Single‐stage revision for chronic fistulized infected total knee arthroplasty achieves infection‐free survival comparable to non‐fistulized cases

PURPOSE: The presence of a sinus tract in chronic periprosthetic joint infection (PJI) has traditionally been considered a contraindication to single-stage total knee arthroplasty (TKA) revision. However, an increasing number of surgeons are now performing single-stage revisions in this context, despite limited comparative data. This study aimed to evaluate whether single-stage revision outcomes differ between fistulized (TKA/F+) and non-fistulized (TKA/F-) infected TKAs. METHOD: A retrospective case-control study was conducted at a regional reference centre for bone and joint infections, including all patients who underwent single-stage TKA revision for chronic infection between January 2013 and June 2023, with a minimum two-year follow-up. Patients were grouped according to the presence (TKA/F+) or absence (TKA/F-) of a sinus tract. The primary outcome was infection-free survival. Surgical procedures, antibiotic protocols and follow-up schedules were standardized across both groups. Survival analysis was performed using the Kaplan-Meier method and log-rank test. RESULTS: A total of 285 patients were included: 47 TKA/F+ and 238 TKA/F-. The TKA/F+ group had significantly older patients, higher body mass index (BMI) and American Society of Anesthesiologists (ASA) scores, and more comorbidities. Polymicrobial infections were more frequent in TKA/F+ (57% vs. 22%). Despite these differences, infection-free survival rates were similar: 81.2% (±4.3) in TKA/F+ versus 83.6% (±2.2) in TKA/F-, with no statistically significant difference. Surgical management included extensive debridement, systematic sampling, gentamicin-loaded cement and local flap coverage when needed. CONCLUSION: Single-stage revision may be effective in patients with a sinus tract when performed within a structured surgical and antibiotic protocol. Some stronger studies are needed to assess whether the presence of a sinus tract should not be considered an absolute contraindication. These findings support broader consideration of single-stage strategies in chronic TKA infections. LEVEL OF EVIDENCE: Level III.