Dr Randall on Revision Strategies for Infection in Orthopedic Oncology Reconstructions

"Regarding revision strategies, there was strong consensus that single-stage, two-stage, and what we call a one-and-a-half-stage revision are all acceptable strategies. However, two-stage revision remains the most reliable method for infection control, particularly in complex megaprosthetic reconstructions."

R. Lor Randall, MD, FACS, the David Linn Endowed Chair for Orthopedic Surgery, the chair of the Department of Orthopedic Surgery, and a professor at UC Davis Comprehensive Cancer Center, expanded on which revision strategies are most effective for complex reconstructions and how biologic options compare with endoprostheses in orthopedic oncology, per consensus findings from the 2024 Birmingham Orthopedic Oncology Meeting (BOOM) report.

This global consensus meeting involved 309 delegates from 53 countries working to establish standardized guidance for managing periprosthetic joint infections in complex reconstructions for patients with sarcoma and chondrosarcoma. Findings from the modified Delphi process, later published in The Bone & Joint Journal, emphasized the utility of various revision strategies, antibiotic prophylaxis, and debridement, antibiotics, and implant retention (DAIR).

Regarding surgical intervention, a strong consensus supported the use of single-stage, two-stage, and "one-and-a-half-stage" revision strategies, Randall reported. He explained that although two-stage revision is the most reliable method for ensuring infection control in complex megaprosthetic reconstructions, it presents significant clinical challenges: patients undergo a debilitating 6-to-10-week period without an implant, often relying on a spacer or DAIR, which can severely compromise limb function, overall quality of life, and potentially even oncologic outcomes. Conversely, single-stage revision may be considered appropriate only when the infecting organism is highly sensitive to oral antibiotics and a full component exchange is feasible, he noted. The emerging one-and-a-half-stage strategy acts as a functional compromise, utilizing an antibiotic-loaded interval prosthesis that allows for improved mobility compared with total removal, Randall explained.

Additionally, the consensus addressed the debate between biologic reconstructions versus metallic endoprostheses, he continued. Data from modern series indicates that infection risk should not be the primary driver of reconstruction choice, as rates do not differ significantly between the two modalities, Randall noted. However, he cautioned that if biologic options like bone transplants or allografts become infected, their success rates are poor, and patients should generally be converted to staged metallic reconstructions. This international consensus provides a vital framework for clinicians navigating the high-stakes management of orthopedic oncology infections, Randall concluded.