OrthoBuzz spotlights a prospective, multicenter, randomized trial now in JBJS.
Periprosthetic joint infection (PJI) can severely impact a patient’s life and is a challenge for surgeons to treat. However, as Fehring et al. point out in a new report, data in the literature have been conflicting as to which is the best treatment strategy for chronic PJI: 1-stage or 2-stage exchange arthroplasty?
“Because of the lack of prospective, randomized outcome studies comparing 1- and 2-stage approaches, surgeons in North America continue to prefer a 2-stage strategy for the management of chronic PJI. In contrast, 1-stage treatment has been adopted in some European centers,” they write.
In the July 15, 2026 issue of JBJS, the authors present the results of a prospective, multicenter, randomized trial comparing 1- and 2-stage treatment of chronic PJI following primary total hip or knee arthroplasty. Of note, the study specifically included patients with draining sinuses, comorbidities, and resistant organisms. Fourteen centers participated in the study.
The investigators found that 1-stage treatment was statistically noninferior to 2-stage treatment at 2 years, with a success rate of 97% for 1-stage and 91% for 2-stage.
Access the full study at JBJS.org: One-Stage Versus Two-Stage Exchange Arthroplasty for Periprosthetic Joint Infection. A Prospective Randomized Trial
Study Participants
- Patients presenting for surgical treatment of chronic PJI with a known organism following primary total hip or total knee arthroplasty. Infection was defined by Musculoskeletal Infection Society (MSIS) criteria. Patients with draining sinuses, comorbidities, and resistant organisms were included
- 323 patients were randomized (166 one-stage and 157 two-stage)
- 258 patients had 2-year follow-up (135 one-stage and 123 two-stage)
- Immunocompromised patients and patients with prior revision, culture-negative infection, fungal infection, or soft-tissue involvement precluding wound closure were excluded
Results
- 97% success rate for 1-stage and 91% success rate for 2-stage at 2 years
- 3-times the odds of overall success for 1-stage vs. 2-stage in a regression analysis, and 3-times the odds of success after adjusting for McPherson host grade, resistant organisms, and draining sinuses
“We believe that 1-stage treatment should be strongly considered as the standard of care for patients with chronic infection following primary hip and knee arthroplasty, provided the indications and protocols described here are explicitly followed,” the investigators concluded. They caution against extrapolating their findings to other patient cohorts or clinical situations.
Access the full study and a downloadable visual abstract at JBJS.org: One-Stage Versus Two-Stage Exchange Arthroplasty for Periprosthetic Joint Infection. A Prospective Randomized Trial
Additional perspective on this study is provided in a commentary by Andrew M. Schwartz, MD: One-Stage Versus Two-Stage: A Potential Paradigm Shift for Patients and Surgeons?