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One-, 1.5-, or Two-Stage Revision for Periprosthetic Hip and Knee Joint Infection? A Network Meta-Analysis Comparing
Amr Selim1, Abdelrahman Ibrahim2, Abu Saeed3
1Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, UK, School of Medicine, Keele University, Staffordshire, UK.
Introduction:
Periprosthetic joint infection (PJI) remains a devastating complication following total hip and knee arthroplasty. Revision strategies for chronic PJI include one-, 1.5-, and two-stage revision procedures. This study compared clinical outcomes of these revision strategies using a network meta-analytic approach.
Methods:
A systematic review and Bayesian network meta-analysis were conducted. Databases were searched through October 2025. Randomized controlled trials and comparative cohort studies evaluating one-, 1.5-, and two-stage revision procedures for hip and knee chronic PJI were included. Chronic PJI was defined by Musculoskeletal Infection Society/International Consensus Meeting (MSIS/ICM) criteria, excluding acute postoperative and hematogenous infections. In the primary network, hip and knee revisions were analyzed together, with pre-specified hip-only and knee-only subgroup networks reported separately. There were 54 studies (10,055 patients) eligible for inclusion.
Results:
Compared with two-stage revision, both one- and 1.5-stage revisions were associated with significantly lower odds of reinfection (odds ratio (OR) = 0.84, 95% credible interval (CrI) 0.72 to 0.99 and OR = 0.58, 95% CrI 0.37 to 0.89, respectively) and reoperation (OR = 0.79, 95% CrI 0.63 to 0.99 and OR = 0.20, 95% CrI 0.05 to 0.82, respectively). The 1.5-stage strategy demonstrated significantly higher infection control success (OR = 1.64, 95% CrI 1.07 to 2.51). The one-stage revision was associated with fewer overall complications (OR = 0.64, 95% CrI 0.48 to 0.86). The 1.5-stage strategy showed a significantly increased risk of aseptic loosening (OR = 4.80, 95% CrI 1.57 to 20.79), while two-stage revision performed best.
Conclusion:
The 1.5-stage revision was associated with the most favorable infection-related outcomes, but a higher risk of aseptic loosening. The one-stage revision showed intermediate results, while the two-stage revision performed less favorably but had the lowest loosening risk. Because the evidence is largely observational and subject to confounding by indication, these associations should be interpreted cautiously.
