. Partial two-stage exchange for infected total hip arthroplasty: a treatment to take into account. J Pers Med 2023; 13: 137.

29.

Shi

Yang

Zhou

, et al. Partial implant retention in two-stage exchange for chronic infected total hip arthroplasty. Int Orthop 2020; 44: 461–469.

30.

Fukui

Kaneuji

Ueda

, et al. Should well-fixed uncemented femoral components be revised in infected hip arthroplasty? Report of five trial cases. J Orthop 2015; 13: 437–442.

31.

Chen

Tsai

, et al. Partial component-retained two-stage reconstruction for chronic infection after uncemented total hip arthroplasty: results of sixteen cases after five years of follow-up. Int Orthop 2017; 41: 2479–2486.

32.

Bertazzoni Minelli

. Release of gentamicin and vancomycin from temporary human hip spacers in two-stage revision of infected arthroplasty. J Antimicrob Chemother 2004; 53: 329–334.

33.

Kelm

Regitz

Schmitt

, et al. In vivo and in vitro studies of antibiotic release from and bacterial growth inhibition by antibiotic-impregnated polymethylmethacrylate hip spacers. Antimicrob Agents Chemother 2006; 50: 332–335.

34.

Crawford

Adams

Morris

, et al. Partial 2-stage exchange for infected total hip arthroplasty: an updated report. J Arthroplasty 2019; 34: 3048–3053.

35.

Castagnini

Tella

Montalti

, et al. Mid-term outcomes of a partial 2-stage approach in late chronic periprosthetic hip infections. Hip Int 2020; 30: 327–332.

36.

Yishake

Tang

Chen

, et al. Partial two-stage exchange: an alternative method for infected total hip arthroplasty. BMC Musculoskelet Disord 2021; 22: 686.

37.

Mortazavi

Vegari

, et al. Two-stage exchange arthroplasty for infected total knee arthroplasty: predictors of failure. Clin Orthop Relat Res 2011; 469: 3049–3054.

38.

Fehring

Odum

Calton

, et al. Articulating versus static spacers in revision total knee arthroplasty for sepsis. Clin Orthop Relat Res 2000; 380: 9–16.

39.

Hart

Jones

RS.

Two-stage revision of infected total knee replacements using articulating cement spacers and short-term antibiotic therapy. J Bone Joint Surg Br 2006; 88: 1011–1015.

40.

Goldman

Scuderi

Insall

JN.

2-stage reimplantation for infected total knee replacement. Clin Orthop Relat Res 1996; 331: 118–124.

41.

Barton

Wang

, et al. Two-stage exchange arthroplasty for periprosthetic joint infection following total hip or knee arthroplasty is associated with high attrition rate and mortality. J Arthroplasty 2020; 35: 1384–1389.

42.

Petis

Perry

Mabry

, et al. Two-Stage exchange protocol for periprosthetic joint infection following total knee arthroplasty in 245 knees without prior treatment for infection. J Bone Joint Surg Am 2019; 101: 239–249.

43.

Morley

Blake

Hubble

MJW

, et al. Preservation of the original femoral cement mantle during the management of infected cemented total hip replacement by two-stage revision. J Bone Joint Surg Br 2012; 94: 322–327.

44.

Vasarhelyi

Somerville

Barton

, et al. Survivorship and outcomes of 2-stage revision for infected total hip arthroplasty at a mean of 7-year follow-up. J Arthroplasty 2024; 39(S1): S243–S247.

45.

Kildow

Springer

Brown

, et al. Long term results of two-stage revision for chronic periprosthetic hip infection: a multicenter study. J Clin Med 2022; 11: 1657.

46.

Burastero

Alessio-Mazzola

Cavagnaro

, et al. Conservative two-stage revision with primary components of infected total hip arthroplasty: an analysis of survival, clinical and radiographic outcomes. PLoS One 2020; 15: e0239981.

47.

Winkler

Stoiber

Kaudela

, et al. One stage uncemented revision of infected total hip replacement using cancellous allograft bone impregnated with antibiotics. J Bone Joint Surg Br 2008; 90: 1580–1584.

48.

Qin

Liu

, et al. Comparative reinfection rate of one-stage versus two-stage revision in the management of periprosthetic joint infection following total hip arthroplasty: a meta-analysis. BMC Musculoskelet Disord 2024; 25: 1056.

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