SINGLE- VERSUS TWO-STAGE REVISION SURGERY IN CASE OF FRACTURE-RELATED INFECTION: A SYSTEMATIC REVIEW

Aims This review aimed to evaluate the current evidence regarding the clinical outcome of single- and two-stage revisions for long bone fracture-related infection (FRI). The review focused on unhealed fractures without critical size bone defects, treated with internal fixation. Method A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. A systematic search was conducted in PubMed, Embase via Elsevier and Web of Science Core collection, and grey literature (Cochrane Central Library and WHO-ICTRP) from inception to 21st of November 2024. Results Out of 21,126 articles initially identified, 35 studies including 985 patients were eligible for the final analysis. Twenty-seven studies examined a single-stage revision approach, five a two-stage, and three included both patients who underwent single-stage and two-stage procedures. The mean bone healing rate was 80% (range: 48%-100%) for single-stage (conventional implant: mean: 80% range: 48%-100%; custom-made polymethyl methacrylate (PMMA)-coated implants: mean: 80%; range: 60%-100%, presumed aseptic non-union: mean: 70%; range 56%-93%), and 77% (range: 33%-100%) for two-stage approaches (conventional implant: mean: 58%; range: 33%-100%; custom-made PMMA-coated implants: mean: 80%; range: 76%-100%). The mean infection eradication rate for single-stage revisions was 87% (range: 56%-100%) (conventional implant: mean: 88%; range: 56%-100%; custom-made PMMA-coated implants: mean: 85%; range: 60%-100%; presumed aseptic non-union: mean: 80%; range: 56%-92%), whereas two-stage revisions demonstrated a mean eradication rate of 81% (range: 33%-100%) (conventional implant: mean: 58%; 33%-100%; custom-made PMMA-coated implants: mean: 85%; range: 76%-100%). On average, 28% of patients (range: 7%-100%) required a secondary procedure following a single-stage approach, and 25% (range: 12%-67%) following a two-stage approach. All included studies, except one, focused mainly on treatment of FRI in patients with unhealed fractures, at least six months after initial fracture treatment. Conclusions For patients with unhealed long bone FRIs without critical-sized bone defects, current literature is of poor quality, heterogenous, and lacks strong evidence to recommend either a single-stage or two-stage approach with internal fixation. Furthermore, high-quality studies focusing on two-stage procedures, especially for the treatment of FRIs within six months after initial fracture fixation, are almost non-existent. Positive cultures found during single-stage procedures in presumed aseptic fracture non-unions, could be related to lower clinical outcomes. Future trials should employ precise definitions for infection and outcomes, ensure a follow-up period of at least one year, and consider variations in patient characteristics, fractures, and soft tissue conditions to inform surgical decision-making.