Staged vs Concurrent Hardware Removal During Conversion Total Knee Arthroplasty

Staged Approach to Tibial Nail Removal Poses Increased Risk for Infection in the Setting of Total Knee Arthroplasty

BACKGROUND

While previous research has addressed conversion arthroplasty scenarios, there is limited data on outcomes of staged or concurrent removal of intramedullary (IM) nails during total knee arthroplasty (TKA). Our study aimed to explore the association between the timing of IM nail removal and the incidence of periprosthetic joint infection (PJI), surgical site infection (SSI), manipulation under anesthesia (MUA), and aseptic revision at 90 days, 1 year, and 2 years after TKA when IM nail removal is performed in either a (1) staged or (2) concurrent manner.

METHODS

We queried a national, all-payer database of all patients who underwent a primary TKA and hardware removal of an IM tibial nail. The group was separated into mutually exclusive cohorts with removal performed either (1) in a staged manner (n = 287) or (2) on the same day of TKA (n = 2,958). Surgical complications included the following: PJIs, SSIs, MUAs, and aseptic revisions. Surgical complications were collected at 90-day, 1 year, and 2-year time points.

RESULTS

Patients who had staged nail removal before TKA demonstrated the highest incidence of PJI at 90 days, 1 year, and 2 years (13.9, 16.7, and 17.1%, respectively). Adjusted multivariate regression analyses demonstrated significantly higher odds of a PJI, SSI, and MUA at 90 days, 1 year, and 2 years for all patients who had staged nail removal TKA (P < .001).

CONCLUSIONS

There was an observed association between concurrent IM nail removal and a decreased risk of PJI, SSI, and MUA when compared to patients who had nail removal in a staged fashion. However, this does not discount the utility of the staged approach, as it may be necessary for patients less tolerant to longer operative times.

Staged vs concurrent hardware removal in total ankle arthroplasty

INTRODUCTION

Ankle osteoarthritis is more commonly posttraumatic. Consequently, dealing with hardware removal is quite frequent when performing a total ankle arthroplasty (TAA). The purpose of this study is to compare outcomes regarding either a staged or concurrent hardware removal when performing TAA.

MATERIALS AND METHODS

275 consecutive patients with TAA previously treated with internal fixation were retrospectively reviewed. Finally, 57 patients were enrolled based on exclusion criteria, and were differentiated into two groups considering the timing of hardware removal (staged-group A vs concurrent-group B) to compare: neurovascular and wound complications, time to recover full weight bearing, scar-tissue esthetic, and surgical time. Moreover, a subgroup comparison considering the surgical approach (single approach, minor additional approach, major additional approach) was performed between the group A and group B.

RESULTS

No statistically significant difference other that longer surgical time (p < 0.05) was observed between group A and group B. When considering surgical approach subgroups, statistically significant higher surgical wound complications and revision rate were reported in group B (concurrent) major additional approach subgroup, and a statistically significant shorter time to full weight bearing was reported in group A (staged) major additional approach subgroup.

CONCLUSIONS

When performing TAA requiring hardware removal, no clear superiority of staged over concurrent hardware removal was observed. However, when considering a subgroup of patients requiring a separate major incision, a staged approach has shown reduced surgical time, less risk of wound complications, and shorter recovery to full weight bearing.

LEVEL OF EVIDENCE

III.

Decreased Risk of Periprosthetic Joint Infection with Concurrent Hardware Removal During Conversion Total Hip Arthroplasty Compared to Staged Removal: A Matched Cohort Analysis

INTRODUCTION

Hardware removal before conversion total hip arthroplasty (cTHA) is a challenging task for the orthopaedic surgeon, although there is little consensus on the timing of hardware removal to mitigate risk of surgery-related complication following cTHA.

METHODS

Using a national insurance database, we evaluated patients who underwent hardware removal either on the same day or within 1 year before cTHA, resulting in a total of 7,756 patients. After matching based on demographic factors and comorbidities, both staged and concurrent groups consisted of 2,752 patients. The 90-day and 1-year risk of revision surgery, periprosthetic joint infection (PJI), periprosthetic fracture, and aseptic loosening were calculated and compared. Demographic factors and comorbidities were further evaluated as risk factors for PJI.

RESULTS

The rates of infection were 1.85% and 3.05% at 90 days postoperatively and 2.94% and 4.14% at 1 year postoperatively for concurrent versus staged cohorts, respectively (P = 0.004 and P = 0.02). No difference was observed at 90 days or 1 year between the two cohorts in risk of fracture, revision surgery, or aseptic loosening. Diabetes (P = 0.002 and P < 0.001), tobacco use (P < 0.001 and P < 0.001), and obesity (P = 0.026 and P = 0.025) were identified as risk factors for PJI at both 90 days and 1 year postoperatively.

DISCUSSION

The timing of hardware removal is associated with an increased risk of PJI, although no difference was observed in revision surgery, fracture, or loosening among staged versus concurrent cohorts. These findings are important to consider when surgeons are evaluating patients with periarticular implants surrounding their hip.

Use of a preoperative 3D templating and proximal lateral tibial fitting patient-specific instrumentation in fixed valgus complex primary total knee arthroplasty for a patient with retaining hardware for internal fixation to treat Schatzker type V tibial plateau fracture: A case report

A 72-year-old female patient with a fixed valgus knee deformity due to a Schatzker type V tibial plateau fracture treated with bilateral locking plates 8 years ago was admitted to our clinic with complaints of chronic pain and knee instability when walking. Radiographs revealed Kellgren-Lawrence Classification grade 4 knee osteoarthritis and 20.5° of valgus knee deformity. She was treated with three-dimensional templating and proximal lateral tibial fitting patient-specific instrumentation-assisted mechanically aligned posterior sacrificing total knee arthroplasty with minimal removal of the retained hardware for the internal fixation of the tibial plateau fracture via a lateral approach, resulting in a favorable clinical outcome. The use of proximal lateral tibial fitting patient-specific instrumentation in fixed valgus complex primary total knee arthroplasty for patients with retaining hardware for internal fixation to treat tibial plateau fractures is considered a treatment option to decrease surgical invasion.

Concurrent Hardware Removal is Associated With Increased Odds of Infection Following Conversion Total Knee Arthroplasty

BACKGROUND

The optimal timing of removal of periarticular implants prior to conversion total knee arthroplasty (TKA) remains to be determined. The purpose of this study was to compare infection rates in conversion TKA when hardware removal was performed in either a staged or concurrent manner.

METHODS

We performed a retrospective study using a national insurance claims database of patients who underwent removal of hardware on the same day or within 1 year before their TKA. A total of 16,099 patients met the criteria. After matching, both final cohorts consisted of 4,502 patients. The 90-day and 1-year rates of prosthetic joint infection were calculated.

RESULTS

The rates of infection were 1.64% and 3.00% in the staged group and 2.62% and 3.95% in the concurrent group at 90 days and 1 year postoperatively, respectively (P = .001, P = .01). Logistic regression analyses demonstrated that patients who had hardware removal greater than 3 months prior to TKA had significantly lower odds of infection at 1-year postop (Odds Ratio 0.61 95% Confidence Interval 0.45-0.84; P = .003).

CONCLUSION

Removal of hardware performed concurrently or within 3 months of a TKA is associated with increased odds of prosthetic joint infection at 1 year postoperatively. Surgeons should consider removing periarticular hardware prior to TKA when possible.

Complications, Implant Survivorships, and Functional Outcomes of Conversion Total Knee Arthroplasty With Prior Hardware

BACKGROUND

End-stage knee osteoarthritis with retained periarticular hardware is a frequent scenario. Conversion total knee arthroplasty (TKA) leads to excellent outcomes, but poses unique challenges. The evidence supporting retention versus removal of hardware during TKA is controversial.

METHODS

Patients who underwent TKA with prior hardware between January 2009 and December 2019 were identified. A total of 148 patients underwent TKA with prior hardware. The mean follow-up was 60 months (range, 24-223). Univariate and multivariable analyses were used to study correlations among factors and surgical-related complications, prosthesis failures, and functional outcomes.

RESULTS

The complication rate was 28 of 148 (18.9%). The use of a quadriceps snips in addition to a medial parapatellar arthrotomy was associated with a higher complication (odds ratio: 20.7, P < .05), implant failures (odds ratio: 13.9, P < .05), and lower the Veterans Rand 12 Mental Score (VR-12 MS) (-14.8, P < .05). Hardware removal versus retention and use of single versus multiple incisions were not associated with complications or prosthesis failures. Removal of all hardware was associated with significantly higher (+7.3, P < .05) VR-12 MS compared to retention of all hardware.

CONCLUSIONS

TKA with prior hardware was associated with more complications, implant failures, and lower VR-12 MS when a more constrained construct or quadriceps snip was performed. This probably reflects the level of difficulty of the procedure rather than the surgical approach used. Hardware removal or retention was not associated with complications or implant failures; however, removal rather than retention of all prior hardware is associated with increased general health outcomes.

LEVEL OF EVIDENCE

IV, cohort without control.

3D templating and patient-specific instrumentation in primary total knee arthroplasty with retained internal fixation hardware: Two case reports

Two elderly female patients with Kellgren-Lawrence grade 4 knee osteoarthritis (KOA) having varus knee deformity and retained hardware for internal fixation in either femur or tibia underwent total knee arthroplasty (TKA) using 3D templating and patient-specific instrumentation (PSI). TKA was performed to treat KOA by minimally removing or without removing the retained hardware for the internal fixation of distal femoral or tibial diaphyseal fractures. Throughout a 2-year follow-up period, no superficial or deep infection was observed. In additions, no radiological symptoms of suspected component loosening were observed. Furthermore, both patients can currently walk without using crutches. 3D templating and PSI in primary TKA for patients with retained hardware for internal fixation of femoral or tibial fractures are considered suitable treatment options for reducing surgical invasion.

Medial Unicompartmental Knee Arthroplasty After Failed Open-Wedge High Tibial Osteotomy

BACKGROUND

Controversy exists whether or not a previous high tibial osteotomy (HTO) influences the outcome and survival of a unicompartmental knee arthroplasty (UKA). The aim of this retrospective study was to evaluate clinical, radiological, and functional outcomes of UKA after failed open-wedge HTO compared with UKA with no previous HTO.

METHODS

Between 2001 and 2017, 24 post-HTO UKAs (group A) with an average follow-up of 8.1 years (range: 5 to 13) were compared with a control group of 30 patients undergoing simple UKA (group B) with an average follow-up of 9.5 years (range: 2 to 16). All patients were evaluated preoperatively and postoperatively using Knee Society Score, University of California at Los Angeles Activity Score, Western Ontario and McMaster University Osteoarthritis Index, and through objective evaluation. Mechanical coronal alignment and Caton-Deschamps index were measured both preoperatively and postoperatively.

RESULTS

In both groups, Knee Society Score, University of California at Los Angeles Activity Score, and Western Ontario and McMaster University Osteoarthritis Index scores significantly improved at follow-up (P < .001). In addition, statistically significant greater improvements in clinical and functional scores were reported in group B compared with group A (P < .001). No statistically significant differences concerning postoperative mechanical axis were observed between groups (2.7° and 3.2°, respectively, P = .27) and with regard to Caton-Deschamps index (1.0° and 1.1°, respectively, P = .44).

CONCLUSION

This study demonstrated improvements in clinical and functional outcomes compared with preoperatory status in both groups irrespective of a previous HTO. A prior HTO was a determinant for having reduced postoperative clinical and functional outcomes after UKA.