What is a 2-Stage Revision Arthroplasty?
A 2-stage revision arthroplasty is a surgical procedure used to treat infected joint replacements, most commonly in the knee or hip. Typically, this is carried out in 2 stages: infected tissue and all joint replacement implants are removed in the first stage, and, after the infection is completely cleared, a new artificial joint is inserted in the second stage.
Indications for a 2-Stage Revision Arthroplasty
A 2-stage revision arthroplasty is typically indicated for the treatment of periprosthetic joint infections (PJI) when the infection cannot be managed effectively by other methods. Specific indications include:
- Chronic or persistent infection that has not responded to previous treatments or single-stage revision attempts.
- Failure of prior debridement, antibiotics, and implant retention (DAIR) procedures.
- Significant bone loss or damage around the joint that complicates infection management and requires reconstruction.
- Poor soft tissue condition around the joint, making it difficult to achieve effective infection control
Preparation for a 2-Stage Revision Arthroplasty
In general, preparation for 2-stage revision arthroplasty may involve the following steps:
- A comprehensive medical evaluation, including medical history review, physical examination, medications/supplements, and allergies.
- Blood tests (e.g., ESR, CRP) to assess the level of inflammation.
- Imaging studies (e.g., X-rays, MRI) to evaluate the joint and surrounding structures.
- Joint aspiration for culture and sensitivity to identify the causative organisms.
- Initiation of appropriate antibiotic treatment based on culture results and sensitivity testing.
- Instructions on fasting before surgery, stopping smoking, and limiting alcohol consumption.
Procedure for a 2-Stage Revision Arthroplasty
In general, a 2-stage revision arthroplasty may involve the following steps:
Stage 1: Removal of the Infected Prosthesis
- Anesthesia: General or regional anesthesia is administered.
- Incision and Exposure: An incision is made to access the infected joint.
- Removal of the Infected Prosthesis: The infected joint prosthesis is removed completely. This includes both the femoral and acetabular components in hip replacements or femoral, tibial, and patellar components in knee replacements.
- Debridement: Thorough cleaning and removal of infected tissue and debris from the joint area, including any necrotic bone.
- Insertion of an Antibiotic Spacer: A temporary antibiotic-loaded cement spacer is placed in the joint. This spacer helps to maintain joint space, provides some degree of mobility, and delivers high local concentrations of antibiotics to the infected area.
- Closure: The wound is closed in layers, and a drain may be placed to remove excess fluid.
Interval Period
- Antibiotic Therapy: During the interval between surgeries, the patient receives systemic antibiotics (usually intravenous) for a period that can range from several weeks to a few months, depending on the severity of the infection and the response to treatment.
- Assessment for Infection Clearance: A new prosthetic joint is implanted once the infection is confirmed to be cleared. This is confirmed through clinical assessment, blood tests (e.g., ESR, CRP), and sometimes joint aspiration.
Stage 2: Reimplantation of a New Prosthesis
- Anesthesia: General or regional anesthesia is administered.
- Incision and Exposure: The previous incision is typically used to access the joint.
- Removal of Spacer: The antibiotic spacer is carefully removed.
- Further Debridement: Additional debridement may be performed if necessary to ensure all infected tissue is removed.
- Implantation of New Prosthesis: New prosthetic components are implanted. The choice of components and fixation technique (cemented or uncemented) depends on the quality of the bone and the patient’s condition.
- Closure: The wound is closed in layers, and a drain may be placed to remove excess fluid.
Postoperative Care and Recovery
In general, postoperative care and recovery for 2-stage revision arthroplasty may include:
- The patient will be transferred to the recovery room where the patient’s vital signs, such as oxygen saturation and blood pressure, are closely monitored as they wake up from anesthesia.
- It is common to experience pain and swelling around the treatment area. Medications are provided as needed to address these.
- Incision care instructions are provided to keep the incision site clean and dry.
- A structured rehabilitation program is initiated to restore joint function and mobility. This includes physical therapy and exercises to strengthen muscles and improve range of motion.
- Regular follow-up visits to monitor the patient’s recovery, assess the function of the new prosthesis, and ensure there are no signs of recurrent infection.
Risks and Complications
Risks and complications associated with 2-stage revision arthroplasty include:
- Infection
- Bleeding
- Wound healing problems
- Implant-related issues
- Functional limitations
- Damage to nerve or blood vessels
Benefits
Advantages of 2-stage revision arthroplasty include:
- Thorough infection control
- Improved joint function
- High success rate
- Improved long-term outcomes