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Mercurio M, Gasparini G, Cofano E, Zappia A, Familiari F, Galasso O. Knee Arthrodesis for Periprosthetic Knee Infection: Fusion Rate, Complications, and Limb Salvage-A Systematic Review. Healthcare (Basel) 2024; 12:804. [PMID: 38610226 PMCID: PMC11011444 DOI: 10.3390/healthcare12070804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/01/2024] [Accepted: 04/05/2024] [Indexed: 04/14/2024] Open
Abstract
The aim of this systematic review was to investigate the outcomes of knee arthrodesis (KA) after periprosthetic joint infection (PJI) of the knee. Differences in clinical outcomes and complication rates among the intramedullary nailing (IMN), external fixation (EF), and compression plating (CP) procedures were compared. A total of 23 studies were included. Demographics, microbiological data, types of implants, surgical techniques with complications, reoperations, fusion, and amputation rates were reported. A total of 787 patients were evaluated, of whom 601 (76.4%), 166 (21%), and 19 (2.4%) underwent IMN, EF, and CP, respectively. The most common causative pathogen was coagulase-negative Staphylococcus (CNS). Fusion occurred in 71.9%, 78.8%, and 92.3% of the patients after IMN, EF, and CP, respectively, and no statistically significant difference was found. Reinfection rates were 14.6%, 15.1%, and 10.5% after IMN, EF, and CP, respectively, and no statistically significant difference was found. Conversion to amputation occurred in 4.3%, 5%, and 15.8% of patients after IMN, EF, and CP, respectively; there was a higher rate after CP than after EF. The IMN technique is the most common option used for managing PJI with KA. No differences in terms of fusion, reinfection, or conversion-to-amputation rates were reported between IMN and EF. CP is rarely used, and the high amputation rate represents an important limitation of this technique.
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Affiliation(s)
- Michele Mercurio
- Department of Orthopaedic and Trauma Surgery, Magna Graecia University, 88100 Catanzaro, Italy; (M.M.); (G.G.); (A.Z.); (F.F.); (O.G.)
- Research Center on Musculoskeletal Health, MusculoSkeletal Health@UMG, Magna Graecia University, 88100 Catanzaro, Italy
| | - Giorgio Gasparini
- Department of Orthopaedic and Trauma Surgery, Magna Graecia University, 88100 Catanzaro, Italy; (M.M.); (G.G.); (A.Z.); (F.F.); (O.G.)
- Research Center on Musculoskeletal Health, MusculoSkeletal Health@UMG, Magna Graecia University, 88100 Catanzaro, Italy
| | - Erminia Cofano
- Department of Orthopaedic and Trauma Surgery, Magna Graecia University, 88100 Catanzaro, Italy; (M.M.); (G.G.); (A.Z.); (F.F.); (O.G.)
| | - Andrea Zappia
- Department of Orthopaedic and Trauma Surgery, Magna Graecia University, 88100 Catanzaro, Italy; (M.M.); (G.G.); (A.Z.); (F.F.); (O.G.)
| | - Filippo Familiari
- Department of Orthopaedic and Trauma Surgery, Magna Graecia University, 88100 Catanzaro, Italy; (M.M.); (G.G.); (A.Z.); (F.F.); (O.G.)
- Research Center on Musculoskeletal Health, MusculoSkeletal Health@UMG, Magna Graecia University, 88100 Catanzaro, Italy
| | - Olimpio Galasso
- Department of Orthopaedic and Trauma Surgery, Magna Graecia University, 88100 Catanzaro, Italy; (M.M.); (G.G.); (A.Z.); (F.F.); (O.G.)
- Research Center on Musculoskeletal Health, MusculoSkeletal Health@UMG, Magna Graecia University, 88100 Catanzaro, Italy
- Clinica Ortopedica Department, San Giovanni di Dio e Ruggi D’Aragona University Hospital, 84100 Salerno, Italy
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, 84081 Salerno, Italy
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Low J, Hoellwarth JS, Akhtar MA, Tetsworth K, Al-Muderis M. Transfemoral amputation versus knee arthrodesis for failed total knee replacement: A systematic review of outcomes. Knee 2024; 47:63-80. [PMID: 38245922 DOI: 10.1016/j.knee.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 11/21/2023] [Accepted: 12/18/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND The options available to salvage a failed total knee replacement (TKR) include transfemoral amputation (TFA) and knee arthrodesis (KA). This systematic review aims to evaluate outcomes following either TFA or KA, comparing ambulatory status, additional subsequent surgery, postoperative infection, pain, health-related quality of life (HRQoL), and mortality rate. METHODS A literature search was conducted in EMBASE, Ovid Medline, and PubMed. Only primary research studies were included and data were independently extracted using a standardized form. The methodological quality of the studies was evaluated using Newcastle-Ottawa Scale. RESULTS Forty-four papers were included, comprising 470 TFA and 1034 KA patients. The methodological quality of the studies was moderate. No TFA versus KA randomized controlled trials could be identified. Pooled data totals via subgroup analyses were performed, owing to inconsistent reporting methods in the included studies. Prosthesis use rate by TFA patients was 157/316 = 49.7%. Significant differences included that TFA patients had lower rates of ambulatory capacity than KA patients (139/294 = 45.6% versus 248/287 = 86.4%, p < 0.001), TFA ambulators were less likely to use an ambulatory aid (55/135 = 40.7% versus 167/232 = 72.0%, p < 0.001), and TFA was associated with a greater postoperative infection rate than KA (29/118 = 24.6% versus 129/650 = 17.2%, p = 0.054). There was a similar rate of revision surgery between TFA and KA (37/183 = 20.2% versus 145/780 = 18.6%, p = 0.612). Data on HRQoL for both TFA and KA were limited, contradictory, and heterogeneous. CONCLUSION No randomized controlled trials comparing TFA versus KA exist;therefore, current data likely reflects substantial selection bias. The currently available evidence suggests that KA patients are significantly more likely to achieve independent bipedal ambulation than TFA patients. In both treatment cohorts, subsequent infection and revision surgery remain a relatively common occurrence.
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Affiliation(s)
- Juin Low
- The University of Edinburgh, Scotland, United Kingdom.
| | - Jason Shih Hoellwarth
- Limb Lengthening and Complex Reconstruction Service, Osseointegration Limb Replacement Centre, Hospital for Special Surgery, New York, United States
| | - Muhammad Adeel Akhtar
- The University of Edinburgh, Scotland, United Kingdom; University of St. Andrews, Scotland, United Kingdom; Department of Trauma and Orthopaedic Surgery, Victoria Hospital Kirkcaldy, Scotland, United Kingdom
| | - Kevin Tetsworth
- Royal Brisbane and Women's Hospital, Brisbane, Australia; University of Queensland School of Medicine, Brisbane, Australia
| | - Munjed Al-Muderis
- The University of Notre Dame Australia, Auburn, New South Wales, Australia; Limb Reconstruction Centre, Macquarie University Hospital, Macquarie Park, Australia
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Outcomes of Second-stage Reimplantation After Modular Knee Arthrodesis for Periprosthetic Joint Infection. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202208000-00006. [PMID: 35951772 PMCID: PMC9374185 DOI: 10.5435/jaaosglobal-d-22-00082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 03/15/2022] [Indexed: 11/18/2022]
Abstract
Modular knee arthrodesis (MKU) is a salvage treatment for recurrent periprosthetic joint infection (PJI) or PJI associated with notable bone loss. Reimplantation endoprosthetic reconstruction (REI) is an option in patients with MKU who have PJI clearance but are not satisfied with pain or functional outcomes with MKU. The purpose of this study was to evaluate the outcomes of MKU to REI conversion.
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Knee Joint Bone Defects: Reconstruction With Bone Transport and Arthrodesis. J Arthroplasty 2021; 36:2896-2906. [PMID: 33812709 DOI: 10.1016/j.arth.2021.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/20/2021] [Accepted: 03/02/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The increasing in primary total knee arthroplasty has led to an increase in infectious complications, revision surgery, and bone loss. Knee joint bone defects (KJBD) may be managed using bone transport and arthrodesis with Ilizarov or bone transport over nail (BTON) techniques. The aim of this study is to compare both techniques in the reconstruction of KJBDs. METHODS This was a retrospective cohort study of 29 patients with extensive KJBD. All patients underwent reconstruction of the KJBD using bone transport (either Ilizarov or BTON techniques). The primary outcome variables for comparison between the two groups included time in frame (days), external fixation index (EFI, days/cm), residual limb length discrepancy (cm), and complications (Caton classification). RESULTS Gender and age profiles were comparable. Mean time spent in frame for bone transport was 566 days (σ = 236, 95% CI 429-702) for the Ilizarov cohort and 191 days (σ = 162, 95% CI 101-280) for BTON (P < .0001). EFI for the period of bone transport was 75.1 d/cm (σ = 41.5, 95% CI 51.1- 99.1) for the Ilizarov cohort and 24.7 d/cm (σ = 24.0, 95% CI 11.4-38) for BTON (P = .0004). Union, limb length discrepancy and complication rates were comparable between both groups. CONCLUSION For the management of KJBD after failed total knee arthroplasty, BTON is preferred due to significantly less time spent in frame, lower EFI, and higher rates of normal mechanical alignment. The Ilizarov method may be useful when there is a contraindication to BTON.
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Frieler S, Yilmaz E, Goodmanson R, Hanusrichter Y, Schildhauer TA, Baecker H. Conversion From Knee Arthrodesis Back to Arthroplasty: A Particular Challenge in Combination With Fungal Periprosthetic Joint Infection. Arthroplast Today 2020; 6:1038-1044. [PMID: 33385048 PMCID: PMC7772458 DOI: 10.1016/j.artd.2020.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/19/2020] [Accepted: 10/24/2020] [Indexed: 11/17/2022] Open
Abstract
A 58-year-old female treated at an outside facility with knee arthrodesis due to persistent periprosthetic joint infection fulfilled all prerequisites for a conversion back to arthroplasty, as part of a 2-stage revision. Owing to the detection of Candida parapsilosis, the treatment concept was converted to a three-stage procedure. A scheduled spacer exchange with additional amphotericin B-loaded polymethylmethacrylate was conducted as an intermediate revision before reimplantation. Conversion in the setting of fungal periprosthetic joint infection presents a challenge, and successful treatment hinges on the use of proper antifungal and antimicrobial protocols, advanced surgical techniques, and a multidisciplinary team approach. At the 3-year follow-up, successful infection eradication as measured by the Delphi-based consensus definition was achieved with a range of motion of 0°-100°.
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Affiliation(s)
- Sven Frieler
- Department of Orthopedics and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum - RUB, Bochum, Germany
- Hansjörg Wyss Hip and Pelvic Center, Swedish Hospital, Seattle, WA, USA
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
- Seattle Science Foundation, Seattle, WA, USA
- Corresponding author. 550 17th Avenue, Suite 600, Seattle, WA 98122, USA. Tel.: +1 206 475 9514.
| | - Emre Yilmaz
- Department of Orthopedics and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum - RUB, Bochum, Germany
| | - Ryan Goodmanson
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
- Seattle Science Foundation, Seattle, WA, USA
| | - Yannik Hanusrichter
- Department of Orthopedics and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum - RUB, Bochum, Germany
| | - Thomas A. Schildhauer
- Department of Orthopedics and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum - RUB, Bochum, Germany
| | - Hinnerk Baecker
- Department of Orthopedics and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum - RUB, Bochum, Germany
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Sun J, Li Q, Gao F, Xiang Z, Huang Q, Li L. Application of the Ilizarov technique for knee joint arthrodesis as a treatment for end-stage tuberculosis of the knee. BMC Musculoskelet Disord 2020; 21:579. [PMID: 32847561 PMCID: PMC7447600 DOI: 10.1186/s12891-020-03603-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 08/18/2020] [Indexed: 02/08/2023] Open
Abstract
Background With the global determination to eliminate tuberculosis (TB), the treatment for end-stage TB of the knee joint is still a great clinical challenge. This study aims to retrospectively determine the clinical and radiographic outcomes after use of the Ilizarov technique for knee joint arthrodesis as a treatment for end-stage knee TB. Methods Twenty-six patients with end-stage knee TB treated by external fixation with the Ilizarov fixator between 2012 and 2017 were examined. Anti-TB drugs were administered preoperatively, intraoperatively, and postoperatively. Clinical and radiologic examinations were performed for comprehensive evaluations, and these include C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), flexion and valgus angle of the knee, leg-length discrepancy, and Lysholm score. Results Twenty-four patients were followed up for an average of 5.8 years (2.2–7 years). All patients achieved bone fusion within a mean of 6.4 months (4–16 months). The ESR and CRP concentrations were observed to return to normal within 5.1 ± 1.1 months postoperatively. There was no recurrence of TB. At last follow-up, the mean leg-length discrepancy was 2.7 ± 1.4 cm, and the mean alignment was 8.7 ± 2.6° flexion and 5.3 ± 1.0° valgus. No patient had a significant rotational deformity. The average Lysholm score was seen to improve significantly from 36.8 ± 18.4 preoperatively to 79.5 ± 5.9 at final follow-up (p < 0.0001). Conclusion This study has demonstrated that the Ilizarov technique for knee joint arthrodesis as a treatment of end-stage knee TB achieved promising outcomes with minimal complications.
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Affiliation(s)
- Jiachen Sun
- Department of Orthopedics, West China Hospital, Sichuan University, Guoxue Lane 37, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Qiang Li
- Department of Orthopaedics, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region, NO.20 Ximianqiao Cross Street, Chengdu, 610041, Sichuan, People's Republic of China
| | - Feng Gao
- Department of Orthopaedics, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region, NO.20 Ximianqiao Cross Street, Chengdu, 610041, Sichuan, People's Republic of China
| | - Zhou Xiang
- Department of Orthopedics, West China Hospital, Sichuan University, Guoxue Lane 37, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Qi Huang
- Department of Orthopaedics, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region, NO.20 Ximianqiao Cross Street, Chengdu, 610041, Sichuan, People's Republic of China.
| | - Lang Li
- Department of Orthopaedics, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region, NO.20 Ximianqiao Cross Street, Chengdu, 610041, Sichuan, People's Republic of China.
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Chalmers BP, Matrka AK, Sems SA, Abdel MP, Sierra RJ, Hanssen AD, Pagnano MW, Mabry TM, Perry KI. Two-stage arthrodesis for complex, failed, infected total knee arthroplasty. Bone Joint J 2020; 102-B:170-175. [PMID: 32475264 DOI: 10.1302/0301-620x.102b6.bjj-2019-1554.r1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Arthrodesis is rarely used as a salvage procedure for patients with a chronically infected total knee arthroplasty (TKA), and little information is available about the outcome. The aim of this study was to assess the reliability, durability, and safety of this procedure as the definitive treatment for complex, chronically infected TKA, in a current series of patients. METHODS We retrospectively identified 41 patients (41 TKAs) with a complex infected TKA, who were treated between 2002 and 2016 using a deliberate, two-stage knee arthrodesis. Their mean age was 64 years (34 to 88) and their mean body mass index (BMI) was 39 kg/m2 (25 to 79). The mean follow-up was four years (2 to 9). The extensor mechanism (EM) was deficient in 27 patients (66%) and flap cover was required in 14 (34%). Most patients were host grade B (56%) or C (29%), and limb grade 3 (71%), according to the classification of McPherson et al. A total of 12 patients (29%) had polymicrobial infections and 20 (49%) had multi-drug resistant organisms; fixation involved an intramedullary nail in 25 (61%), an external fixator in ten (24%), and dual plates in six (15%). RESULTS Survivorship free from amputation, persistent infection, and reoperation, other than removal of an external fixator, at five years was 95% (95% confidence interval (CI) 89% to 100%), 85% (95% CI 75% to 95%), and 64% (95% CI 46% to 82%), respectively. Reoperation, other than removal of an external fixator, occurred in 13 patients (32%). After the initial treatment, radiological nonunion developed in ten knees (24%). Nonunion was significantly correlated with persistent infection (p = 0.006) and external fixation (p = 0.005). Of those patients who achieved limb salvage, 34 (87%) remained mobile and 31 (79%) had 'absent' or 'minimal' pain ratings. CONCLUSION Knee arthrodesis using a two-stage protocol achieved a survivorship free from amputation for persistent infection of 95% at five years with 87% of patients were mobile at final follow-up. However, early reoperation was common (32%). This is not surprising as this series included worst-case infected TKAs in which two-thirds of the patients had a disrupted EM, one-third required flap cover, and most had polymicrobial or multi-drug resistant organisms. Cite this article: Bone Joint J 2020;102-B(6 Supple A):170-175.
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Affiliation(s)
- Brian P Chalmers
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexis K Matrka
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Stephen A Sems
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Rafael J Sierra
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Arlen D Hanssen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark W Pagnano
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Tad M Mabry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kevin I Perry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Aparicio G, Otero J, Bru S. High Rate of Fusion but High Complication Rate After Knee Arthrodesis for Infected Revision Total Knee Replacement. Indian J Orthop 2020; 54:616-623. [PMID: 32850025 PMCID: PMC7429668 DOI: 10.1007/s43465-020-00163-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 05/29/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Knee arthrodesis is a demanding technique regarding difficulties to achieve bone fusion, control of infection and its associated complications. The purpose of this study was to evaluate if knee arthrodesis should still be indicated after failed revision total knee replacement. METHODS This was a retrospective study of 45 patients. Age, gender, follow-up, pathogens, Charlson comorbidity index, time from primary arthroplasty to arthrodesis, number of previous procedures, surgical technique, functional capability assessed by the SF-12 score, limb-length discrepancy after arthrodesis, presence of radiographic knee fusion, and complications were recorded. RESULTS The mean age at the time of operation was 72 years. 29% of patients were men, 71% were women, and the mean follow-up was 8.5 years. The average Charlson comorbidity index was 4.5. The most common microorganisms isolated were Staphylococcus epidermidis (29%), Staphylococcus aureus (22%), and Pseudomonas aeruginosa (15%). In 20% of patients, no microorganism was identified, and in 37% of patients the infection was polymicrobial. Time from primary total knee arthroplasty to arthrodesis was 55 months, and patients underwent a mean of 3.9 previous surgeries. The surgical technique used was an intramedullary long nail in 95.5%. Functionally, 93.3% of patients walked with weight bearing. The SF-12 was higher after arthrodesis (p < 0.05). Mean limb length discrepancy was 2.4 cm. Among the group treated with long intramedullary nailing, 91.1% obtained tibiofemoral fusion. Complications occurred in 37.6% of patients. CONCLUSIONS Knee arthrodesis with a long intramedullary nail after failed infected revision total knee replacement has a high rate of fusion, but the complication rate is high.
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Affiliation(s)
- Gustavo Aparicio
- grid.411068.a0000 0001 0671 5785Department of Orthopedic Surgery and Traumatology, Hospital Clínico San Carlos, 28040 Madrid, Spain
| | - Julio Otero
- grid.411068.a0000 0001 0671 5785Department of Orthopedic Surgery and Traumatology, Hospital Clínico San Carlos, 28040 Madrid, Spain
| | - Silvia Bru
- grid.411319.f0000 0004 1771 0842Department of Preventive Medicine, Hospital Infanta Cristina, Parla, Madrid Spain
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Makhdom AM, Buksbaum J, Rozbruch SR, Da Cunha R, Fragomen AT. Antibiotic Cement-Coated interlocking Intramedullary Nails in the Treatment of Septic Complex Lower Extremity Reconstruction; A Retrospective Analysis with Two year Minimum Follow up. J Bone Jt Infect 2020; 5:176-183. [PMID: 32670771 PMCID: PMC7358971 DOI: 10.7150/jbji.46570] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 05/09/2020] [Indexed: 01/22/2023] Open
Abstract
Background: To report on our experience with antibiotic cement coated interlocking intramedullary nails (ACC-IMNs) for limb salvage in septic complex lower extremity reconstruction with a minimum of 2-year follow up. Methods: We retrospectively reviewed the records of all consecutive patients who underwent a limb salvage procedure with ACC-IMNs. We reviewed patients' demographics, the preoperative infecting organism, and host type, time to bone union, complications, limb salvage rates, and infection control rates. Results: There were 28 patients with a mean age of 62 years (range 22-88). The mean follow up period was 40 months (range 28-84). The ACC-IMNs were used in 14 patients (50 %) to achieve knee fusion after failed revisions of infected total knee arthroplasty, in 8 patients (28%) for septic tibial nonunion, and in 6 patients (21%) with ankle fusion nonunions. Bony union/fusion was achieved in 87 % (21/24) of patients. The infection was controlled in 80% (21/26) of patients. Four out the five patients who had recurrent infection were type B hosts (p=0.63). The limb salvage rate was 89% (25/28). The overall complication rate was 32%. Conclusions: The use of ACC-IMNs was an effective treatment strategy and associated with high limb salvage and bone union rates. Furthermore, the infection recurrence rate was low. Knee fusion patients after failed TKA should be counseled preoperatively for a potential high complication rate.
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Affiliation(s)
- Asim M Makhdom
- Foothills Medical Group, Upper Alleghany Health System, Olean, NY and Bradford, PA, USA
| | - Joshua Buksbaum
- Hospital for Special Surgery, Weill Cornell Medicine, Cornell University, New York, NY, USA.,SUNY Downstate Health Sciences University, College of Medicine, Brooklyn, NY, USA
| | - S Robert Rozbruch
- Hospital for Special Surgery, Weill Cornell Medicine, Cornell University, New York, NY, USA
| | - Rachael Da Cunha
- Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Austin T Fragomen
- Hospital for Special Surgery, Weill Cornell Medicine, Cornell University, New York, NY, USA
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10
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Corona PS, Jurado M, Scott-Tennent A, Fraile R, Carrera L, Vicente M. Uniplanar versus biplanar monolateral external fixator knee arthrodesis after end-stage failed infected total knee arthroplasty: a comparative study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 30:815-825. [PMID: 32020375 DOI: 10.1007/s00590-020-02633-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 01/22/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND External fixator knee arthrodesis is a salvage procedure used primarily in cases of end-stage infected total knee replacement (iTKR). Stable fixation combined with bone-end compression is essential to achieve knee fusion, but providing sufficient stability can be challenging in the presence of severe bone loss. Our hypothesis is that using an external fixation biplanar configuration would bring about a fusion rate superior to that of a monolateral frame. METHODS This study compares outcomes of biplanar external fixator knee fusion due to non-revisable iTKR with those of a historical cohort control study with patients managed with a monoplanar configuration. Primary endpoints were fusion rate, time to achieve bone fusion and infection eradication rate. Limb-length discrepancy, pain level, patient satisfaction and health-related quality of life were evaluated. RESULTS A total of 29 knee fusion cases were included. In the biplanar group, infection was eradicated in 100% of the patients and fusion was achieved in all cases within an average of 5.24 months. In comparison, in the monolateral group, infection was eradicated in 86% of the cases and fusion was achieved in 81% of the patients after a mean of 10.3 months (p < 0.05). In both groups, postoperative pain was mild and patients expressed a high degree of satisfaction once fusion was achieved. CONCLUSIONS According to our data, external fixation knee fusion is a useful limb-salvage procedure in end-stage cases of knee PJI. We conclude that a biplanar configuration can halve the time required to achieve solid bone fusion in such a complex scenario.
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Affiliation(s)
- Pablo S Corona
- Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall D'Hebron University Hospital, Universitat Autónoma de Barcelona, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain.,Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall D'Hebron University, Barcelona, Spain.,Musculoskeletal Tissue Engineering Group, Vall D'Hebron Research Institute, Universidad Autónoma de Barcelona (UAB), Barcelona, Spain
| | - Maria Jurado
- Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall D'Hebron University Hospital, Universitat Autónoma de Barcelona, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain.,Musculoskeletal Tissue Engineering Group, Vall D'Hebron Research Institute, Universidad Autónoma de Barcelona (UAB), Barcelona, Spain
| | - Ana Scott-Tennent
- Orthopaedic Surgery Department, Arnau de Vilanova University Hospital, Lleida, Spain
| | - Rosa Fraile
- Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall D'Hebron University, Barcelona, Spain.,Surgical Nurse Team, Vall D'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Luis Carrera
- Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall D'Hebron University Hospital, Universitat Autónoma de Barcelona, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain.,Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall D'Hebron University, Barcelona, Spain.,Musculoskeletal Tissue Engineering Group, Vall D'Hebron Research Institute, Universidad Autónoma de Barcelona (UAB), Barcelona, Spain
| | - Matías Vicente
- Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall D'Hebron University Hospital, Universitat Autónoma de Barcelona, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain. .,Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall D'Hebron University, Barcelona, Spain. .,Musculoskeletal Tissue Engineering Group, Vall D'Hebron Research Institute, Universidad Autónoma de Barcelona (UAB), Barcelona, Spain.
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Hutchison RE, Lucas EM, Marro J, Gambon T, Bruneau KN, DesJardins JD. The effects of simulated knee arthrodesis on gait kinematics and kinetics. Proc Inst Mech Eng H 2019; 233:723-734. [DOI: 10.1177/0954411919850028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Eric M Lucas
- Department of Bioengineering, Clemson University, Clemson, SC, USA
| | - Justin Marro
- Department of Bioengineering, Clemson University, Clemson, SC, USA
| | - Taylor Gambon
- Department of Bioengineering, Clemson University, Clemson, SC, USA
| | - Kaitlin N Bruneau
- Department of Health Sciences, Furman University, Greenville, SC, USA
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12
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Makhdom AM, Fragomen A, Rozbruch SR. Knee Arthrodesis After Failed Total Knee Arthroplasty. J Bone Joint Surg Am 2019; 101:650-660. [PMID: 30946199 DOI: 10.2106/jbjs.18.00191] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Asim M Makhdom
- Hospital for Special Surgery, Weill Cornell Medicine, Cornell University, New York, NY
| | - Austin Fragomen
- Hospital for Special Surgery, Weill Cornell Medicine, Cornell University, New York, NY
| | - S Robert Rozbruch
- Hospital for Special Surgery, Weill Cornell Medicine, Cornell University, New York, NY
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13
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White CJ, Palmer AJR, Rodriguez-Merchan EC. External Fixation vs Intramedullary Nailing for Knee Arthrodesis After Failed Infected Total Knee Arthroplasty: A Systematic Review and Meta-Analysis. J Arthroplasty 2018; 33:1288-1295. [PMID: 29258761 DOI: 10.1016/j.arth.2017.10.055] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 10/20/2017] [Accepted: 10/30/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The aim of this study is to compare intramedullary nailing with external fixation for knee arthrodesis after failed infected total knee arthroplasty (TKA). Primary outcome is radiographic union. Secondary outcomes include recurrent deep infection, revision arthrodesis, and amputation. METHODS Systematic review and meta-analysis of studies comparing outcomes from intramedullary nailing and external fixation in patients with infected TKA undergoing arthrodesis procedures was performed. Randomized controlled trials and cohort studies were included. RESULTS Intramedullary nailing achieves a significantly higher rate of radiographic union compared with external fixation (odds ratio [OR] 5.17, 95% confidence interval [CI] 2.74-9.75, P < .00001) at a mean follow-up of 44.22 months. There is no significant difference in the rate of recurrent deep infection (OR 0.91, 95% CI 0.38-2.15, P = .83) or amputation (OR 0.94, 95% CI 0.23-3.84, P = .93). The rate of revision arthrodesis procedures is significantly lower for intramedullary nailing compared with external fixation (OR 0.28, 95% CI 0.08-0.93, P = .04). CONCLUSION Intramedullary nailing is more effective than external fixation with respect to several clinically important outcomes. Therefore, we recommend intramedullary nailing for achieving knee arthrodesis as a salvage procedure for infected TKA in the absence of specific indications for external fixation.
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Affiliation(s)
| | - Antony J R Palmer
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
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14
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Prophylactic Postoperative Antibiotics May Not Reduce Pin Site Infections After External Fixation. HSS J 2017; 13:165-170. [PMID: 28690467 PMCID: PMC5481261 DOI: 10.1007/s11420-016-9539-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Accepted: 11/25/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pin infection continues to be a nuisance when using definitive external fixation. Prophylactic antibiotic treatment has been proposed in an effort to decrease pin complications. QUESTIONS/PURPOSES We performed a prospective, randomized, single-blinded study to answer the following questions: (1) what was the effect of a 10-day course of oral prophylactic antibiotics administered immediately after external fixation surgery on the incidence of a subsequent pin infection, (2) what was the effect on the severity of a subsequent pin infection, and (3) what was the effect on the timing of a subsequent pin infection? METHODS Patients were randomized into antibiotic treatment and control groups, and incidence, severity, and time of onset of pin infection were recorded. RESULTS The incidence of pin infection for the entire cohort during the 90-day observation period was 46/58 (79%) without a statistically significant difference (p = 0.106). There was no statistical difference found (p = 0.512) in pin infection severity. There was no significant difference in the time of onset of infection between the two groups from the date of surgery (p = 0.553). CONCLUSIONS Our randomized data do not suggest that oral antibiotics alter the incidence, timing, or severity of pin infection. This study does not support the use of prophylactic oral antibiotics in healthy patients.
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15
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Lucas EM, Marais NC, DesJardins JD. Knee arthrodesis: procedures and perspectives in the US from 1993 to 2011. SPRINGERPLUS 2016; 5:1606. [PMID: 27652179 PMCID: PMC5028356 DOI: 10.1186/s40064-016-3285-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 09/11/2016] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Eric M Lucas
- Department of Bioengineering, Clemson University, 301 Rhodes Engineering Research Center, Clemson, SC 29634 United States
| | - Nicholas C Marais
- Department of Bioengineering, Clemson University, 301 Rhodes Engineering Research Center, Clemson, SC 29634 United States
| | - John D DesJardins
- Department of Bioengineering, Clemson University, 301 Rhodes Engineering Research Center, Clemson, SC 29634 United States
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16
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Jauregui JJ, Buitrago CA, Pushilin SA, Browning BB, Mulchandani NB, Maheshwari AV. Conversion of a Surgically Arthrodesed Knee to a Total Knee Arthroplasty-Is it Worth it? A Meta-Analysis. J Arthroplasty 2016; 31:1736-41. [PMID: 26883158 DOI: 10.1016/j.arth.2016.01.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 12/07/2015] [Accepted: 01/11/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Conversion of a surgically arthrodesed knee to total knee arthroplasty (TKA) is an option for a select group of patients who are not satisfied with their results. However, there is a paucity of literature on this topic. A systematic review of literature was performed to (1) describe the overall demographic characteristics; (2) evaluate the clinical outcomes; (3) determine the overall rate of complications; and (4) evaluate the overall satisfaction of patients who underwent conversion of an arthrodesed knee to TKA. METHODS A comprehensive literature search was systematically performed to evaluate all studies included in the literature until July 2015. The specific search terms used were "fusion knee" and "arthrodesis knee," which revealed a total of 2206 studies. A review and selection of these abstracts were then performed based on inclusion and/or exclusion criteria; a total of 10 articles were used for final review. RESULTS There were a total of 98 surgically arthrodesed knees that subsequently underwent TKA. Patients had a mean age of 55 years and were followed up for a mean of 5 years. Using a random effects model, there was an overall complication rate of 47%, an overall revision rate of 25%, and an overall failure rate of 11%. However, most patients were overall satisfied with the procedure. CONCLUSION Fusion takedown is a challenging procedure that should only be performed by experienced surgeons after extensive discussion with the patients. The clinical outcomes are good with overall patient satisfaction, but complication rates are high including risk of repeat fusion or amputation.
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Affiliation(s)
- Julio J Jauregui
- Department of Orthopaedic Surgery and Rehabilitation, SUNY Downstate Medical Center, Brooklyn, New York
| | - Carlos A Buitrago
- Department of Orthopaedic Surgery and Rehabilitation, SUNY Downstate Medical Center, Brooklyn, New York
| | - Sergei A Pushilin
- Department of Orthopaedic Surgery and Rehabilitation, SUNY Downstate Medical Center, Brooklyn, New York
| | - Benjamin B Browning
- Department of Orthopaedic Surgery and Rehabilitation, SUNY Downstate Medical Center, Brooklyn, New York
| | - Neil B Mulchandani
- Department of Orthopaedic Surgery and Rehabilitation, SUNY Downstate Medical Center, Brooklyn, New York
| | - Aditya V Maheshwari
- Department of Orthopaedic Surgery and Rehabilitation, SUNY Downstate Medical Center, Brooklyn, New York
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Streitbuerger A, Hardes J, Gosheger G, Dieckmann R, Hoell S. Knee salvage in revision arthroplasty after massive bone loss of the femur condyles (≥Engh III) with a single-modular-hinged knee revision implant. Arch Orthop Trauma Surg 2016; 136:1077-83. [PMID: 27370883 DOI: 10.1007/s00402-016-2491-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Indexed: 01/29/2023]
Abstract
PURPOSE Massive bone loss of the femur condyles in revision arthroplasty often requires modular-hinged revision implants to restore a stable joint situation. In the present series, the outcome after knee revision surgery using a single modular-hinged revision implant in patients with severe bone defects (>Engh III) is investigated. METHODS Sixty patients with severe bone defects (≥Engh III) after failed primary and revision knee arthroplasty were included. Medium follow-up was 47 (range 10-84) months after knee revision surgery. Medium patient age was 70 (range 33-87) years at the time of surgery. An average of 2.3 prior knee operations per patient was performed. 70 % of the patients required the knee revision implant after two-stage revision because of a deep implant infection. RESULTS Estimated 5 year extremity survival was 95 and 65 % implant survival. Reasons for implant revision in decreasing order were reinfection (30 %), aseptic loosening (13 %), and periprosthetic fracture (9.8 %). The average active range of motion in the knee joint was 88° (range 40°-115°) for flexion. An extension deficit of a mean of -6° was (range -50-5° hyper-extension) observed. Patient age influenced the functional results significantly in terms of reduced walking distances and decreased modified WOMAC score. CONCLUSION In consideration of this complex study, population acceptable functional results can be achieved using a modular knee revision endoprosthesis. In younger patients (<60 years), satisfying results in terms of walking ability and overall satisfactory can be expected. The outcome in older multimorbid patients is worse. Yet, operation in these patients can be feasible to restore enough mobility for daily household activities.
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Affiliation(s)
- Arne Streitbuerger
- Department of Orthopedics, University Hospital of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, NRW, Germany.
| | - Jendrik Hardes
- Department of Orthopedics, University Hospital of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, NRW, Germany
| | - Georg Gosheger
- Department of Orthopedics, University Hospital of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, NRW, Germany
| | - Ralf Dieckmann
- Department of Orthopedics, University Hospital of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, NRW, Germany
| | - Steffen Hoell
- Department of Orthopedics, Paracelsus-Klink Osnabrück, Osnabrück, Germany
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Knee arthrodesis with a long intramedullary nail as limb salvage for complex periprosthetic infections. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 26:907-914. [PMID: 27473317 DOI: 10.1007/s00590-016-1827-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 07/19/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Periprosthetic infection following total knee arthroplasty is a devastating complication, which is not always satisfactorily resolved by revision surgery. Arthrodesis is a salvage alternative to above-knee amputation or permanent resection arthroplasty. Fixation options include internal compression plating, external fixation, and intramedullary nails. METHODS We retrospectively reviewed twelve consecutive cases (9 males, 3 females; mean age, 67 years) of knee arthrodesis with a long intramedullary nail, performed at a single institution between 2003 and 2014. Desired outcomes were the ability to mobilize without pain, solid radiographic fusion, and the eradication of infection. RESULTS Mean follow-up was 48.5 months (range, 9-120 months). Eleven patients (92 %) demonstrated stable fusion, ten patients (83 %) were ambulatory without pain, and ten patients (83 %) remained without infection at most recent follow-up. Eight patients (67 %) achieved union at an average of 12 months; three required repeat procedures, achieving union at an average of 9 months. There was a significant difference (P < 0.01) between the numbers of previous operations amongst the eight patients who initially achieved union (mean, 3.25) and three who subsequently required repeat procedures (mean, 8.33). CONCLUSIONS In contrast to similar studies, we performed a single-stage exchange where possible, while comparable ambulatory and fusion rates were observed. Numerous previous attempts at revision arthroplasty, co-morbidities, and infections with highly resistant organisms have been associated with further complications. Although technically challenging, knee arthrodesis with a long intramedullary nail offers an acceptable limb salvage procedure for carefully selected patients with complex periprosthetic infections.
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Contribution of G.A. Ilizarov to bone reconstruction: historical achievements and state of the art. Strategies Trauma Limb Reconstr 2016; 11:145-152. [PMID: 27432154 PMCID: PMC5069200 DOI: 10.1007/s11751-016-0261-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 07/09/2016] [Indexed: 02/07/2023] Open
Abstract
Methodological solutions of Prof. G.A. Ilizarov are the core stone of the contemporary bone lengthening and reconstruction surgery. They have been acknowledged in the orthopaedic world as one of the greatest contributions to treating bone pathologies. The Ilizarov method of transosseous compression–distraction osteosynthesis has been widely used for managing bone non-union and defects, bone infection, congenital and posttraumatic limb length discrepancies, hand and foot disorders. The optimal conditions for implementing distraction and compression osteogenesis were proven by numerous experimental studies that Prof. G.A. Ilizarov organized and supervised at a large orthopaedic research institute in Kurgan. The tension stress effect on regeneration and growth of tissues was thoroughly investigated with radiographic, histological and biochemical methods. The impact of the Ilizarov method on the progress of bone lengthening and reconstruction surgery could be called revolutionary.
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Jiranek WA, Waligora AC, Hess SR, Golladay GL. Surgical Treatment of Prosthetic Joint Infections of the Hip and Knee: Changing Paradigms? J Arthroplasty 2015; 30:912-8. [PMID: 25922125 DOI: 10.1016/j.arth.2015.03.014] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 02/26/2015] [Accepted: 03/13/2015] [Indexed: 02/07/2023] Open
Abstract
Prosthetic joint infection (PJI) of the hip and knee remains one of the most common and feared arthroplasty complications. The impact and cost of PJI is significant, both to the patient and to the health care system. Recent reports of results of different treatment strategies have led many surgeons to modify their approach to management of PJI. This paper will explore apparent paradigm shifts, both to indications and technique, including the importance of waiting for bacterial identification, the decreasing role for irrigation and debridement (I&D) with retention of components, the increased utilization of single stage revision, and conversely a decreasing role for two-stage exchange. Strategies for treating drug-resistant organisms and management of failed treatment will also be examined.
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Affiliation(s)
- William A Jiranek
- Department of Orthopaedic Surgery, VCU School of Medicine, Richmond, Virginia
| | - Andrew C Waligora
- Department of Orthopaedic Surgery, VCU School of Medicine, Richmond, Virginia
| | - Shane R Hess
- Department of Orthopaedic Surgery, VCU School of Medicine, Richmond, Virginia
| | - Gregory L Golladay
- Department of Orthopaedic Surgery, VCU School of Medicine, Richmond, Virginia
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