One‐stage versus two‐stage exchange arthroplasty for infected total knee arthroplasty: a systematic review

Abstract Purpose Infection complicating total knee arthroplasty (TKA) has serious implications. Traditionally the debate on whether one‐ or two‐stage exchange arthroplasty is the optimum management of infected TKA has favoured two‐stage procedures; however, a paradigm shift in opinion is emerging. This study aimed to establish whether current evidence supports one‐stage revision for managing infected TKA based on reinfection rates and functional outcomes post‐surgery. Methods MEDLINE/PubMed and CENTRAL databases were reviewed for studies that compared one‐ and two‐stage exchange arthroplasty TKA in more than ten patients with a minimum 2‐year follow‐up. Results From an initial sample of 796, five cohort studies with a total of 231 patients (46 single‐stage/185 two‐stage; median patient age 66 years, range 61–71 years) met inclusion criteria. Overall, there were no significant differences in risk of reinfection following one‐ or two‐stage exchange arthroplasty (OR −0.06, 95 % confidence interval −0.13, 0.01). Subgroup analysis revealed that in studies published since 2000, one‐stage procedures have a significantly lower reinfection rate. One study investigated functional outcomes and reported that one‐stage surgery was associated with superior functional outcomes. Scarcity of data, inconsistent study designs, surgical technique and antibiotic regime disparities limit recommendations that can be made. Conclusion Recent studies suggest one‐stage exchange arthroplasty may provide superior outcomes, including lower reinfection rates and superior function, in select patients. Clinically, for some patients, one‐stage exchange arthroplasty may represent optimum treatment; however, patient selection criteria and key components of surgical and post‐operative anti‐microbial management remain to be defined. Level of evidence III.