Top

Archives of Orthopaedic and Trauma Surgery

Published in:

01-10-2018 | Knee Revision Surgery

Comparison of two-stage revision arthroplasty and intramedullary arthrodesis in patients with failed infected knee arthroplasty

Authors: Martin Gathen, Matthias D. Wimmer, Milena M. Ploeger, Leonie Weinhold, Matthias Schmid, Dieter C. Wirtz, Sascha Gravius, Max J. Friedrich

Published in: Archives of Orthopaedic and Trauma Surgery | Issue 10/2018

Abstract

Background

Failed total knee arthroplasty (TKA) with significant bone loss and compromised soft-tissues is challenging and the final results are often inferior to patient’s expectation. The objective of this study was to present a comparison of outcomes in patients with failed infected TKA treated with two-stage revision TKA or knee arthrodesis and to assess clinical and functional results, implant survival and infection recurrence. The hypothesis was that an arthrodesis may result in beneficial effects on patients’ outcome.

Methods

Clinical data of 81 patients with periprosthetic joint infection (PJI) of the knee joint were collected and analyzed retrospectively. Between 2008 and 2014, a total of 36 patients had been treated within a two-stage exchange procedure and reimplantation of a modular intramedullary arthodesis nail and 45 patients with revision TKA. Patients were treated according to the same structured treatment algorithm. Clinical and functional evaluation was performed using the Oxford knee score (OKS) and the visual analogue scale (VAS).

Results

The mean follow-up was 32.9 ± 14.0 months. The rate of definitely free of infection at last follow-up in the arthrodesis group was 32 of 36 (88.9%) and 36 of 45 (80.0%) in the revision TKA group (p = 0.272). Mean VAS for pain in the arthrodesis group was 3.1 ± 1.4 compared to 3.2 ± 1.6 in the revision TKA group (p = 0.636). The OKS in the arthrodesis group was 38.7 ± 8.9 and 36.5 ± 8.9 (p = 0.246) in patients with revision TKA. Rate of revisions in the revision-TKA group was 2.8 ± 3.7 compared to 1.2 ± 2.4 in the arthrodesis group (p = 0.021).

Conclusion

Treatment of PJI needs a distinct therapy with possible fallback strategies in case of failure. A knee arthrodesis is a limb salvage procedure that showed no significant benefits on the considered outcome factors compared to revision TKA but is associated with significantly lower revision rate. After exhausted treatment modalities, a knee arthrodesis should be considered as an option in selected patients.

Level of evidence

Level III, retrospective cohort study.

Peersman G, Laskin R, Davis J, Peterson M (2001) Infection in total knee replacement: a retrospective review of 6489 total knee replacements. Clin Orthop Relat Res 392:15–23CrossRef

Gollwitzer H, Diehl P, Gerdesmeyer L, Mittelmeier W (2006) [Diagnostic strategies in cases of suspected periprosthetic infection of the knee. A review of the literature and current recommendations]. Der Orthopaede 35:904:906–908. https://doi.org/10.1007/s00132-006-0977-z. 910 – 906.CrossRef

Ong K. Mowat F, Lau E, Saleh K, Schmier J, Kurtz S (2007) Projected economic burden of revision THA and TKA for medicare enrollees in the next decade. Exponent 14–18:1–7

Glynn MK, Sheehan JM (1983) An analysis of the causes of deep infection after hip and knee arthroplasties. Clin Orthop 178:202–206

Gordon SM, Culver DH, Simmons BP (1990) Risk factors for wound infection after total knee arthroplasty. Am J Epidemiol 131:905–916CrossRefPubMed

Laffer RR, Graber P, Ochsner PE, Zimmerli W (2006) Outcome of prosthetic knee-associated infection: evaluation of 40 consecutive episodes at a single centre. Clin Microbiol Infect 12:433–439 https://doi.org/10.1111/j.1469-0691.2006.01378 CrossRefPubMed

Friedrich MJ, Randau TM, Wimmer MD, Reichert B, Kuberra D, Stoffel-Wagner B, Wirtz DC, Gravius S (2014) Lipopolysaccharide-binding protein: a valuable biomarker in the differentiation between periprosthetic joint infection and aseptic loosening? Int orthop 38:2201–2207. https://doi.org/10.1007/s00264-014-2351-9 CrossRefPubMed

Gollwitzer H, Dombrowski Y, Prodinger PM, Peric M, Summer B, Hapfelmeier A, Saldamli B, Pankow F, von Eisenhart-Rothe R, Imhoff AB, Schauber J, Thomas P, Burgkart R, Banke IJ (2013) Antimicrobial peptides and proinflammatory cytokines in periprosthetic joint infection. J Bone Joint surg 95:644–651. https://doi.org/10.2106/JBJS.L.00205 CrossRefPubMed

Randau TM, Friedrich MJ, Wimmer MD, Reichert B, Kuberra D, Stoffel-Wagner B, Limmer A, Wirtz DC, Gravius S (2014) Interleukin-6 in serum and in synovial fluid enhances the differentiation between periprosthetic joint infection and aseptic loosening. PloS one 9:e89045. https://doi.org/10.1371/journal.pone.0089045 CrossRefPubMedPubMedCentral

10.

Wimmer MD, Randau TM, Petersdorf S, Pagenstert GI, Weisskopf M, Wirtz DC, Gravius S (2013) Evaluation of an interdisciplinary therapy algorithm in patients with prosthetic joint infections. Int Orthop 37:2271–2278. https://doi.org/10.1007/s00264-013-1995-1 CrossRefPubMedPubMedCentral

11.

Hwang SC, Kong JY, Nam DC, Kim DH, Park HB, Jeong ST, Cho SH (2010) Revision total knee arthroplasty with a cemented posterior stabilized, condylar constrained or fully constrained prosthesis: a minimum 2-year follow-up analysis. Clin Orthop Surg 2:112–130CrossRefPubMedPubMedCentral

12.

Petersen KK, Simonsen O, Laursen MB, Nielsen TA, Rasmussen S, Arendt-Nielsen L (2015) Chronic postoperative pain after primary and revision total knee arthroplasty. Clin J Pain 31:1–6CrossRefPubMed

13.

Hanssen AD, Trousdale RT, Osmon DR (1995) Patient outcome with reinfection following reimplantation for the infected total knee arthroplasty. Clin Orthop Relat Res 321:55.67

14.

Conway JD, Mont MA, Bezwada HP (2004) Arthrodesis of the knee. J Bone Joint Surg Am 86:835–848CrossRefPubMed

15.

Razil N, Abbas AM, Kakar R, Agarwal S, Morgan-Jones R (2016) Knee arthrodesis with a long intramedullary nail as limb salvage for complex periprosthetic infections. Eur J Orthop Surg Traumatol 26:907–914CrossRef

16.

Christie MJ, De Boer DK, McQueen DA, Cooke FW, Hahn DL (2003) Salvage procedures for failed total knee arthroplasty. J Bone Joint Surg Am 85:58–62CrossRef

17.

Bargiotas K, Wohlrab D, Sewecke JJ, Lavigne G, DeMeo PJ, Sotereanos NG (2007) Arthrodesis of the knee with a long intramedulalary nail following the failure of a total knee arthroplasty as the result of infection. Surgical technique. J Bone Joint Surg Am 89:103–110CrossRefPubMed

18.

Friedrich MJ, Schmolders J, Wimmer MD, Strauss AC, Ploeger MM, Wirtz DC, Gravius S, Randau TM (2017) Two-stage knee arthrodesis with a modular intramedullary nail due to septic failure of revision total knee arthroplasty with extensor mechanism deficiency. Knee. https://doi.org/10.10116/j.knee.2017.05.019 PubMedCrossRef

19.

Zimmerli W, Trampuz A, Ochsner PE (2004) Prosthetic-joint infections. New Engl J Med 351:1645–1654. https://doi.org/10.1056/NEJMra040181 CrossRefPubMed

20.

Trampuz A, Hanssen AD, Osmon DR, Mandrekar J, Steckelberg JM, Patel R (2004) Synovial fluid leukocyte count and differential for the diagnosis of prosthetic knee infection. Am J Med 117:556–562. https://doi.org/10.1016/j.amjmed.2004.06.022 CrossRefPubMed

21.

Mirra JM, Marder RA, Amstutz HC (1982) The pathology of failed total joint arthroplasty. Clin Orthop Relat Res 170:175–183

22.

Lonner JH, Desai P, Dicesare PE, Steiner G, Zuckerman JD (1996) The reliability of intraoperative frozen sections for identifying active infection during revision hip or knee arthroplasty. J Bone Joint Surg Am 78:1553–1558CrossRefPubMed

23.

Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckelberg JM, Rao N, Hannsen A, Wilson WR (2013) Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin infect Dis 56:e1–e25CrossRefPubMed

24.

Renz N, Perka C, Trampuz A (2016) Management of periprosthetic infections of the knee. Orthopaede 45(1):65–71CrossRef

25.

McPherson EJ, Woodson C, Holtom P, Roidis N, Shufelt C, Patzakis M (2002) Periprosthetic total hip infection: outcomes using a staging system. Clinical orthopaedics and related research 403:8–15CrossRef

26.

Trampuz A, Zimmerli W (2005) Prosthetic joint infections: update in diagnosis and treatment. Swiss Med Wkly 135:243–251 doi: 2005/17/smw-10934.PubMed

27.

Pagenstert G, Zimmerlie W, Weber O, Hoppe T, Gravius S (2012) Prothesenassoziierte Infekte. In: Rucholtz S, Wirtz DC (Hrsg) Orthopädie und Unfallchirurgie, Intensivkurs zur Weiterbildung, 2 Aufl. Thieme, Stuttgart, pp 150–159

28.

Mittal Y, Fehring TK, Hanssen A, Marculescu C, Odum SM, Osmon D (2007) Two stage reimplantation for periprosthetic knee infection involving resistant organisms. J Bone Joint Surg Am 89:1227–1231CrossRefPubMed

29.

Salgado CD, Dash S, Cantey JR, Marculescu CE (2007) Higher risk of failure of methicillin-resistant Staphylococcus aureus prosthetic joint infections. Clin Orthop Relat Res 461:48–53PubMed

30.

Jaemsen E, Stogiannidis I, Malmivaara A, Pajamaeki J, Puolakka T, Konttinen YT (2009) Outcome of prosthesis exchange for infected kee arthroplasty: the effect of treatment approach. Acta Orthop 80:67–77CrossRef

31.

Romano CL, Gala L, LOgoluso N, Romano D, Grago L (2012) Two-stage revision of septic knee prosthesis with articulating knee spacers yields better infection eradication rate than one-stage or two-stage revision with static spacers. Kee Surg Sports Traumatol Arthrosc. 20:2445–2453

32.

Lichstein P, Su S, Hedlund H, Suh G, Maloney WJ, Goodman SB, Huddleston Jl (2016) Treatment of periprosthetic knee infection with a two-stge protocol using static spacers. Clin Orthop Relat Res 474:120–125CrossRefPubMed

33.

Kunutsor SK, Whitehouse MR, Lenguerrand E, Blom AW, Beswick AD. Re-Infection outcomes following one and two-stage surgical revision of infected knee prosthesis: a systemic review and meta-analysis. PLoS One 2016;11;11(3)

34.

Sherrell JC, Fehring TK, Odum S, HAnsen E, Zmistowski B, Dennos A, Kalore N (2011) The Chitranjan Ranawat Award: fate of two-stage reimplantation after failied irrigation and debridement for periprosthetic knee infection. Clin Orthop Relat Res 469:18–25CrossRefPubMed

35.

George DA, Haddah FS (2014) Surgical management of periprosthetic joint infections: two-stage exchange. J Knee Surg 27:279–282CrossRefPubMed

36.

Kheir MM, Tan TL, Gomez MM, Chen AF, Parvizi J (2016) Patients with failed prior two-stage exchange have poor outcomes after surgical intervention. J Arthroplasty 32(4):1262–1265CrossRefPubMed

37.

van Kempen RW, Schimmel JJ, van Hellemondt GG, Vandenneucker H, Wymenga AB (2013) Reason for revision TKA predicts clinica l outcome: prospective evaluation of 150 patients with 2-years folloup. Clin Othop Relat Res 47:2296–2302CrossRef

38.

Barton TM, White SP, Mintowt-Czyz W, Porteous AJ, Newman JH (2008) A comparison of patient based outcome following knee arthrodesis for failed total knee arthroplasty and revision knee arthroplasty. Knee 15:98–100CrossRefPubMed

39.

Gottfriedsen TB, Schroder HM, Odgaard A (2016) Knee arthrodesis after failure of knee arthroplasty: a nationwide register-based study. J Bone Joint Surg Am 17(16):1370–1377 98(CrossRef

40.

Van Rensch PJ, Van de Pol GJ, Goosen JH, Wymenga AB, De Man FH (2014) Arthrodesis of the knee following failed arthroplasty. Knee Surg Sports Traumatol Arthrosc 22(8):190–198

41.

Mabry TM, Jacofsky DJ, Haidukewych GJ, Hanssen AD (2007) Comparison of intramedullary nailing and external fixation knee arthrodesis for the infected knee replacement. Clin Orthop Relat Res 464:11–15. https://doi.org/10.1097/BLO.0b013e31806a9191 PubMedCrossRef

42.

Hawi N, Kendoff D, Citak M, Gehrke T, Haasper C (2015) Septic single-stage knee arthrodesis after failed total knee arthroplasty using a cemented coupled nail. Bone Joint J 5:649–653CrossRef

43.

Somayaji HS, Tsaggerides P, Ware HE, Dowd GS (2008) Knee arthrodesis—a review. Knee 15:247–254CrossRefPubMed

44.

Hungerer S, Kiechle M, von Rüden C, Miliz M, Beitzel K, Morgenstern M (2017) Knee arthrodesis versus above-the-knee amputation after septic failure of revision total knee arthroplasty: comparison of functional outcome and complication rates. BMC Musculoskelet Disord 18:443. https://doi.org/10.1186/s12891-017-1806-8 CrossRefPubMedPubMedCentral

45.

Maempel JF, Clement ND, Brenkel IJ, Walmsley PJ (2016) Range of movement correlates with the Oxford knee score after knee replacement. Knee 23:511–516CrossRefPubMed

46.

Davies AP (2002) Rating systems for total knee replacement. Knee 9:261–266CrossRefPubMed

47.

Putman S, Kern G, Senneville E, Beltrand E, Migaud H (2013) Knee arthrodesis using a customised modular intramedullary nail in failed infected total knee arthroplasty. Orthop Traumatol Surg Re 99:391–398CrossRef

48.

McPherson EJ, Tontz W, Patzakis M, Woodsome C, Holtom P, Norris L, Shufelt C (1999) Outcome of infected total knee utilizing a staging system for prosthetic joint infection. Am j Orthop 28:161–165PubMed

49.

McPherson EJ, Patzakis MJ, Gross JE, Holton PD, Song M, Dorr LD (1997) Infected total knee arthroplasty. Two-stage reimplantation with a gastrocnemius flap. Clin Othop Relat Res 341:73–81

Title: Comparison of two-stage revision arthroplasty and intramedullary arthrodesis in patients with failed infected knee arthroplasty
Authors: Martin Gathen
Matthias D. Wimmer
Milena M. Ploeger
Leonie Weinhold
Matthias Schmid
Dieter C. Wirtz
Sascha Gravius
Max J. Friedrich
Publication date: 01-10-2018
Publisher: Springer Berlin Heidelberg
Published in: Archives of Orthopaedic and Trauma Surgery / Issue 10/2018
Print ISSN: 0936-8051
Electronic ISSN: 1434-3916
DOI: https://doi.org/10.1007/s00402-018-3007-9

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Comparison of two-stage revision arthroplasty and intramedullary arthrodesis in patients with failed infected knee arthroplasty

Abstract

Background

Methods

Results

Conclusion

Level of evidence

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

Level of evidence

Please log in to get access to this content

Other articles of this Issue 10/2018

Correlation of CT imaging and histology to guide bone graft selection in scaphoid non-union surgery

Reverse shoulder arthroplasty: the role of physical therapy on the clinical outcome in the mid-term to long-term follow-up

What are the factors to affect outcome and healing of meniscus bucket handle tears?

Total hip arthroplasty following illicit drug abuse

Stability of supramalleolar osteotomies using different implants in a sawbone model

Increased medial and lateral tibial posterior slopes are independent risk factors for graft failure following ACL reconstruction