What are pros and cons of it vis-a-vis the gold standard two stage revision surgery?
Helo Raju,
I believe it is safe based on what I have seen when working in orthopedics. However, the surgeons I used to work with liked to perform a single stage revision if the procedure was associated with heavy concentrations of local intra-articular antibiotics (I do not recall what antibiotic was used). But the procedure was very similar to one of the articles I am suggesting below.
My experience supporting the patients during research and intervention was that these patients were no different from the ones who had the two-stage revision. In fact some of them did better because of the heavy antibiotics. Moreover, it is only one procedure, and the cost is also lower to the hospital (In Canada - public system - lower cost is very important).
Best regards!!
Both articles are from 2015 and 2014 - very recent findings
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4524167/
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4390922/
My tactics depends on several variables. Early or late infection ? Microbiological findings: less severe (sensitive to adequate antibiosis) or severe (resistent to most antibiotics) ? Bone stock: good or severely damaged ? In early, less severe and good bone stock - single stage revision. In the other cases- 2-stage-revision. Arthrodesis should not be excluded in persistent infection.
Yes, I also agree that there are several variable and these variable may provide the suitable conditions for surgery. It means if patients meets some conditions it seems safe to proceed as I suggested above.
Hi,
single stage treatment of an infected artificial joint is an excellent, time proven, solution provided that it is performed by a high volume dedicated team focused into prosthetic joint infection with algorithms for selection of appropriate patients, surgical skills needed for adequate radical debridement (which is extremely important), antibiofim antibiotic protocols tailored for each particular causative agent and steered by a dedicated infectologist. An excellent microbiology support with knowledge how to cultivate difficult to grow bacteria is also indispensable.
If a dedicated team is not available the safest and wisest option is a two stage protocol with an early reimplantation in case of easy to treat causative agents.
Dear Dr. Trebse,
Did you publish your experience with single stage revision ?
Please, post some references. Especially, what percentage of single-stage revisions needed re-revision, re-re-revison, etc. in your series. As far as I remember, in the past Dr. Bucholz of the St.Georg Endoklinik in Hamburg published cases that have been revised up to 7 times till the infection settled. It is interesting to know the recent situation.
Regards
One-stage exchange is moste effective and least damaging for the tissues as well as least toxic because you spare one anaesthesia und those: conditions:
You have a clear microbiology-antibiogram
It is not a multiresistent germ
You have the facilities to add the appropriate antibiotics into the cement in order to generate a long effective local antibioses.
Or the germ/germs are sensitive to gentamicin or clindamycin; then you can use this readymade cement. The microbiologist with the moste experience in this matter is Lars Frommelt (available in reaserchgate). He has worked on thousands of such cases.
I feel that the best case scenario for one stage revision for infected TKA is as follow:
1. Non-immunocompromised patient with no significant comorbid conditions like diabetes, morbid obesity, Rheumatoid arthritis, etc.
2. Established microbial growth of organisms with a known antibiotic susceptibility.
3. Absence of chronic discharging sinus and good skin condition over the knee
4. Insignificant bone loss with no major ligament laxity
5. EXPERIENCED SURGEON AND GOOD INFRASTRUCTURE
Dear dr Tanchev,
Our team treats about 70 prosthetic join infections a year and about 20 % are one stage revisions. I have not yet published the results but I am planning to publish all the series included in the algorithmic approach including debridements and two stages with early late and no re-implantations. It is my experience that one stage is surgically the most demanding because it needs years of experience to be able to be radical enough but still preserving the functional tissues: muscles and tendons. In our algorithm we consider every treatment as a failure if it needs more than one debridement. In our hands the one stage has about 80% of long term success rate using mostly cementless implants.
One stage revision is a well established option of treatment in infected TKRs. There is the need to remember that only certain patients will be benefited from such treatment as they need to be selected and the surgical team performing them needs to be experienced on the subject and understand fully the concept. There are publications mainly from the University of Cardiff by Rhidian Morgan-Jones who is expert on the field.
The selection of one or two-stage exchange in the treatment of periprosthetic joint infection remains a controversial issue,
One-stage exchange appears to be a viable alternative to two-stage exchange, provided there are no contra-indications, producing similar results in terms of eradication rates and functional outcomes, and offering the advantage of a unique surgical procedure, lower morbidity and reduced costs.
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