Marco Zugnoni

Introduction & Aim: The 1.5-stage revision strategy — implantation of an antibiotic-loaded functional construct without a planned second stage — has gained traction as an intermediate alternative to formal one-stage exchange in periprosthetic joint infection (PJI). Its theoretical appeal lies in sparing patients a second surgery while managing cases deemed unsuitable for single-stage revision. However, if 1.5-stage revision shares the same procedural logic as one-stage exchange — potentially a single definitive implantation — it must be held to the same clinical standard. Existing literature has compared 1.5-stage predominantly against two-stage revision, obscuring this critical question. This systematic review and meta-analysis is the first to directly compare one-stage and 1.5-stage revision, evaluating whether the latter offers any clinical advantage over the former. Methods: Following PRISMA guidelines, PubMed, EMBASE, and Scopus were searched for studies comparing one-stage and 1.5-stage TKA revisions. Primary outcomes included infection relapse, reintervention rates, and time-to-failure. Results: Sixty-seven studies (59 one-stage, 8 1.5-stage) involving 1,145 patients were included. Indication criteria for 1.5-stage were not broader than those for one-stage; both shared major contraindications like massive bone loss and MDR organisms. 1.5-stage was predominantly reserved for elderly patients with high comorbidities. The pooled infection relapse rate was 8.5%, with no significant difference between one-stage and 1.5-stage procedures (8.5% vs. 11.2%; p=0.345). Similarly, overall reintervention rates showed no significant difference (16.6% vs. 18.5%; p=0.653). Crucially, 1.5-stage studies had significantly shorter mean follow-up (2.89 vs. 4.84 years; p=0.021), yet showed a trend toward earlier reintervention (1.45 vs. 2.52 years; p=0.087) and shorter time to reinfection (0.96 vs. 1.79 years; p=0.312). Conclusions: This meta-analysis found no clinical advantage of 1.5-stage over one-stage revision for PJI. Despite shorter follow-up, the 1.5-stage group showed numerically higher failure rates and earlier time to failure. Since the 1.5-stage does not expand patient eligibility and involves inherent potential for a second surgery without outperforming a single-procedure strategy, it cannot be supported as a primary treatment option. It should be regarded as a salvage strategy for selected patients rather than a reliable alternative to one-stage revision.

Aim: Periprosthetic fracture-related infections (PFRIs) are a serious complication of total arthroplasty, with incidence rates increasing in line with the growing number of joint replacements. PFRI can lead to prolonged hospitalization, multiple surgical procedures and suboptimal functional outcomes. The diagnosis of PFRI remains challenging due to the overlap of clinical symptoms with other post-traumatic conditions, and identification of the pathogen often fails through conventional methods. This study also highlights the importance of a personalized medicine approach in managing PFRI, where diagnostic and therapeutic decisions are tailored to the individual patient’s comorbidities, immune status and bone healing capacity. By integrating clinical, microbiological and imaging data, our findings support precision-based strategies to optimize outcomes and minimize complication. Methods: This retrospective case series was conducted at the Unit of Osteoarticular Infection of the University of Turin, Italy, from January 2018 to December 2023. Patients who developed septic complications after open reduction and internal fixation (ORIF) of periprosthetic fractures involving hip or knee implants were included. The infection was diagnosed in accordance with established guidelines, and treatment decisions were based on clinical, microbiological and radiological findings. Results: In the present study, periprosthetic fractures complicated by infections were identified in nine patients (5.4%), constituting a small but significant subset of cases. The cases were then categorized into four clinical scenarios based on the following variables: joint involvement, fracture healing and infection progression. Scenario A, involving fractures without prosthetic involvement and unhealed fractures, included three patients (33%) and was treated with debridement and change of the fixation device. Scenario B, involving fractures without prosthetic involvement but with healed fractures, involved one patient (11%), where the ongoing infection was confirmed despite the healed fracture and where the device could be removed. The third scenario (C), which pertains to cases involving prosthetic involvement, included three patients (33%) who required replacement or removal of the prosthesis and, in some cases, a second stage. The fourth scenario, involving patients with limited operability, included two patients (22%) for whom no surgery was performed. Despite the significant clinical challenges encountered, the paucity of literature on the management of periprosthetic fractures with septic complications is limited, highlighting the need for further research in this understudied area. Conclusions: PFRI remains a challenging complication that necessitates a multidisciplinary approach to diagnosis and treatment. Despite advances in imaging and microbiological testing, the early detection and identification of pathogens remain challenging, emphasizing the necessity for enhanced diagnostic methods. This study offers valuable insights into the management of PFRI and provides a foundation for future research to develop optimal diagnostic and therapeutic strategies.