Managing chronic periprosthetic joint infection (PJI) following a total knee arthroplasty remains one of the most grueling clinical battles in modern orthopedics. For decades, the two-stage exchange has stood as the undisputed “gold standard” for eradication. However, recent high-profile literature has heavily criticized this protocol, pointing to alarming morbidity rates during the interstage period and the early post-reimplantation window. These reports have sparked a growing, aggressive push within the community to adopt single-stage exchanges, operating under the assumption that the two-stage treatment itself is the root cause of these high complication rates.
But is the two-stage protocol truly to blame, or are we simply looking at the statistical reality of operating on some of the sickest, most systemically compromised patients in the healthcare system? When high-volume academic referral centers publish their complication rates, their cohorts are often loaded with late-chronic infections and severe medical comorbidities. If the morbidity is cohort-specific rather than protocol-specific, abandoning the two-stage exchange for a single-stage gamble could be a disastrous clinical miscalculation. We set out to rigorously audit the true complication profile of the two-stage exchange by directly comparing an independent cohort against the most comprehensive morbidity study published to date.
