Chronic infections in hip arthroplasties: comparing risk of reinfection following one-stage and two-stage revision: a systematic review and meta-analysis

Jeppe Lange^1,2, Anders Troelsen³, Reimar W Thomsen⁴, Kjeld Søballe^1,5
1Lundbeck Foundation Centre for Fast-Track Hip and Knee Surgery, Aarhus C, ²Center for Planned Surgery, Silkeborg Regional Hospital, Silkeborg, ³Department of Orthopaedics, Hvidovre Hospital, Hvidovre, ⁴Department of Clinical Epidemiology, Aarhus University Hospital, Aalborg, ⁵Department of Orthopaedics, Aarhus University Hospital, Aarhus C, Denmark

Background: Two-stage revision is regarded by many as the best treatment of chronic infection in hip arthroplasties. Some international reports, however, have advocated one-stage revision. No systematic review or meta-analysis has ever compared the risk of reinfection following one-stage and two-stage revisions for chronic infection in hip arthroplasties.
Methods: The review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Relevant studies were identified using PubMed and Embase. We assessed studies that included patients with a chronic infection of a hip arthroplasty treated with either one-stage or two-stage revision and with available data on occurrence of reinfections. We performed a meta-analysis estimating absolute risk of reinfection using a random-effects model.
Results: We identified 36 studies eligible for inclusion. None were randomized controlled trials or comparative studies. The patients in these studies had received either one-stage revision (n = 375) or two-stage revision (n = 929). Reinfection occurred with an estimated absolute risk of 13.1% (95% confidence interval: 10.0%–17.1%) in the one-stage cohort and 10.4% (95% confidence interval: 8.5%–12.7%) in the two-stage cohort. The methodological quality of most included studies was considered low, with insufficient data to evaluate confounding factors.
Conclusions: Our results may indicate three additional reinfections per 100 reimplanted patients when performing a one-stage versus two-stage revision. However, the risk estimates were statistically imprecise and the quality of underlying data low, demonstrating the lack of clear evidence that two-stage revision is superior to one-stage revision among patients with chronically infected hip arthroplasties. This systematic review underscores the need for improvement in reporting and collection of high-quality data and for large comparative prospective studies on this issue.

Keywords: infection, arthroplasty, hip replacement, one-stage, two-stage, reoperation