JOA - 2026-09-07 - Journal Article
One-, 1.5-, or Two-Stage Revision for Periprosthetic Hip and Knee Joint Infection? A Network Meta-Analysis Comparing Revision Strategies.
Selim A, Ibrahim A, Saeed A, Khamdan K, Farhan-Alanie MM, Sadiq S, Govilkar S, Thomas G
Topics
Key Takeaway
In 54 studies of 10,055 chronic PJI patients, 1.5-stage revision achieved the highest infection control success versus two-stage (OR 1.64) but carried a 4.8-fold increased risk of aseptic loosening.
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Summary
This Bayesian network meta-analysis compared one-, 1.5-, and two-stage revision strategies for chronic PJI (MSIS/ICM criteria) across hip and knee arthroplasty using RCTs and comparative cohort studies through October 2025. Both one-stage (OR 0.84) and 1.5-stage (OR 0.58) revisions showed significantly lower reinfection odds versus two-stage, and 1.5-stage demonstrated superior infection control success (OR 1.64). However, 1.5-stage carried a markedly elevated aseptic loosening risk (OR 4.80), while one-stage had fewer overall complications (OR 0.64) versus two-stage.
Key Limitation
Confounding by indication is the dominant threat to validity—two-stage revision is preferentially applied to the highest-risk cases (resistant organisms, poor bone stock, immunocompromised hosts), making its apparently inferior infection outcomes uninterpretable without patient-level covariate adjustment.
Original Abstract
INTRODUCTION
Periprosthetic joint infection (PJI) remains a devastating complication following total hip and knee arthroplasty. Revision strategies for chronic PJI include one-, 1.5-, and two-stage revision procedures. This study compared clinical outcomes of these revision strategies using a network meta-analytic approach.
METHODS
A systematic review and Bayesian network meta-analysis were conducted. Databases were searched through October 2025. Randomized controlled trials and comparative cohort studies evaluating one-, 1.5-, and two-stage revision procedures for hip and knee chronic PJI were included. Chronic PJI was defined by Musculoskeletal Infection Society/International Consensus Meeting (MSIS/ICM) criteria, excluding acute postoperative and hematogenous infections. In the primary network, hip and knee revisions were analyzed together, with pre-specified hip-only and knee-only subgroup networks reported separately. There were 54 studies (10,055 patients) eligible for inclusion.
RESULTS
Compared with two-stage revision, both one- and 1.5-stage revisions were associated with significantly lower odds of reinfection (odds ratio (OR) = 0.84, 95% credible interval (CrI) 0.72 to 0.99 and OR = 0.58, 95% CrI 0.37 to 0.89, respectively) and reoperation (OR = 0.79, 95% CrI 0.63 to 0.99 and OR = 0.20, 95% CrI 0.05 to 0.82, respectively). The 1.5-stage strategy demonstrated significantly higher infection control success (OR = 1.64, 95% CrI 1.07 to 2.51). The one-stage revision was associated with fewer overall complications (OR = 0.64, 95% CrI 0.48 to 0.86). The 1.5-stage strategy showed a significantly increased risk of aseptic loosening (OR = 4.80, 95% CrI 1.57 to 20.79), while two-stage revision performed best.
CONCLUSION
The 1.5-stage revision was associated with the most favorable infection-related outcomes, but a higher risk of aseptic loosening. The one-stage revision showed intermediate results, while the two-stage revision performed less favorably but had the lowest loosening risk. Because the evidence is largely observational and subject to confounding by indication, these associations should be interpreted cautiously.