One- or Two-Stage Hip Revision? High Mortality in One-Stage Challenges Its Growing Popularity: A Registry Study.

Abstract

Periprosthetic joint infection is a severe complication after hip arthroplasty. While one-stage revision is increasingly used in Germany and other countries, the two-stage procedure remains the gold standard in much of the world. Meta-analyses report comparable or superior success rates for one-stage procedures, but it is unclear whether results from large orthopaedic centers can be reproduced in registry data reflecting broader clinical practice. This observational cohort study used German Endoprosthesis Registry data (2013 to 2023) to compare re-revision and mortality rates between one-stage and two-stage revision total hip arthroplasty (RTHA). Cases included first-time RTHA (one-stage: n = 12,418; two-stage: n = 1,000) and multiple RTHA (one-stage: n = 2,459; two-stage: n = 810). Kaplan-Meier estimates were applied for analysis. Re-revision rates after first-time RTHA were similar at five years (21.1% one-stage versus 19.9% two-stage, P = 0.068), though slightly higher at one year for one-stage (16.1% versus 14.1%, P = 0.022). In multiple revisions, one-stage showed higher re-revision rates (one year: 26.5 versus 21.0%; five years: 32.2 versus 26.5%, P = 0.001). Mortality after first-time RTHA was higher for one-stage at one year (9.9 versus 6.3%, P = 0.014), but not significant at five years (26.5 versus 23.9%, P = 0.077). In multiple RTHA, mortality remained higher in the one-stage group (one year: 12.8 versus 5.5%, P < 0.001; five years: 31.9 versus 23.7%, P = 0.008). Despite the excellent results reported for one-stage RTHA by individual large centers, nationwide data show significantly higher mortality rates in this procedure. This discrepancy raises concerns about broader implementation outside of specialized centers. Significant differences within the first year indicate an increased perioperative mortality for one-stage revision. While the re-revision rates are comparable, the increased mortality risk suggests that the one-stage approach cannot be recommended for wide use.