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One-stage versus two-stage revision of prosthetic joint infection (PJI): It's a topic that has been up for debate in the orthopedic surgery community. A from the Infectious Diseases Society of America states that a "1-stage or direct exchange strategy for the treatment of PJI is not commonly performed in the U.S. but may be considered in patients with a total hip arthroplasty (THA) infection who have a good soft tissue envelope provided that the identity of the pathogens is known preoperatively and they are susceptible to oral antimicrobials with excellent oral bioavailability."

The 2022 pragmatic trial out of the U.K. showed that at 18 months, single-stage revision was not superior to the two-stage approach in the hip, at least based on patient-reported outcomes, although single-stage revision had a better short-term outcome, fewer intraoperative complications, and was cost effective.

Single-stage revision got an additional boost from a U.S. study demonstrating that single-stage exchange, and an all-oral course of rifampin and linezolid, was successful in the treatment of Cutibacterium acnes (C. acnes) PJI.

It was a small study -- nine patients (median age 65; majority male) -- but after a long-term follow-up of 3 years, seven of eight contactable patients reported continued clinical improvement, with no progression of symptoms or evidence of active infection, according to Kevin Kohm, MD, of Rutgers Robert Wood Johnson Medical School in New Brunswick, New Jersey.

One patient had persistent pain that had worsened, they stated in .

"This with patients whose devices were treated with a combination of surgery with or without oral regimens," the authors wrote. "The demonstration that can be successfully treated with both one-stage intervention and an oral-only antibiotic regimen has the potential to positively affect the treatment of infected prostheses."

By reducing the need for additional surgery, single-stage revision with oral antibiotics could lower patient morbidity as well as healthcare costs, they said, adding that "Use of this approach requires further prospective studies to be considered in clinical practice."

Below are some highlights from the study by Kohm and colleagues.

How common is C. acnes a cause of PJI?

C. acnes, previously referred to as Propionibacterium acnes, is an anaerobic gram-positive bacillus that is part of the normal skin flora. It is recognized as a cause of PJI, but can be difficult to diagnose and treat.

How has the approach to PJI evolved?

Traditionally, infected prosthetic devices have been with a combination of operative intervention and intravenous antibiotics, with or without adjunctive oral antibiotics. However, debridement and antibiotics with implant retention and single-stage implant exchange with immediate re-implantation is being considered to limit morbidity. Similarly, the use of oral rather than IV antibiotics for bone and joint infections is increasingly used to limit risk without impacting outcome.

Is your study one of the first to use an oral-only antibiotic regimen?

The successful use of less disruptive surgical approaches and an oral-only antibiotic regimen for C. acnes prosthetic device infection has not been widely . In fact, patients in the two largest reports on C. acnes prosthetic joint infection treatment received a course of IV oral antibiotics.

Which prosthetic devices were most commonly infected?

Six infections were seen in a prosthetic shoulder, two in a prosthetic hip, and one was in a prosthetic knee.

What was the median time from index surgery?

Sixty months: Seven of the nine cases were diagnosed >24 months after index surgery; one case was diagnosed between 3-24 months; and 1 was diagnosed <3 months after index surgery.

Why linezolid and rifampin?

Linezolid and rifampin are oral agents that have favorable bioavailability, achieve good infiltration of bone and joints, and have reported ability to penetrate biofilms. Linezolid has demonstrated and has shown the ability to penetrate C. acnes biofilms in vivo and when used in conjunction with rifampin.

What about the persistent pain reported by one patient?

This could represent ongoing occult infection with C. acnes. However, the absence of inflammatory signs or symptoms or any further surgery precludes a definitive answer.

In related research, Derek F. Amanatullah, MD, PhD, of Stanford University in California, and colleagues assessed how surgical team turnover, composition, and preferred staff were linked with intraoperative efficiency in total joint arthroplasties. "A growing body of evidence suggests that intraoperative turnover among staff is associated with both reduced operative efficiency and increased rates of preventable adverse events," they wrote in . For instance, a 2016 study found that turnover among staff was associated with higher rates of surgical site infection, Amanatullah's group noted.

Indeed, they reported that turnover among operative staff was tied with procedural inefficiency. "In contrast, the presence of surgeon-preferred staff may facilitate intraoperative efficiency. Administrative or technologic support of perioperative communication and team continuity may help improve operative efficiency," Amanatullah and colleagues concluded. They also found that, contrary to popular thought, the "presence of nonresident trainees...was not associated with significant increases in operative duration" for knee or hip arthroplasties. In some cases, "the presence of residents was associated with significantly decreased operative time."

Amanatullah, along with co-author Henry C. Cousins, MPhil, also of Stanford, discussed the research in a 2023 JAMA Surgery podcast.

What was the impetus for the ?

Amanatullah: [In 2017] I was chosen as Stanford faculty biodesign fellow...I thought, like most surgeons, that my team was the one who operated with me ... [but] ... there were more members of my team that contributed to how my operating room [OR] ran beyond the actual execution of the procedure ... that really led us to think about how entire surgical teams perform, and how they communicated, and how they were more efficient across multiple surgeons and that really led to the genesis of this study.

How can operative efficiency serve as a proxy for surgical team effectiveness?

Cousins: Our driving question, which was this relationships between operating team dynamics and surgical outcomes, is very broad...we wanted to try to remove as many confounders as possible ... what we did was restrict our analysis to intraoperative considerations only...our main outcome variable was operative efficiency or operative duration...the basic idea there is that, if you are controlling for case complexity, then operative duration represents a measure of surgical efficiency...operative duration is an intuitive metric that is readily available for all cases.

What about the finding regarding trainees?

Cousins: We were very intrigued by this finding...reduced case complexity is one factor that might be associated with greater resident involvement...for me, what this ultimately highlights is that residents play a multifaceted role in the OR and, in addition to being students, in some circumstances, they can be real assets in surgery.

What is a take-home message from the study?

Amanatullah: We talk about surgical time really as something that we are saving in miniscule amounts. But we see [time] savings as high as 20% of the total procedure time...the key here is that, if you don't measure it, you can't manage it. If you're not actively paying attention to managing team dynamics, this doesn't autoassemble, and it doesn't autoassemble inside of the preferences of surgeons...it is identifying the best performing team members...unless we put some effort into metrics and measuring how teams perform together...we aren't going to be able to accomplish that...[determining] which teams perform best and which teams associate with the best safety, and highest quality result in the lowest amount of time.

Additional reporting by Shalmali Pal.

You can read the study abstract here.