Six-Week Protocol for Two-Stage Exchange Arthroplasty in a High-Risk Population

Periprosthetic joint infection (PJI) remains a devastating and serious complication following total joint arthroplasty. The gold standard for infection eradication is a 2-stage exchange, yet there remains no consensus on optimal timing, antibiotics regimen, holidays, or aspirations. This study aims to evaluate a 6-week 2-stage exchange protocol in treating PJI for hip and knee arthroplasties in a high-risk population.

A retrospective review was conducted of patients who underwent 2-stage revision for PJI between January 1, 2018, and December 31, 2022. Patients met Musculoskeletal Infection Society (2018) criteria for PJI and were treated with a standardized 6-week 2-stage exchange protocol. The primary outcome was infection eradication, defined as the absence of reoperation. Secondary outcomes included infecting organisms, culture positivity rates, and outcomes in patients with mega-prostheses.

Seventy-five patients (77 joints), of which 42 joints (55%) were mega-prosthetics met criteria, 42% demonstrated pathology-proven osteomyelitis. Infection eradication was achieved in 88% of cases at a minimum of 1 year. Nine patients (8/9 were mega-prosthetics) returned for reoperation. The culture positivity rate was 69%, with Staphylococcus aureus and coagulase-negative Staphylococcus being the most common pathogens. Thirty-one patients (40%) remained on suppressive antibiotic therapy for 1 year (27/31 were mega-prosthetics).

A shortened multidisciplinary 6-week protocol for 2-stage exchange revisions is a viable, reliable, and effective strategy for managing PJI. Despite a high-risk population with osteomyelitis and mega-prostheses, outcomes were similar or better than traditional approaches. This shortened protocol demonstrated high eradication rates while potentially reducing resource utilization, costs, and patient's burden.