Courtesy: Dr Hemant Wakankar, Dr Ashok Shyam, Ortho TV

Two-Stage Revision for Periprosthetic Joint Infection (PJI)

Core Concept & Rationale

• Primary Concern: Recurrent infection remains the main driver for choosing two-stage revision.

• Gold Standard: Two-stage exchange arthroplasty remains the benchmark for chronic PJI eradication.

• Microbiological Prerequisite:

  • Discontinue all systemic antibiotics for at least 2 weeks before joint aspiration or intraoperative tissue sampling.

  • Ensures reliable culture yields and accurate sensitivity profiles.

• Treatment Options:

  • Antibiotic suppression alone for non-surgical or medically fragile patients.

  • Debridement, Antibiotics, and Implant Retention (DAIR).

  • Single-stage revision arthroplasty.

  • Two-stage revision arthroplasty.

Literature Benchmarks & Eradication Rates

• Single-Stage Reported Outcomes: Eradication rates range between 70% and 85% in carefully selected cohorts.

• Two-Stage Literature Rates: Overall success ranges between 80% and 100%.

• Italian Series: Reported an 89.9% eradication rate at a mean follow-up of 3.4 years.

• Royal National Orthopaedic Hospital (Stanmore, UK) Series (2015):

  • Evaluated 51 complex tertiary referral cases (mean follow-up of 43 months).

  • Primary two-stage revisions achieved infection control in 65% of patients.

  • Repeat two-stage revisions (19 cases) dropped to a 42% success rate.

  • Third two-stage attempts (5 cases) succeeded in only 3 patients; remaining cases required salvage amputation.

  • Multidrug-resistant (MDR) organisms occurred in 69% of these complex cases.

  • Polymicrobial infections occurred in 47% of patients.

• Rothman Institute Series (Parvizi et al., 1999–2013):

  • Analyzed 504 PJI cases from 32,000 primary total joints.

  • Overall two-stage success rate was 81.4% at a mean follow-up of 56 months.

  • Mean interval from resection to reimplantation was 4.2 months.

  • 11.9% of patients required an unplanned interim spacer exchange.

  • 87 of 504 patients (17.3%) never completed second-stage reimplantation.

  • Salvage outcomes in this non-reimplanted group included 86 amputations, 5 Girdlestone resections, and 4 arthrodeses.

  • 72 patients retained their functional spacer indefinitely (termed a 1.5-stage revision).

  • 36 patients died prior to planned second-stage reimplantation.

Contraindications to Single-Stage & Failure Predictors

• Immunosuppressed host status.

• Severe unoptimized medical comorbidities.

• Polymicrobial periprosthetic infection.

• Multidrug-resistant (MDR) bacterial pathogens.

• Significant local soft-tissue compromise or extensive sinus tracts.

• History of multiple failed prior revision procedures.

Surgical Technique: Stage 1 (Resection & Spacer)

• Antibiotic Timing: Withhold empirical perioperative antibiotics until deep tissue and fluid specimens are collected.

• Explant & Debridement:

  • Remove all prosthetic components and acrylic bone cement.

  • Preserve remaining host bone stock.

  • Perform a complete synovectomy and excise all non-viable tissue.

• Spacer Selection:

  • Static Spacers:

    • Fashioned with high-dose antibiotic-impregnated bone cement (typically two packs).

    • Cement stems are placed into the tibial and femoral canals.

    • An additional block bridges the joint gap anteriorly.

    • Independent cement blocks prevent cement-bone interlock and minimize bone loss during extraction.

    • Requires post-operative cylinder cast or brace immobilization; permits protected weight-bearing.

  • Articulating Spacers / Prefabricated Molds:

    • Preformed molds (e.g., Pelicos molds) maintain joint motion and collateral ligament tension.

    • Prevents severe soft-tissue contracture and eases second-stage exposure.

Interim Management & Stage 2 (Reimplantation)

• Interim Medical Therapy:

  • Targeted intravenous antibiotic therapy for 6 weeks directed by intraoperative cultures.

  • Monitor wound healing and serial serum inflammatory markers (ESR and CRP).

• Stage 2 Timing:

  • Delay reimplantation until the joint is clinically quiet, the wound has healed, and serum markers trend down.

• Second-Stage Procedure:

  • Carefully extract the cement spacer without sacrificing residual cortical bone.

  • Send repeat tissue samples for frozen section and microbiological culture.

  • Reconstruct the joint using modular revision implants (e.g., LCCK / constrained or hinged systems) with appropriate stems, augments, or cones.