Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
Clinical Orthopaedics and Related Research®
Published in: Clinical Orthopaedics and Related Research® 10/2012

01-10-2012 | Symposium: 2011 Musculoskeletal Infection Society

Better Function for Fusions Versus Above-the-knee Amputations for Recurrent Periprosthetic Knee Infection

Authors: Antonia F. Chen, MD, MBA, Nicholas C. Kinback, BS, Alma E. Heyl, LAS, RTR, CCRC, Edward J. McClain, MD, Brian A. Klatt, MD

Published in: Clinical Orthopaedics and Related Research® | Issue 10/2012

Login to get access

Abstract

Background

Treatment of chronic periprosthetic joint infections (PJIs) after TKA is limited to fusions, above-the-knee amputations (AKAs), revision TKA, and antibiotic suppression and is often based on the patient’s medical condition. However, when both fusion and AKA are options, it is important to compare these two procedures with regard to function.

Questions/purposes

Do patients receiving a knee fusion for PJI after TKA have better function compared to patients receiving an AKA?

Methods

We retrospectively reviewed patients who were eligible for either fusion or AKA after PJI TKA. Thirty-seven patients underwent a fusion for PJIs after TKA between 1999 and 2010. Nine patients died postoperatively and eight patients were lost to followup, leaving 20 patients. Patients completed a specialized questionnaire about their fusion, and functional capability was assessed by the SF-12. We compared fusions to a previously published group of six patients who underwent AKA for recurrent PJI after TKA.

Results

For patients with fusion, community ambulators increased from five to 10 and nonambulators decreased from three to one. For patients with AKA, nonambulatory patients increased from zero to two, and community ambulators decreased from four to one. The SF-12 physical component summary measurements were higher for fusions (51) than for AKAs (26). The mental component summary was also higher in fusions (60) than in AKAs (44). Seventy percent of patients indicated they would undergo a fusion again instead of undergoing an amputation if they were presented with both options after undergoing their operation.

Conclusions

Patients receiving knee fusions for treating recurrent PJIs after TKA have better function and ambulatory status compared to patients receiving AKA.

Level of Evidence

Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
Appendix
Available only for authorised users
Literature
1.
Aksnes LH, Bauer HC, Jebsen NL, Folleras G, Allert C, Haugen GS, Hall KS. Limb-sparing surgery preserves more function than amputation: a Scandinavian sarcoma group study of 118 patients. J Bone Joint Surg Br. 2008;90:786–794.PubMedCrossRef
2.
Arroyo JS, Garvin KL, Neff JR. Arthrodesis of the knee with a modular titanium intramedullary nail. J Bone Joint Surg Am. 1997;79:26–35.PubMedCrossRef
3.
Bargiotas K, Wohlrab D, Sewecke JJ, Lavinge G, Demeo PJ, Sotereanos NG. Arthrodesis of the knee with a long intramedullary nail following the failure of a total knee arthroplasty as the result of infection. J Bone Joint Surg Am. 2006;88:553–558.PubMedCrossRef
4.
Bargiotas K, Wohlrab D, Sewecke JJ, Lavinge G, DeMeo PJ, Sotereanos NG. Arthrodesis of the knee with a long intramedullary nail following the failure of a total knee arthroplasty as the result of infection: surgical technique. J Bone Joint Surg Am. 2007;89(suppl 2 pt 1):103–110.PubMedCrossRef
5.
Bauer T, Piriou P, Lhotellier L, Leclerc P, Mamoudy P, Lortat-Jacob A. [Results of reimplantation for infected total knee arthroplasty: 107 cases] [in French]. Rev Chir Orthop Reparatrice Appar Mot. 2006;92:692–700.PubMedCrossRef
6.
Benson ER, Resine ST, Lewis CG. Functional outcome of arthrodesis for failed total knee arthroplasty. Orthopedics. 1998;21:875–879.PubMed
7.
Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, Sanders RW, Jones AL, McAndrew MP, Patterson BM, McCarthy ML, Cyril JK. A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores. J Bone Joint Surg Am. 2001;83:3–14.PubMedCrossRef
8.
Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, Sanders RW, Jones AL, McAndrew MP, Patterson BM, McCarthy ML, Travison TG, Castillo RC. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med. 2002;347:1924–1931.PubMedCrossRef
9.
Buechel FF, Femino FP, D’Alessio J. Primary exchange revision arthroplasty for infected total knee replacement: a long-term study. Am J Orthop (Belle Mead NJ). 2004;33:190–198; discussion 198.
10.
Conway JD, Mont MA, Bezwada HP. Arthrodesis of the knee. J Bone Joint Surg Am. 2004;86:835–848.PubMed
11.
David R, Shtarker H, Horesh Z, Tsur A, Soudry M. Arthrodesis with the Ilizarov device after failed knee arthroplasty. Orthopedics. 2001;24:33–36.PubMed
12.
Davis AM, Devlin M, Griffin AM, Wunder JS, Bell RS. Functional outcome in amputation versus limb sparing of patients with lower extremity sarcoma: a matched case-control study. Arch Phys Med Rehabil. 1999;80:615–618.PubMedCrossRef
13.
Domingo LJ, Caballero MJ, Cuenca J, Herrera A, Sola A, Herrero L. Knee arthrodesis with the Wichita fusion nail. Int Orthop. 2004;28:25–27.PubMedCrossRef
14.
Donley BG, Matthews LS, Kaufer H. Arthrodesis of the knee with an intramedullary nail. J Bone Joint Surg Am. 1991;73:907–913.PubMed
15.
Enneking WF, Shirley PD. Resection-arthrodesis for malignant and potentially malignant lesions about the knee using an intramedullary rod and local bone grafts. J Bone Joint Surg Am. 1977;59:223–236.PubMed
16.
Fairhurst MJ. The function of below-knee amputee versus the patient with salvaged Grade III tibial fracture. Clin Orthop Relat Res. 1994;301:227–232.PubMed
17.
Fedorka CJ, Chen AF, McGarry WM, Parvizi J, Klatt BA. Functional ability after above-the-knee amputation for infected total knee arthroplasty. Clin Orthop Relat Res. 2011;469:1024–1032.PubMedCrossRef
18.
Georgiadis GM, Behrens FF, Joyce MJ, Earle AS, Simmons AL. Open tibial fractures with severe soft-tissue loss: limb salvage compared with below-the-knee amputation. J Bone Joint Surg Am. 1993;75:1431–1441.PubMed
19.
Ginsberg JP, Rai SN, Carlson CA, Meadows AT, Hinds PS, Spearing EM, Zhang L, Callaway L, Neel MD, Rao BN, Marchese VG. A comparative analysis of functional outcomes in adolescents and young adults with lower-extremity bone sarcoma. Pediatr Blood Cancer. 2007;49:964–969.PubMedCrossRef
20.
Goksan SB, Freeman MA. One-stage reimplantation for infected total knee arthroplasty. J Bone Joint Surg Br. 1992;74:78–82.PubMed
21.
Goldman RT, Scuderi GR, Insall JN. 2-stage reimplantation for infected total knee replacement. Clin Orthop Relat Res. 1996;331:118–124.PubMedCrossRef
22.
Hak DJ, Lieberman JR, Finerman GA. Single plane and biplane external fixators for knee arthrodesis. Clin Orthop Relat Res. 1995;316:134–144.PubMed
23.
Haleem AA, Berry DJ, Hanssen AD. Mid-term to long-term followup of two-stage reimplantation for infected total knee arthroplasty. Clin Orthop Relat Res. 2004;428:35–39.PubMedCrossRef
24.
Hanssen AD, Trousdale RT, Osmon DR. Patient outcome with reinfection following reimplantation for the infected total knee arthroplasty. Clin Orthop Relat Res. 1995;321:55–67.PubMed
25.
Harris IE, Leff AR, Gitelis S, Simon MA. Function after amputation, arthrodesis, or arthroplasty for tumors about the knee. J Bone Joint Surg Am. 1990;72:1477–1485.PubMed
26.
Hirakawa K, Stulberg BN, Wilde AH, Bauer TW, Secic M. Results of 2-stage reimplantation for infected total knee arthroplasty. J Arthroplasty. 1998;13:22–28.PubMedCrossRef
27.
Hopyan S, Tan JW, Graham HK, Torode IP. Function and upright time following limb salvage, amputation, and rotationplasty for pediatric sarcoma of bone. J Pediatr Orthop. 2006;26:405–408.PubMedCrossRef
28.
Incavo SJ, Lilly JW, Bartlett CS, Churchill DL. Arthrodesis of the knee: experience with intramedullary nailing. J Arthroplasty. 2000;15:871–876.PubMedCrossRef
29.
Irrgang JJ, Snyder-Mackler L, Wainner RS, Fu FH, Harner CD. Development of a patient-reported measure of function of the knee. J Bone Joint Surg Am. 1998;80:1132–1145.PubMed
30.
Isiklar ZU, Landon GC, Tullos HS. Amputation after failed total knee arthroplasty. Clin Orthop Relat Res. 1994;299:173–178.PubMed
31.
Jenkinson C, Layte R. Development and testing of the UK SF-12 (short form health survey). J Health Serv Res Policy. 1997;2:14–18.PubMed
32.
Jenkinson C, Layte R, Jenkinson D, Lawrence K, Petersen S, Paice C, Stradling J. A shorter form health survey: can the SF-12 replicate results from the SF-36 in longitudinal studies? J Public Health Med. 1997;19:179–186.PubMedCrossRef
33.
Kilgus DJ, Howe DJ, Strang A. Results of periprosthetic hip and knee infections caused by resistant bacteria. Clin Orthop Relat Res. 2002;404:116–124.PubMedCrossRef
34.
Klinger HM, Spahn G, Schultz W, Baums MH. Arthrodesis of the knee after failed infected total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2006;14:447–453.PubMedCrossRef
35.
Kuo AC, Meehan JP, Lee M. Knee fusion using dual platings with the locking compression plate. J Arthroplasty. 2005;20:772–776.PubMedCrossRef
36.
Lange RH. Limb reconstruction versus amputation decision making in massive lower extremity trauma. Clin Orthop Relat Res. 1989;243:92–99.PubMed
37.
MacKenzie EJ, Bosse MJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, Sanders R, Jones AL, McAndrew MP, Patterson B, McCarthy ML, Rohde CA. Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma. J Trauma. 2002;52:641–649.PubMedCrossRef
38.
Maheshwari AV, Gioe TJ, Kalore NV, Cheng EY. Reinfection after prior staged reimplantation for septic total knee arthroplasty: is salvage still possible? J Arthroplasty. 2010;25:92–97.PubMedCrossRef
39.
Mittal Y, Fehring TK, Hanssen A, Marculescu C, Odum SM, Osmon D. Two-stage reimplantation for periprosthetic knee infection involving resistant organisms. J Bone Joint Surg Am. 2007;89:1227–1231.PubMedCrossRef
40.
Mont MA, Waldman BJ, Hungerford DS. Evaluation of preoperative cultures before second-stage reimplantation of a total knee prosthesis complicated by infection: a comparison-group study. J Bone Joint Surg Am. 2000;82:1552–1557.PubMed
41.
Pring DJ, Marks L, Angel JC. Mobility after amputation for failed knee replacement. J Bone Joint Surg Br. 1988;70:770–771.PubMed
42.
Puranen J, Kortelainen P, Jalovaara P. Arthrodesis of the knee with intramedullary nail fixation. J Bone Joint Surg Am. 1990;72:433–442.PubMed
43.
Rand JA, Bryan RS, Chao EY. Failed total knee arthroplasty treated by arthrodesis of the knee using the Ace-Fischer apparatus. J Bone Joint Surg Am. 1987;69:39–45.PubMed
44.
Rao N, Crossett LS, Sinha RK, Le Frock JL. Long-term suppression of infection in total joint arthroplasty. Clin Orthop Relat Res. 2003;414:55–60.PubMedCrossRef
45.
Renard AJ, Veth RP, Schreuder HW, van Loon CJ, Koops HS, van Horn JR. Function and complications after ablative and limb-salvage therapy in lower extremity sarcoma of bone. J Surg Oncol. 2000;73:198–205.PubMedCrossRef
46.
Rougraff BT, Simon MA, Kneisl JS, Greenberg DB, Mankin HJ. Limb salvage compared with amputation for osteosarcoma of the distal end of the femur: a long-term oncological, functional, and quality-of-life study. J Bone Joint Surg Am. 1994;76:649–656.PubMed
47.
48.
Saklad M. Grading of patients for surgical procedures. Anesthesiology. 1941;2:281–284.CrossRef
49.
Salgado CD, Dash S, Cantey JR, Marculescu CE. Higher risk of failure of methicillin-resistant Staphylococcus aureus prosthetic joint infections. Clin Orthop Relat Res. 2007;461:48–53.PubMed
50.
Scott SJ, Hennessey MS, Parkinson RW, Molloy AP. Long-term outcome of the “Beefburger” procedure in patients unsuitable for two-stage revision following infected total knee replacement. Knee. 2001;8:281–286.PubMedCrossRef
51.
Sierra RJ, Trousdale RT, Pagnano MW. Above-the-knee amputation after a total knee replacement: prevalence, etiology, and functional outcome. J Bone Joint Surg Am. 2003;85:1000–1004.PubMed
52.
Thornhill TS, Dalziel RW, Sledge CB. Alternatives to arthrodesis for the failed total knee arthroplasty. Clin Orthop Relat Res. 1982;170:131–140.PubMed
53.
Ulstrup AK, Folkmar K, Broeng L. Knee arthrodesis with the Sheffield external ring fixator: fusion in 6 of 10 consecutive patients. Acta Orthop. 2007;78:371–376.PubMedCrossRef
54.
Waldman BJ, Mont MA, Payman KR, Freiberg AA, Windsor RE, Sculco TP, Hungerford DS. Infected total knee arthroplasty treated with arthrodesis using a modular nail. Clin Orthop Relat Res. 1999;367:230–237.PubMedCrossRef
55.
Ware J, Kosinski M, Keller S. SF-12: an even shorter health survey. Medical Outcomes Study. Med Care. 1995;33:AS264–AS279.PubMedCrossRef
56.
Ware J, Kosinski M, Keller S. SF-12: How to Score the SF-12 Physical and Mental Health Summary Scales. Boston, MA: The Health Institute, New England Medical Center; 1995.
57.
Wasielewski RC, Barden RM, Rosenberg AG. Results of different surgical procedures on total knee arthroplasty infections. J Arthroplasty. 1996;11:931–938.PubMedCrossRef
58.
Waters RL, Perry J, Antonelli D, Hislop H. Energy cost of walking of amputees: the influence of level of amputation. J Bone Joint Surg Am. 1976;58:42–46.PubMed
59.
Windsor RE, Insall JN, Urs WK, Miller DV, Brause BD. Two-stage reimplantation for the salvage of total knee arthroplasty complicated by infection: further follow-up and refinement of indications. J Bone Joint Surg Am. 1990;72:272–278.PubMed
Metadata
Title
Better Function for Fusions Versus Above-the-knee Amputations for Recurrent Periprosthetic Knee Infection
Authors
Antonia F. Chen, MD, MBA
Nicholas C. Kinback, BS
Alma E. Heyl, LAS, RTR, CCRC
Edward J. McClain, MD
Brian A. Klatt, MD
Publication date
01-10-2012
Publisher
Springer-Verlag
Published in
Clinical Orthopaedics and Related Research® / Issue 10/2012
Print ISSN: 0009-921X
Electronic ISSN: 1528-1132
DOI
https://doi.org/10.1007/s11999-012-2322-7

Other articles of this Issue 10/2012

Clinical Orthopaedics and Related Research® 10/2012 Go to the issue

Basic Research

Peripheral Triangular Fibrocartilage Complex Tears Cause Ulnocarpal Instability: A Biomechanical Pilot Study

Symposium: 2011 Musculoskeletal Infection Society

Culture-negative Periprosthetic Joint Infection Does Not Preclude Infection Control

Symposium: 2011 Musculoskeletal Infection Society

Does Dual Antibiotic Prophylaxis Better Prevent Surgical Site Infections in Total Joint Arthroplasty?

Symposium: 2011 Musculoskeletal Infection Society

Preoperative Anemia in Total Joint Arthroplasty: Is It Associated with Periprosthetic Joint Infection?

50 Years Ago in CORR

50 Years Ago in CORR: Suppurative Arthritis of the Hip Joint in Infants Benjamin E. Obletz, MD CORR 1962;22:17–33

Clinical Research

Acetabular Tilt Correlates with Acetabular Version and Coverage in Hip Dysplasia