Single-stage revision for chronic fistulized infected total knee arthroplasty achieves infection-free survival comparable to non-fistulized cases.

Abstract Purpose The presence of a sinus tract in chronic periprosthetic joint infection (PJI) has traditionally been considered a contraindication to single‐stage total knee arthroplasty (TKA) revision. However, an increasing number of surgeons are now performing single‐stage revisions in this context, despite limited comparative data. This study aimed to evaluate whether single‐stage revision outcomes differ between fistulized (TKA/F+) and non‐fistulized (TKA/F–) infected TKAs. Method A retrospective case‐control study was conducted at a regional reference centre for bone and joint infections, including all patients who underwent single‐stage TKA revision for chronic infection between January 2013 and June 2023, with a minimum two‐year follow‐up. Patients were grouped according to the presence (TKA/F+) or absence (TKA/F–) of a sinus tract. The primary outcome was infection‐free survival. Surgical procedures, antibiotic protocols and follow‐up schedules were standardized across both groups. Survival analysis was performed using the Kaplan–Meier method and log‐rank test. Results A total of 285 patients were included: 47 TKA/F+ and 238 TKA/F–. The TKA/F+ group had significantly older patients, higher body mass index (BMI) and American Society of Anesthesiologists (ASA) scores, and more comorbidities. Polymicrobial infections were more frequent in TKA/F+ (57% vs. 22%). Despite these differences, infection‐free survival rates were similar: 81.2% (±4.3) in TKA/F+ versus 83.6% (±2.2) in TKA/F–, with no statistically significant difference. Surgical management included extensive debridement, systematic sampling, gentamicin‐loaded cement and local flap coverage when needed. Conclusion Single‐stage revision may be effective in patients with a sinus tract when performed within a structured surgical and antibiotic protocol. Some stronger studies are needed to assess whether the presence of a sinus tract should not be considered an absolute contraindication. These findings support broader consideration of single‐stage strategies in chronic TKA infections. Level of Evidence Level III.