The Future of PJI Treatment: Will One-Stage Exchange Become the New Gold Standard?

Commentary The article by Parvizi highlights the evolving strategies for managing chronic periprosthetic joint infection (PJI), particularly the growing interest in 1-stage exchange arthroplasty. While multiple treatment options are available, the choice often depends on institutional protocols, patient-specific factors, and surgeon or patient preferences. Despite this variability, 2-stage exchange arthroplasty has long been considered the gold standard. Globally, however, the concept of 1-stage exchange arthroplasty is gaining traction, particularly in specialized centers, signaling a potential paradigm shift in PJI management. As highlighted by Parvizi, Professor Cao Li performs 1-stage exchange arthroplasty almost exclusively. Similarly, our institution employs this approach in over 85% of all cases of chronic PJI. Notably, 1-stage septic exchange arthroplasty was first introduced in the 1970s by Professor Hans-Wilhelm Buchholz at the ENDO-Klinik in Hamburg, Germany. In an initial 10-year series of 583 patients, a success rate of 77% was reported following the first attempt at 1-stage exchange arthroplasty1. One-stage exchange arthroplasty is not merely a surgical technique but rather a holistic, multidisciplinary, perioperative protocol. It begins with the suspicion of infection and continues beyond the operating room into the postoperative follow-up phase, emphasizing comprehensive patient care at every stage. Current evidence indicates that 1- and 2-stage exchange strategies achieve comparable infection eradication rates; however, 1-stage exchange offers several advantages, such as lower complication rates and greater cost-effectiveness2. This raises the question: why shouldn’t all chronic PJIs be managed with the 1-stage protocol? While the notion that 2-stage exchange is becoming obsolete has merit, it lacks clarity and nuance. One-stage exchange will gain further worldwide acceptance and may eventually become the new gold standard; however, not all patients are suitable candidates for this approach. Furthermore, not all institutions are equipped to adopt 1-stage exchange arthroplasty, as failure of this approach carries dire consequences. A recent topic of interest is the management of culture-negative infections using this protocol. As described in our study, identifying the causative organism and its susceptibility, at minimum through aspiration or open biopsy, is essential3. Current evidence supporting 1-stage exchange arthroplasty continues to grow; however, to declare this as the “new gold standard” requires cautious optimism. There is considerable potential for 1-stage exchange to replace 2-stage revision, but a global shift depends on several factors, including long-term outcome data, advancements in diagnostic techniques, and the standardization of protocols, which remain unresolved. The accurate identification of the causative organism remains of utmost importance, yet no diagnostic test currently achieves a 100% identification rate. Next-generation sequencing has shown promising results in detecting microorganisms in culture-negative infections, but further research is needed to refine and standardize those methods. Lastly, the intraoperative visualization of infected tissue requires greater focus. Radical debridement remains a key factor for successful outcomes in 1-stage exchange arthroplasty. Developing tools that enable surgeons to distinguish between infected and healthy tissue in real time would represent a major milestone in chronic PJI treatment4. For example, in brain tumor surgery, tumor tissue can be demarcated with the use of 5-aminolevulinic acid and intraoperative fluorescent light. Adapting similar techniques to surgery for PJI could enhance the precision of debridement and potentially improve infection eradication rates, preserving function in patients with PJI. Future research will determine whether 1-stage exchange becomes the new gold standard for the management of PJI worldwide.