Introduction:

Repeat two-stage exchange is an established treatment option for persistent or recurrent periprosthetic joint infection (PJI) following initial two-stage revision of total hip or knee arthroplasty.

However, outcomes following repeat two-stage exchange remain poorly defines.

Aim:Toquantify pooled re-infection and all-cause mortality rates following repeat two-stage exchange for chronic PJI.

Methods:

Included studies reported reinfection after THA or TKA in patients who completed both stages of a repeat two-stage exchange arthroplasty.

Exclusion criteria included case reports, review articles, studies evaluating the first two-stage exchange, and patients who did not complete both stages of repeat exchange.

A total of 239 studies were identified; 15 were included for reinfection analysis and 6 for mortality analysis.

Pooled events per person-years analyses were performed to estimate reinfection and mortality rates while accounting for follow-up duration.

Meta-analyses were conducted using a random-effects model, and heterogeneity was assessed with the I2 statistic.

Statistical significance was defined as p < 0.05.

Results:

Fifteen studies comprising 591 repeat two-stage exchanges for hip or knee periprosthetic joint infection (PJI) were included, with a mean follow-up of 5 years. The pooled re-infection rate was 10 per 100 person-years (I² = 89%).

On subgroup analysis, TKA was associated with a higher re-infection rate than THA (18 vs. 6 per 100 person-years; I² = 95% and 74%, respectively).

Six studies comprising 186 cases reported mortality outcomes. The pooled all-cause mortality rate was 3 per 100 person-years (I² = 37%) over a mean follow-up of 3 years.

Conclusion:

Repeat two-stage exchange for chronic PJI is associated with substantial risk of re-infection and mortality, with TKA: ~18% re-infection per year and THA: ~6% re-infection per year and mortality: ~15% at 5 years.

These findings underscore the high-risk nature of repeat two-stage exchange and can help guide realistic patient–surgeon discussions when considering treatment options for persistent or recurrent PJI.