Distraction arthrodesis with intramedullary nail and mixed bone grafting after failed infected total knee arthroplasty

Knee Arthrodesis with a Modular Silver-Coated Endoprosthesis for Infected Total Knee Arthroplasty with Extensive Bone Loss: A Retrospective Case-Series Study

INTRODUCTION

Knee arthrodesis is a limb salvage intervention for persistent periprosthetic joint infection (PJI) when revision total knee arthroplasty fails. Conventional arthrodesis techniques are associated with the increased rate of complications, especially in patients with extensive bone loss and extensor tendon deficiency.

METHODS

Eight patients with a modular silver-coated arthrodesis implant after failed exchange arthroplasty for infection, were retrospectively reviewed. All patients had significant bone loss, while 5 displayed extensor tendon deficiency. Survivorship, complications, leg length discrepancy, median Visual Analogue Scale (VAS) and Oxford Knee score (OKS) were evaluated.

RESULTS

The median follow up was 32 months (range 24-59 months). The survivorship rate of the prosthesis was 86% during the minimum time of follow up of 24 months. In one patient recurrence of the infection was observed and above-knee amputation was performed. The median postoperative leg length discrepancy was 2.07 ± 0.67 cm. Patients were able to ambulate with mild or no pain. The median VAS and OKS was 2.14 ± 0.9 and 34.7 ± 9.3, respectively.

CONCLUSIONS

The results of our study demonstrated that knee arthrodesis with a silver coated arthrodesis implant, performed for persistent PJI in patients with significant bone loss and extensor tendon deficit, provided a stable construct, allowed eradication of infection and was associated with good functional outcome.

Periprosthetic knee infection: treatment options

Infection is one of the most catastrophic complication following total knee arthroplasty (TKA) and represents the second most common cause of TKA failure. Treatment of a patient with periprosthetic joint infection (PJI) could require often costly and prolonged hospital stays, weeks or months of antibiotic therapy, and multiple surgical procedures. The best management is still highly debating, whereas many treatment options are available. These include suppressive antibiotics, arthroscopic irrigation and debridement, open debridement with insert exchange, single-stage reimplantation and two-stage reimplantation. The choice of the treatment depends on many variables, including integrity of implant, timing of the infection, host factors (age, health, immunologic status), virulence of the infecting organism and wishes of the patient. The aim of this review is to provide a comprehensive understaning of the different options for knee PJIs.

Knee arthrodesis using a custom modular intramedullary nail in failed, infected knee arthroplasties: A concise follow-up note of 31 cases at a median of 13 years post-arthrodesis

INTRODUCTION

Knee arthrodesis utilizes an arthrodesis nail as a salvage technique for infected total knee arthroplasty (TKA), especially when the extensor mechanism is damaged, or the skin is compromised. This implant helps to minimize or prevent leg length discrepancy, while allowing immediate weight bearing without requiring bone fusion. However, there is a risk of infection. Surgical revisions were required in 19% of patients at 50 months' follow-up in our team's initial 31-patient case series. Since there is little long-term outcome data, we reviewed this same group of patients after a mean of 13 years to determine: (1) the implant's long-term survival, (2) the functional outcomes, (3) the microbiological changes in revision cases.

HYPOTHESIS

The long-term survival of knee arthrodesis using an arthrodesis nail for failed infected TKA is acceptable.

MATERIAL AND METHODS

Thirty-one patients operated on between January 2005 and December 2008 were retrospectively included in the initial study. The functional outcomes consisted of pain on a visual analog scale (VAS), neuropathic pain (DN4) and the Oxford Knee Score. All surgical revisions were documented with repeat microbiology samples.

RESULTS

The median follow-up time was 13.1 years [11.5-13.5]. No mechanical failure (implant failure or aseptic loosening) was observed. Eight patients were re-operated on due to new infections. The nail had to be removed in five of these patients. None of the patients required an amputation. Among the eight patients who were re-operated on, only two (25%) had been re-operated on since the initial study and underwent a two-stage arthrodesis revision. At 10 years, the cumulative incidence of surgical revision at the knee was 26% [95% CI: 12%-43%] and 16% [95% CI: 5.7%-31%] for an implant change. Six (75%) of the re-operated patients had their revision within the first 72 months of the initial TKA, while 4 (50%) had it within the first 26 months. Among the 15 patients who were still alive, the median Oxford Knee Score was 17/48 [12-28]. At the final assessment, the median pain level was 0 [0-5], although 4 of the 10 analyzable patients (of the 15 living patients, 3 had a cognitive impairment and 2 refused to participate) had neuropathic pain and pain on VAS of 3/10. The microbiologic findings were the same during the surgical revision in five of the eight re-operated patients (62%); however, one patient who had a Staphylococcus aureus infection had acquired a resistance to methicillin. In one patient, only one of the two bacteria identified initially was still present (methicillin-susceptible Coagulase-negative staphylococci [CNS]) and while in two patients, the infectious agent changed completely (shift from Gram-negative bacilli to methicillin-susceptible CNS, and the opposite for the other patient).

DISCUSSION

Knee arthrodesis with a custom modular intramedullary nail is a viable limb salvage option in failed infected TKA cases with long-term survival, and it is comparable to other arthrodesis techniques. In most cases, recurrence of the infection occurred in the short term (<72 months). Later recurrences of the infection (>72 months) were rarer and were found in only two of our patients (6%). There were no mechanical failures.

LEVEL OF EVIDENCE

IV; Retrospective cohort study.

Salvage Procedures for Management of Prosthetic Joint Infection After Hip and Knee Replacements

Background:

The increasing load placed by joint replacement surgery on health care systems makes infection, even with the lowest rates, a serious concern that needs to be thoroughly studied and addressed using all possible measures.

Methods:

A comprehensive review of the current literature on salvage procedures for recurrent PJIs using PubMed, EMBASE and CINAHL has been conducted.

Results:

Prolonged suppressive antibiotic therapy (PSAT), resection arthroplasty and arthrodesis were the most common procedures performed. Suppressive antibiotic therapy is based on the use of well tolerated long term antibiotics in controlling sensitive organisms. Resection arthroplasty which should be reserved as a last resort provided more predictable outcomes in the hip whereas arthrodesis was associated with better outcomes in the knee. Various methods for arthrodesis including internal and external fixation have been described.

Conclusion:

Despite good union and infection control rates, all methods were associated with complications occasionally requiring further surgical interventions.

Knee arthrodesis: procedures and perspectives in the US from 1993 to 2011

BACKGROUND

The incidence and prevalence of knee arthrodesis (fusion) in the United States is largely unknown, in spite of numerous case reports and review articles that have called attention to this life altering procedure.

PURPOSE

This study was conducted to determine long-term knee arthrodesis incidence and patient populations, and to characterize the associated healthcare burden.

METHODS

The Nationwide Inpatient Sample was used to evaluate knee arthrodesis procedures performed in the United States between 1993 and 2011. Patient age, sex, and reimbursement method were evaluated along with hospital attributes. Procedural rates for individual demographics were calculated using population data from the US Census. Commonly occurring diagnoses and procedures in knee arthrodesis were compiled.

RESULTS

The annual number of reported knee arthrodesis procedures remained relatively unchanged between 1993 and 2011 (Mean 1014, Standard Deviation 113), but there was a small but significant decrease in the procedure rate when taking population changes into account. Over 80 % of patients were aged 45 or above. Approximately 65 % of patients utilized governmental payers for reimbursement. Nearly all of the procedures were performed in metropolitan area hospitals (92.5 %), and a significant majority performed in teaching hospitals (62 %).

CONCLUSIONS

The low incidence of knee arthrodesis procedures reflects both clinician and patient antipathy for this undesirable surgery. Case studies continue to reflect an interest to improve methodology, but also suggest a significant number of patients that go untreated given the current state of the art. Future work should seek to quantify the prevalence of patients with a severely dysfunctional knee who might otherwise undergo arthrodesis, but opt against it given the significant quality of life issues associated with the procedure.

Knee arthrodesis using a unilateral external fixator combined with crossed cannulated screws for the treatment of end-stage tuberculosis of the knee

Background

The treatment of end-stage tuberculosis (TB) of the knee remains a significant clinical challenge, and clinical data are lacking. This study aimed to retrospectively determine the outcome of single-stage knee arthrodesis with a unilateral external fixator combined with cannulated screws for the treatment of end-stage TB.

Methods

Twenty-six patients with end-stage knee TB were treated by single-stage arthrodesis. All patients underwent open debridement and the insertion of a unilateral external fixator combined with crossed cannulated screws and received systemic antitubercular therapy. Clinical evaluations and radiographic analyses were performed after an average follow-up duration of 5.5 years.

Results

The mean time to radiographic bone fusion was 5.6 months. Primary full union was achieved in 25 patients (96.2 %) within 8 months, and the remaining patients achieved bone fusion at 14 months postoperatively. The mean post-operative alignment was 5.4° valgus and 12.5° flexion. The mean leg-length discrepancy was 2.8 cm. The mean VAS score improved from 67.3 before surgery to 16.2 at the last follow-up (P < 0.01), and the mean WOMAC score improved from 58.8 to 13.7 (P < 0.01). The erythrocyte sedimentation rate (ESR) and C-reactive protein level returned to normal in 25 patients by 3 months postoperatively. No recurrence in the target knee was noted.

Conclusions

Single-stage arthrodesis with a unilateral external fixator combined with cannulated screws can be regarded as efficacious for the treatment of end-stage knee TB. Additional studies are necessary to confirm the findings of our study.

Knee arthrodesis as limb salvage for complex failures of total knee arthroplasty

Patients with multiple failures of total knee arthroplasty (TKA) are challenging limb salvage cases. Twenty one patients over the last 10 years were referred to our service for knee fusion by arthroplasty surgeons who felt they were not candidates for revision TKA. Active infection was present in 76.2% and total bone loss averaged 6.6 cm. Lengthening was performed in 7/22 patients. Total time in Ilizarov frames was 9 months, with 93.3% union. Patients treated with IM fusion nails had 100% union. Average LLD increased from 3.6 to 4.5 cm following intervention, while those with concurrent lengthening improved to 1.6 cm. Findings suggest that bone loss and the soft-tissue envelope dictate knee fusion method, and multiple techniques may be needed. A treatment algorithm is presented.

Outcomes of knee arthrodesis following infected total knee arthroplasty: a retrospective analysis of 8 cases

BACKGROUND

There is insufficient information regarding patient-based outcomes after knee arthrodesis following infected total knee arthroplasty (TKA). The purpose of this study was to analyze outcomes in patients who underwent knee arthrodesis following infected TKA using clinical and radiographic measurements including a patient-based outcome measuring system.

METHODS

We evaluated 8 patients (mean age 72.9 years) who were followed for more than 3 years after arthrodesis. Clinical and radiographic evaluation was performed, including examination of the patient's function and use of supportive equipment for walking. The Japanese knee osteoarthritis measurement (JKOM) was used for measuring patient-based outcomes and health-related quality of life.

RESULT

Knee fusion was achieved in 7 patients. The mean limb-length discrepancy was 5.4 cm. All patients could walk at least inside the house, and activity of daily living (ADL) independence was achieved by the patients with successful knee fusion, although walking aids, including a shoe lift causing little discomfort, were required. The results of JKOM for the patients with successful fusion were comparable to the data for patients who underwent TKA.

CONCLUSIONS

When knee arthrodesis was performed for infected TKA cases, pain was reduced and ADL independence was established when knee fusion was achieved. This study demonstrated that information from subjective and functional evaluations of knee arthrodesis patients is useful in understanding postoperative activity and situations, and revealed the importance of supportive elements for walking.

Arthrodesis of the knee following failed arthroplasty

PURPOSE

Primary stability in arthrodesis of the knee can be achieved by external fixation, intramedullary nailing or plate fixation. Each method has different features and results. We present a practical algorithm for arthrodesis of the knee following a failed (infected) arthroplasty, based on our own results and a literature review.

METHODS

Between 2004 and 2010, patients were included with an indication for arthrodesis after failed (revision) arthroplasty of the knee. Patients were analyzed with respect to indication, fusion method and bone contact. End-point was solid fusion.

RESULTS

Twenty-six arthrodeses were performed. Eighteen patients were treated because of an infected arthroplasty. In total, ten external fixators, ten intramedullary nails and six plate fixations were applied; solid fusion was achieved in 3/10, 8/10 and 3/6, respectively.

CONCLUSIONS

There is no definite answer as to which method is superior in performing an arthrodesis of the knee. Intramedullary nailing achieved the best fusion rates, but was used most in cases without--or cured--infection. Our data and the contemporary literature suggest that external fixation can be abandoned as standard fusion method, but can be of use following persisting infection. The Ilizarov circular external fixator, however, seems to render high fusion rates. Good patient selection and appropriate individual treatment are the key to a successful arthrodesis. Based upon these findings, a practical algorithm was developed.

Knee arthrodesis using a customised modular intramedullary nail in failed infected total knee arthroplasty

BACKGROUND

Knee arthrodesis is used to treat patients with failed infected total knee arthroplasty (TKA). Among fixation methods, intramedullary nailing increases the chances of bone union but may carry a risk of infection around the nail. This risk is not well understood, because available case-series studies were not confined to patients with knee infection.

HYPOTHESIS

Infection recurrence rates after knee arthrodesis with intramedullary nailing used to treat failed infected TKA are similar to those seen with other fixation methods.

METHODS

We retrospectively reviewed 31 cases of knee arthrodesis with fixation by a modular intramedullary nail performed at a subspecialized center treating complex osteoarticular infections (CRIOAC). The antibiotic regimen was determined based on multidisciplinary discussions and microbiological studies of preoperative and intraoperative specimens. Mean follow-up was 50 ± 22 months (range, 28-90 months). Arthrodesis was performed in one stage (n=6) or two stages (n=25). Success was defined as presence, after a postoperative follow-up of at least 24 months, based on the following criteria: normal erythrocyte sedimentation rate and/or C-reactive protein, no wound inflammation or sinus tract, no revision surgery, and no antibiotic treatment. Bone union was not a criterion for a successful arthrodesis procedure.

RESULTS

Removal of the fixation material was required in three patients and long-term palliative antibiotic therapy in three patients (fixation material in place with repeated positive specimens) for a total of six failures due to infection (6/31, 19.4%). None of the patients experienced mechanical failure (no breakage of the material and no fixation failure of the nails designed to allow osteointegration). The mean leg length discrepancy was 10 ± 10 mm (range, 5-34 mm) and the mean Oxford score was 41 ± 11 (range, 23-58). The 50-month rate of arthrodesis survival to revision surgery for nail removal was 77.8 ± 4% and the 50-month rate of arthrodesis survival without revision surgery for persistent infection was 74.6 ± 4.2%.

DISCUSSION

The infection recurrence rate was higher than with other fixation methods but remained acceptable (19.4%). Use of a modular intramedullary nail prevented major leg-length discrepancies, which are often poorly accepted by the patients, and allowed immediate weight bearing despite the often severe bone loss.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Outcomes of knee arthrodesis following infected total knee arthroplasty: a retrospective analysis of 8 cases

BACKGROUND: There is insufficient information regarding patient-based outcomes after knee arthrodesis following infected total knee arthroplasty (TKA). The purpose of this study was to analyze outcomes in patients who underwent knee arthrodesis following infected TKA using clinical and radiographic measurements including a patient-based outcome measuring system. METHODS: We evaluated 8 patients (mean age 72.9 years) who were followed for more than 3 years after arthrodesis. Clinical and radiographic evaluation was performed, including examination of the patient's function and use of supportive equipment for walking. The Japanese knee osteoarthritis measurement (JKOM) was used for measuring patient-based outcomes and health-related quality of life. RESULT: Knee fusion was achieved in 7 patients. The mean limb-length discrepancy was 5.4 cm. All patients could walk at least inside the house, and activity of daily living (ADL) independence was achieved by the patients with successful knee fusion, although walking aids, including a shoe lift causing little discomfort, were required. The results of JKOM for the patients with successful fusion were comparable to the data for patients who underwent TKA. CONCLUSIONS: When knee arthrodesis was performed for infected TKA cases, pain was reduced and ADL independence was established when knee fusion was achieved. This study demonstrated that information from subjective and functional evaluations of knee arthrodesis patients is useful in understanding postoperative activity and situations, and revealed the importance of supportive elements for walking.