A Meta-Analysis of Success Rates of One-Stage Versus Two-Stage Revisions in Knee Prosthetic Joint Infections

Prosthetic joint infections (PJIs) pose significant challenges following total joint arthroplasties and cause profound complications. They are associated with significant morbidity and mortality. One-stage revision involves the removal of the infected implant and simultaneous re-implantation of a new prosthesis in a single surgical procedure. The two-stage approach is traditionally more common in the United States and follows a deliberate sequence: the infected implant is first removed, followed by a period of antibiotic therapy, and then a second surgery for implant reinsertion. While two-stage revisions were traditionally considered the gold standard, recent advancements have introduced one-stage revisions as a viable alternative. One-stage revision offers the advantage of being a single procedure, significantly reducing the patient's downtime without a functioning knee. Currently, there has not been a comprehensive exploration of the comparative outcomes between two-stage revisions and one-stage revisions. This systematic review and meta-analysis aimed to assess the outcomes of both one- and two-stage revisions for total knee arthroplasties (TKAs), by utilizing comparison studies as the foundation for analysis. Our search encompassed databases such as MEDLINE (Medical Literature Analysis and Retrieval System Online), Embase, and Cochrane to identify articles examining the comparative efficacy and outcomes of one- and two-stage revision procedures between January 2000 and June 2023. We employed keywords relevant to knee PJIs to identify comparative studies reporting on success rates, reinfection rates, microbiological findings, and other pertinent outcomes. Statistical analysis for this investigation was performed using Review Manager 5.4 (The Cochrane Collaboration, 2020) with a standard significance threshold set at a p-value less than .05. This meta-analysis incorporated six comparison articles and 802 patients. Two-stage revisions (547 patients) were associated with greater success rates (i.e., infection eradication) than one-stage revisions (255 patients) (p = .03). The studies did not suggest a difference in the microbiology of the infections. Two-stage revisions are associated with higher success rates than one-stage revisions in the treatment of knee PJIs. Future randomized controlled trials should evaluate the optimization of the management of these complications.