Single- or Two-stage Revision for Infected Total Hip Arthroplasty? A Systematic Review of the Literature

BACKGROUND: The best approach for surgical treatment of an infected THA remains controversial. Two-stage revision is believed to result in lower reinfection rates but may result in significant functional impairment. Some authors now suggest that single-stage revision may provide comparable results in terms of infection eradication while providing superior functional outcomes. QUESTIONS/PURPOSES: We performed a systematic review to determine whether single- or two-stage revision for an infected THA provides lower reinfection rates and higher functional outcome scores. METHODS: We conducted a comprehensive search of PubMed and Embase, using the search string Infection AND ("total hip replacement" OR "total hip arthroplasty") AND revision. All studies comparing reinfection rates or functional scores for single- and two-stage revision were retrieved and reviewed. A systematic review was performed according to the PRISMA checklist. RESULTS: The initial search retrieved 1128 studies. Following strict exclusion criteria, we identified nine comparative studies comparing reinfection rates (all nine studies) or functional scores (four studies) between single- and two-stage revisions. The overall quality of studies was poor with no randomized studies being identified. Groups often varied in their baseline characteristics. There was no consensus among the studies regarding the relative incidence of reinfection between the two procedures. There was a trend toward better functional outcomes in single-stage surgery, but this reached significance in only one study. CONCLUSIONS: In appropriate patients, single-stage revision appears to be associated with similar reinfection rates when compared with two-stage revision with superior functional outcomes. This concurs with earlier studies, but given the methodologic quality of the included studies, these findings should be treated with caution. High-quality randomized studies are needed to compare the two approaches to confirm these findings, and, if appropriate, to determine which patients are appropriate for single-stage revision.