Intra-articular antibiotics paired with one-stage revision show promise against joint implant infections

When a joint replacement becomes infected, the consequences can be devastating. Prosthetic joint infection is one of the most serious complications of hip and knee arthroplasty, and it is the most common cause of joint revision surgery. It is highly disabling, often impairing rehabilitation, requiring prolonged antibiotic therapy and hospitalization, and carrying risks of antibiotic resistance and adverse drug reactions. Beyond the toll on patients, it places a substantial burden on healthcare systems. A new systematic review now examines a treatment strategy that combines two ideas gaining ground in orthopaedic surgery: performing the revision in a single operation, and delivering antibiotics directly into the joint rather than relying solely on intravenous therapy.

The review, published in the journal Arthroplasty, was led by Xinyue Chang and colleagues and registered in advance on the PROSPERO registry. The researchers searched PubMed, Web of Science, Embase and the Cochrane Library up to 30 November 2025, looking for studies of adults with periprosthetic joint infection treated by one-stage revision combined with intra-articular antibiotic delivery, with at least twelve months of follow-up for infection-related outcomes. From 285 records identified, sixteen full-text articles were assessed and ten studies made the final analysis. All of them were retrospective in design: eight were retrospective case series and two were retrospective comparative studies involving hip and knee arthroplasty populations. Only two studies included control groups.

One-stage revision means removing the infected prosthetic components, extensively debriding the tissue, taking microbiological samples, irrigating the wound and implanting new components in a single operation. Its appeal is practical: it reduces the morbidity and scarring associated with repeat surgeries, shortens overall treatment time, accelerates recovery, shortens hospital stays and lowers costs. Recent evidence suggests that one-stage revision can achieve satisfactory infection control for chronic infection, with eradication rates comparable to the traditional two-stage approach. In a recent meta-analysis cited in the review, Xie and colleagues reported a lower reinfection rate after one-stage than after two-stage revision, 10.02 percent versus 14.75 percent. Even with surgery, antimicrobial agents remain critical to treatment, and that is where local delivery enters the picture.

Intra-articular antibiotic delivery was first reported in 1991 as a treatment option for prosthetic joint infection. The rationale is rooted in the biology of these infections. Biofilm formation is a key factor in why the infection persists, because eradicating bacteria embedded in biofilm requires antibiotic concentrations 100 to 1000 times the minimum inhibitory concentration measured in the laboratory. Systemic antibiotic therapy may be limited by toxicity, restricting the drug levels that can safely be achieved locally. In contrast, direct intra-articular delivery can achieve higher local antibiotic concentrations than intravenous therapy, potentially reaching levels sufficient to target biofilm-embedded organisms. It may also reduce systemic exposure and allow flexible dose adjustment or temporary discontinuation when clinically necessary.

The ten studies included in the review were published between 2011 and 2025 and showed substantial heterogeneity in how the strategy was implemented. In catheter-based protocols, Hickman catheters and three-branch catheters were the most commonly reported devices, with intermittent intra-articular administration. Some knee protocols instead used direct intra-articular needle injection without an indwelling catheter. The timing of therapy varied: most protocols began during the early postoperative period, although one study initiated therapy only after microbiological confirmation. The reported duration of intra-articular antibiotic therapy ranged from 14 to 42 days. Most studies combined intra-articular delivery with systemic antibiotic therapy, though the specific systemic regimens differed among studies.

Antibiotic selection was primarily guided by microbiological findings. The infections reported across the included studies comprised Gram-positive, Gram-negative, polymicrobial, fungal and culture-negative organisms. Vancomycin-based regimens were frequently reported, particularly for Gram-positive organisms including staphylococcal species. Broad-spectrum antimicrobial agents, including carbapenem-based regimens, were used in studies involving Gram-negative, polymicrobial or culture-negative infections, and antifungal agents such as fluconazole and voriconazole were reported in studies involving fungal infections. Standard one-stage revision principles were consistent across studies, including removal of infected components, extensive debridement, microbiological sampling and irrigation, but variations were observed in implant fixation methods, soft-tissue management and the local antibiotic delivery approach.

On outcomes, the review found that individual studies reported relatively high rates of infection control, with infection-control outcomes assessed according to the criteria reported in each study. The authors describe the findings as satisfactory infection-control outcomes across individual studies. However, subsequent surgical interventions after the index one-stage revision were reported in most studies, including implant-retaining debridement, debridement with insert exchange, repeat single-stage revision, spacer implantation, component removal followed by reimplantation, and salvage procedures such as above-knee amputation. Non-operative management strategies were also reported, with chronic suppressive antibiotic therapy described among patients managed after treatment failure or subsequent intervention, and one study reported medical management without further surgery after treatment failure.

Safety findings were summarized descriptively rather than pooled, because complication reporting and definitions varied across studies. Catheter-related complications mainly involved technical or device-related issues such as catheter occlusion, leakage and catheter loss. Other local adverse events included local irritation or rash, fistula or drainage-related events, and transient pressure or tenderness. Surgical complications included dislocation, periprosthetic fracture, radiolucent changes, osteotomy-related complications, arthrofibrosis, instability and wound-related problems. Systemic complications mainly involved renal function abnormalities, acute kidney injury, antimicrobial-related adverse events, elevated serum antibiotic levels and thrombotic events. Renal-related adverse events were among the most frequently reported systemic complications, yet no significant long-term renal impairment was documented in the included studies. The authors also note that indwelling catheters may theoretically serve as a portal for microbial entry and increase the risk of secondary infection, although previous studies of intra-articular pain catheters in total knee arthroplasty have not demonstrated increased deep infection rates.

Because of inconsistent reporting, clinical and methodological heterogeneity, and potential overlap between patient cohorts, the authors performed no quantitative pooling or formal meta-analysis. According to the National Institutes of Health quality assessment tool used in the review, eight studies were rated as fair quality and two as good quality. Most included studies were retrospective, involved small sample sizes, and lacked control groups. Several reports originated from the same centers across different time periods, raising the possibility of partial overlap in patient cohorts. The authors emphasize that the independent contribution of intra-articular antibiotic delivery beyond standard one-stage revision remains uncertain, and that the current evidence is largely retrospective and heterogeneous.

Despite these caveats, the review offers a useful surgery-specific synthesis. Previous reviews have generally evaluated intra-articular antibiotic delivery across mixed revision strategies rather than specifically examining its use with one-stage revision, and the effectiveness of local delivery may depend on the surgical context. The authors state that this is the first systematic review specifically evaluating intra-articular antibiotic delivery within a one-stage revision framework, and that it provides a foundation for future research on localized antibiotic strategies in the management of prosthetic joint infection. They call for high-quality, multicenter, prospective comparative studies incorporating standardized surgical techniques, clearly defined intra-articular antibiotic protocols and consistent outcome reporting, to better define the incremental clinical value of this combined strategy. Until such studies are completed, the strategy remains a promising but unproven adjunct in the surgical treatment of an infected joint replacement.

Subject of Research: Intra-articular antibiotic delivery combined with one-stage revision for periprosthetic joint infection

Article Title: Intra-articular antibiotic delivery combined with one-stage revision for periprosthetic joint infection: a systematic review

Article References: Chang, X., Luk, M. H., Cheung, A., Lau, L. C. M., Leung, T. K. C., & Fu, H. (2026). Intra-articular antibiotic delivery combined with one-stage revision for periprosthetic joint infection: a systematic review. Arthroplasty, 8(1), Article 79. https://doi.org/10.1186/s42836-026-00440-4

Image Credits: AI Generated

DOI: 10.1186/s42836-026-00440-4

Keywords: periprosthetic joint infection, one-stage revision, intra-articular antibiotics, systematic review, arthroplasty, biofilm, catheter antibiotic infusion, local antibiotic delivery, hip replacement, knee replacement, surgical complications, renal adverse events