Single Stage Knee Arthroplasty Revision Surgery, Our Experience with Eleven Cases and Review of the Literature

Andreas X. Papadopoulos M.D. PhD1, Athanasios Karageorgos M.D. PhD1,Charalampos Matzaroglou M.D. Associate Professor2,Spyros A. Syggelos M.D. Assistant Professor3, Christos A. Papadopoulos Physiotherapist1, Ioannis  D. Gelalis M.D. Professor4

1Department of Orthopaedic Surgery, Olympion Medical Center, Patras, Greece
2Department of Rehabilitation Sciences, University of Patras, Greece
3Department Anatomy – Histology – Embryology, University of Patras
4Orthopaedic Department, University of Ioannina, Greece

Knee replacement is a widely performed and very successful procedure for the management of knee arthritis. Nevertheless, it is postulated that a total of 2-5% of primary and revision total knee arthroplasties (TKAs) is infected every year [1,2]. Despite the low incidence, the absolute numbers of prosthetic joint infections (PJIs) are growing, owing to an increased number of replacement surgeries, and are associated with significant morbidity and socioeconomic burden [3,4].

Although several definitions of PJI exist, Musculoskeletal Infection’s Society (MSIS) definition is based on strict criteria and is one of the most used [5].

Patients with certain risk factors have an increased risk to develop PJI [6,7]. Risk factors include presence of systemic or local active infection in an arthritic knee; previous operative procedures in the same knee, diabetes mellitus, malnutrition, smoking, alcohol consumption, co-morbidities, and immunosuppression; end-stage renal disease on hemodialysis, liver disease, intravenous drug abuse, and low safety operative room environment.

PJIs are classified according to the depth of infection, to superficial and deep infections. Superficial infections are limited to the incision and superficial tissues, while deep infections, that involve deep layers, may occur up to one year postoperatively, and influence surgical management strategy. Timing of infection is also an important factor in guiding treatment. PJIs are classified to acute postoperative, within a month of the index procedure, acute haematogenous, presenting with acute symptoms in a previously well – functioning joint, and late chronic, where infection develops later than one month postoperatively [8].

Management of PJI’s is mainly surgical, reserving conservative treatment for patients unable to undergo surgery [9]. Surgical options include debridement and retention of the prosthetic implants (DAIR), two – stage exchange revision, single – stage exchange revision, permanent resection arthroplasty, and finally amputation as the last measure [10]. DAIR is a viable option in early stages of acute infections, but established chronic infections necessitate more radical methods.

Two – stage revision that was originally described by Install [11], secondly modified through the development of static spacers [12], and then articulating spacers [13], is considered the gold standard of TKA infection management [14]. A large volume of literature reports successful eradication of PJIs in more than 90% of patients using this approach [15,16,17]. Nevertheless, this procedure is costly, time-consuming, develops stiffness, arthrofibrosis, impairs mobility and increases inpatient stay. Single-stage revision arthroplasty for infection was first described in the 1980s [18, 19], has gained popularity for use in selected patients [20]. Infection control using this approach is achieved in 67% to 95% of patients [21, 22, 23, 24]. Furthermore, it is associated with less patient morbidity, improving functional outcome and reducing cost [25, 20].

This paper seeks to systematically review the results of using single – stage revision arthroplasty for chronic infection of TKAs. Furthermore, we report our experience with eleven cases of chronic knee arthroplasty infection, which were treated with the aforementioned technique.

Keywords: Single Stage Knee, Arthroplasty Revision Surgery

Free Full-text PDF

How to cite this article:
Andreas X. Papadopoulos , Athanasios Karageorgos, Charalampos Matzaroglou, Spyros A. Syggelos, Christos A. Papadopoulos, Ioannis D. Gelalis. Single Stage Knee Arthroplasty Revision Surgery, Our Experience with Eleven Cases and Review of the Literature. American Journal of Orthopedic Research and Reviews, 2021; 4:20. DOI: 10.28933/ajorr-2021-01-1605


1. Patel A, Pavlou G, Mújica-Mota RE, Toms AD.: The epidemiology of revision total knee and hip arthroplasty in England and Wales: a comparative analysis with projections for the United States. A study using the National Joint Registry dataset. Bone Joint J. 2015 Aug; 97-B(8):1076-81.
2. Kurtz SM, Lau E, Schmier J, Ong KL, Zhao K, Parvizi J.: Infection burden for hip and knee ar-throplasty in the United States. J Arthroplasty. 2008 Oct;23(7):984-91. doi: 10.1016/j.arth.2007. 10.017. Epub 2008 Apr 10.
3. Bratzler DW, Hunt DR.: The surgical infection prevention and surgical care improvement pro-jects: national initiatives to improve outcomes for patients having surgery. Clin Infect Dis. 2006 Aug 1;43(3):322-30.
4. Bozic KJ, Ries MD.: The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization. J Bone Joint Surg Am. 2005 Aug;87(8):1746-51.
5. Parvizi J, Zmistowski B, Berbari EF, et al.: New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res. 2011 Nov;469(11): 2992-4.
6. Zimmerli W, Trampuz A, Ochsner PE.: Prosthet-ic-joint infections. N Engl J Med. 2004 Oct 14;351(16):1645-54.
7. Wang CJ, Huang TW, Wang JW, Chen HS. : The often poor clinical outcome of infected total knee arthroplasty. J Arthroplasty. 2002 Aug;17(5):608-14.
8. Tsukayama DT, Estrada R, Gustilo RB. : Infection after total hip arthroplasty. A study of the treat-ment of one hundred and six infection. J Bone Joint Surg Am 1996 Apr;78(4):512-23.
9. Tsukayama DT, Wicklund B, Gustilo RB. : Sup-pressive antibiotic therapy in chronic prosthetic joint infections. Orthopedics. 1991 Aug;14(8):841-4.
10. Osmon DR, Berbari EF, Berendt AR, et al.: Di-agnosis and management of prosthetic joint in-fection: clinical practice guidelines by the Infec-tious Diseases Society of America. Clin Infect Dis. 2013 Jan; 56(1):1-25.
11. Insall JN, Thompson FM, Brause BD.: Two-stage reimplantation for the salvage of infected total knee arthroplasty. J Bone Joint Surg Am. 1983 Oct;65(8):1087-98.
12. Calton TF, Fehring TK, Griffin WL. : Bone loss associated with the use of spacer blocks in in-fected total knee arthroplasty. Clin Orthop Relat Res. 1997 Dec;(345):148-54.
13. Goldstein WM, Kopplin M, Wall R, Berland K.: Temporary articulating methylmethacrylate anti-biotic spacer (TAMMAS). A new method of in-traoperative manufacturing of a custom articu-lating spacer. J Bone Joint Surg Am2001;83-A:92-7.
14. Leone S, Borrè S, Monforte Ad, et al. GISIG (Gruppo Italiano di Studio sulle Infezioni Gravi) Working Group on Prosthetic Joint Infections.: Consensus document on controversial issues in the diagnosis and treatment of prosthetic joint infections. Int J Infect Dis. 2010 Oct; 14 Suppl 4:s67-77.
15. Haddad FS, Masri BA, Campbell D, McGraw RW, Beauchamp CP, Duncan CP.: The PROSTALAC functional spacer in two-stage revision for in-fected knee replacements. Prosthesis of antibi-otic-loaded acrylic cement. J Bone Joint Surg Br. 2000 Aug;82(6): 807-12.
16. Laffer RR , Graber P, Ochsner PE, Zimmerli W.: Outcome of prosthetic knee-associated infection: evaluation of 40 consecutive episodes at a single centre. Clin Microbiol Infect. 2006 May;12(5):433-9.
17. Zimmerli W, Trampuz A, Ochsner PE.: Prosthet-ic-joint infections. N Engl J Med. 2004 Oct 14;351(16):1645-54.
18. Freeman MA, Sudlow RA, Casewell MW, Radcliff SS.: The management of infected total knee re-placements. J Bone Joint Surg Br. 1985 Nov; 67(5):764-8.
19. Buchholz HW, Elson RA, Engelbrecht E, Lo-denkämper H, Röttger J, Siegel A.: Management of deep infection of total hip replacement. J Bone Joint Surg Br. 1981;63-B(3):342-53.
20. Oussedik SI, Dodd MB, Haddad FS. : Outcomes of revision total hip replacement for infection after grading according to a standard protocol. J Bone Joint Surg Br. 2010 Sep;92(9):1222-6.
21. Buechel FF, Femino FP, D’Alessio J.: Primary exchange revision arthroplasty for infected total knee replacement: a long-term study. Am J Or-thop (Belle Mead NJ). 2004 Apr;33(4):190-8.
22. Göksan SB, Freeman MA.: One-stage reimplan-tation for infected total knee arthroplasty. J Bone Joint Surg Br. 1992 Jan;74(1):78-82.
23. Singer J, Merz A, Frommelt L, Fink B.: High rate of infection control with one-stage revision of septic knee prostheses excluding MRSA and MRSE. Clin Orthop Relat Res. 2012 May;470(5):1461-71.
24. Sofer D, Regenbrecht B, Pfeil J.: [Early results of one-stage septic revision arthroplasties with an-tibiotic-laden cement. A clinical and statistical analysis]. Orthopade. 2005 Jun;34(6):592-602.
25. Gulhane S, Vanhegan IS, Haddad FS.: Single stage revision: regaining momentum. J Bone Joint Surg Br. 2012 Nov;94(11 Suppl A):120-2.
26. Ji B, Zhang X, Xu B, Guo W, Mu W, Cao L.: Sin-gle-Stage Revision for Chronic Fungal Peripros-thetic Joint Infection: An Average of 5 Years of Follow-Up. J Arthroplasty. 2017 Aug;32(8):2523-2530.
27. Jenny JY, Barbe B, Cazenave A, Roche O, Massin P.: Patient selection does not improve the suc-cess rate of infected TKA one stage exchange. Knee. 2016 Dec;23(6):1012-1015.
28. Zahar A, Kendoff DO, Klatte TO, Gehrke TA.: Can Good Infection Control Be Obtained in One-stage Exchange of the Infected TKA to a Rotating Hinge Design? 10-year Results. Clin Orthop Relat Res. 2016 Jan;474(1):81-7
29. Haddad FS, Sukeik M, Alazzawi S.: Is sin-gle-stage revision according to a strict protocol effective in treatment of chronic knee arthroplasty infections? Clin Orthop Relat Res. 2015 Jan; 473(1):8-14.
30. Tibrewal S, Malagelada F, Jeyaseelan L, Posch F, Scott G.: Single-stage revision for the infected total knee replacement: results from a single centre. Bone Joint J. 2014 Jun;96-B(6):759-64.
31. Klatte TO, Kendoff D, Kamath AF, et al.: Sin-gle-stage revision for fungal peri-prosthetic joint infection: a single-centre experience. Bone Joint J. 2014 Apr;96-B(4):492-6.
32. Baker P, Petheram TG, Kurtz S, Konttinen YT, Gregg P, Deehan D.: Patient reported outcome measures after revision of the infected TKR: comparison of single versus two-stage revision. Knee Surg Sports Traumatol Arthrosc. 2013 Dec; 21(12):2713-20.
33. Jenny JY, Barbe B, Gaudias J, Boeri C, Argenson JN.: High infection control rate and function after routine one-stage exchange for chronically in-fected TKA. Clin Orthop Relat Res. 2013 Jan; 471(1):238-43.
34. Whiteside LA, Peppers M, Nayfeh TA, Roy ME. Methicillin-resistant Staphylococcus aureus in TKA treated with revision and direct intra-articular antibiotic infusion. Clin Orthop Relat Res. 2011 Jan;469(1):26-33
35. Mereddy P, Pydisetty R, Howard K, Kay PR, Parkinson RW.: ‘2-in 1’single stage revision for infected total knee replacement: the wirral and wrightington experience. J Bone Joint Br Proc 2011; 93-B:15
36. Anguita-Alonso P, Rouse MS, Piper KE, Jacof-sky DJ, Osmon DR, Patel R.: Comparative study of antimicrobial release kinetics from polymethylmethacrylate. Clin Orthop Relat Res. 2006 Apr;445:239-44.
37. Salvati EA, Callaghan JJ, Brause BD, Klein RF. Small RD.: Reimplantation in infection. Elution of gentamicin from cement and beads. Clin Orthop Relat Res. 1986 Jun;(207):83-93
38. Lloyd KC, Stover SM, Pascoe JR, Baggot JD, Kurpershoek C, Hietala S.: Plasma and synovial fluid concentrations of gentamicin in horses after intra-articular administration of buffered and un-buffered gentamicin. Am J Vet Res. 1988 May;49(5):644-9
39. Neut D, Hendriks JG, van Horn JR, van der Mei HC, Busscher HJ.: Pseudomonas aeruginosa biofilm formation and slime excretion on antibi-otic-loaded bone cement. Acta Orthop. 2005 Feb; 76(1):109-14.
40. Kunutsor SK, Whitehouse MR, Lenguerrand E, Blom AW, Beswick AD; INFORM Team. Re-Infection Outcomes Following One- And Two-Stage Surgical Revision of Infected Knee Pro- sthesis: A Systematic Review and Me-ta-Analysis. PLoS One. 2016 Mar 11;11(3):e0151537.