Don't Risk Your Patient's Leg: The Dangers of 1-Stage Exchange Arthroplasty
How meticulous debridement, antibiotic spacers, and strict reimplantation criteria resulted in a 100% success rate for early and acute hematogenous infections.
Total hip arthroplasty (THA) has conferred functional independence and improved quality of life for millions of patients in the United States and worldwide. Sadly, the operation of the century also has resulted in infection for as many as 1 (international registry data) to 2 (United States Medicare data) of every 100 patients. Absent reliable prevention measures for PJI, safe and effective treatment protocols to manage this complication have become an essential defense. Surgical treatments include irrigation and debridement (I&D) with implant retention; 1-stage exchange arthroplasty with implant removal and reimplantation in the same operative episode; and 2-stage exchange arthroplasty involving implant removal and placement of a temporary antibiotic-loaded spacer in the first surgery with a second surgery for reimplantation.
Two-stage treatment has been the gold standard in the United States, whereas 1-stage treatment is more common in Europe. The popularity of 1-stage exchange arthroplasty has been growing in the United States, with reports of comparable or better outcomes, reduced morbidity and mortality, enhanced quality of life, and cost savings. It is a concern, however, that conclusions implying the equivalence and in several cases the superiority of 1-stage treatment for PJI based on low-quality studies confounded by substantial heterogeneity in infection characteristics, patient comorbidities, bacterial profiles, details of treatment, definitions of PJI, and definitions of success are so rapidly influencing treatment decisions.
