KNEE
Septic single-stage knee arthrodesis after failed total knee arthroplasty using a cemented coupled nail N. Hawi, D. Kendoff, M. Citak, T. Gehrke, C. Haasper From Orthopaedic Surgery, Helios ENDO-Klinik, Hamburg, Germany
Knee arthrodesis is a potential salvage procedure for limb preservation after failure of total knee arthroplasty (TKA) due to infection. In this study, we evaluated the outcome of singlestage knee arthrodesis using an intramedullary cemented coupled nail without bone-onbone fusion after failed and infected TKA with extensor mechanism deficiency. Between 2002 and 2012, 27 patients (ten female, 17 male; mean age 68.8 years; 52 to 87) were treated with septic single-stage exchange. Mean follow-up duration was 67.1months (24 to 143, n = 27) (minimum follow-up 24 months) and for patients with a minimum follow-up of five years 104.9 (65 to 143,; n = 13). A subjective patient evaluation (Short Form (SF)-36) was obtained, in addition to the Visual Analogue Scale (VAS). The mean VAS score was 1.44 (SD 1.48). At final follow-up, four patients had recurrent infections after arthrodesis (14.8%). Of these, three patients were treated with a one-stage arthrodesis nail exchange; one of the three patients had an aseptic loosening with a third single-stage exchange, and one patient underwent knee amputation for uncontrolled sepsis at 108 months. All patients, including the amputee, indicated that they would choose arthrodesis again. Data indicate that a single-stage knee arthrodesis offers an acceptable salvage procedure after failed and infected TKA. Cite this article: Bone Joint J 2015;97-B:649–53.
N. Hawi, MD, Orthopaedic Surgeon, Trauma Department Hannover Medical School (MHH), Carl-Neuberg-Str. 1, 30625 Hannover, Germany. D. Kendoff , MD, Orthopaedic Surgeon, Professor, Orthopaedic Surgery M. Citak, MD, Orthopaedic Surgeon, Orthopaedic Surgery T. Gehrke, MD, Orthopaedic Surgeon, Professor, Orthopaedic Surgery C. Haasper, MD, Orthopaedic Surgeon, Professor, Orthopaedic Surgery Helios ENDO-Klinik, Hamburg, Holstenstr. 2, 22767 Hamburg, Germany. Correspondence should be sent to Dr N. Hawi; e-mail: [email protected] ©2015 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.97B5. 34902 $2.00 Bone Joint J 2015;97-B:649–53. Received 1 August 2014; Accepted after revision 8 December 2014
VOL. 97-B, No. 5, MAY 2015
Given the increasing absolute number of total knee arthroplasties (TKA), a corresponding increase in complications is to be expected.1 Despite recent gains in prosthetic design and surgical technique, complications such as infection, instability, persistent pain, or bone loss still occur.2,3 Infections are devastating and are often accompanied by prolonged treatment and recurrent surgical interventions. In general, single-stage or two-stage revisions are the treatment of choice and achieve adequate success rates for most patients.2-4 However, risks of failure include recurrent infections, ligamentous instability, extensor mechanism deficiency, extensive bone defects, and osteonecrosis. Alternative treatments include resection arthroplasty, amputation, or arthrodesis.5-9 In carefully selected patients with realistic expectations, knee arthrodesis can relieve pain and avoid additional surgery or extensive post-operative rehabilitation.8,10 Arthrodesis after prosthetic joint infection (PJI) is associated with a low risk of re-infection,8,10 with low levels of pain, and provides a stable limb. Several devices and techniques have been described to perform knee arthrodesis. Although external fixation is an effective technique, it is accompanied by high rates of
complication with variable outcomes.10-13 Plating with internal fusion is another option to obtain arthrodesis, but is less popular.14 Intramedullary devices have become more popular for knee arthrodesis because they are associated with lower rates of complication and earlier bony consolidation.6,15 However, limb shortening after knee arthrodesis using an intramedullary nail can range from 2.5 cm to 6.4 cm,5,16 and there are few publications that describe outcomes following using this technique for PJI.17-22 The best operative technique before performing an arthrodesis in PJI remains controversial.5,6,11 Most authors describe a two-stage procedure for the management of PJI in TKA16,17,23,24 The aim of this study was to evaluate the clinical and functional outcomes of single-stage arthrodesis after PJI with extensor mechanism deficiency using an intramedullary cemented coupled nail without bone-on-bone fusion.
Patients and Methods All patients with PJI after TKA, who were undergoing an arthrodesis had a one-stage exchange procedure. The indication for arthrodesis was extensor mechanism deficiency. 649
650
N. HAWI, D. KENDOFF, M. CITAK, T. GEHRKE, C. HAASPER
Fig. 1a
Fig. 1b
Anteroposterior radiographs of an a) 63 year-old and b) 87 year-old women with an infected revision total knee arthroplasty.
Fig. 2a
Fig. 2b
Anteroposterior radiographs of a) the same 63 year-old and b) 87 year-old women from Figure 1 treated with intermedullary nail arthrodesis.
Knowledge of the pathogenic organism and its antibiotic sensitivity were identified before performing a one-stage exchange. This was achieved by knee joint aspiration to obtain synovial fluid which was incubated for at least 14 days.25 Antibiotics were discontinued at least two weeks before knee joint aspiration. Operative treatment consisted of surgical debridement, removal of TKA components and the bone cement, obtaining fibrous tissue and bone samples, and insertion of the femoral and tibial cemented nail (Figs 1 and 2). Our technique of intramedullary nailing does not include bone-onbone fusion. We used the Link nail (Link, Hamburg, Germany), which consists of two separate and cemented femoral and tibial components, for the arthrodesis in all patients. Appropriate antibiotics were added to the cement, based on the cultures and the recommendations of the
Fig. 3 Intra-operative photograph showing the coupling mechanism.
microbiologist. The two components were coupled by reciprocal interlocking of their base-plates and two antero-posterior screws to lock the assembly. To prevent breaking out, each assembly screw has a hole (in the threaded section) in which to place an ultra-high molecular weight polyethylene peg before securing the screws (Fig. 3). The bone gap between the tibia and femur was also filled with cement containing the appropriate antibiotics. Once assembled, the nail has 5° valgus in the frontal plane and 5° flexion in the sagittal plane. Post-operative intravenous antibiotic therapy followed by oral antibiotic treatment was continued based on preoperative cultures, clinical signs, and monitoring of the C-reactive protein (CRP) and white blood cell count (WBC). Usually this consists of a mean antibiotic treatment of 17 days (14 to 23) (with the exception of Streptococcal infections).26 Between 2002 and 2012 there were 27 patients who underwent knee arthrodesis following PJI after TKA. All patients had extensor mechanism deficiency, so an arthrodesis was the last possible salvage procedure. Local Institutional Review Board approval and informed consent were obtained. In all ten patients were female and 17 patients were male with a mean age at arthrodesis of 68.8 years (52 to 87). The median number of previous operations was 7 (3 to 14) and the median number of previous infection-related operations was 4 (1 to 13). The mean follow-up time was 67.1 months (24 to 143) for all patients (n = 27) with a minimum follow-up of two years and a mean follow-up duration of 104.9 months (65 to 143) with a minimum follow-up of five years (n = 13). The end point was the need for further septic revision surgery. A subjective patient evaluation (Short Form (SF)-36) was employed to assess general health status.27 In addition, the Visual Analogue Scale (VAS; 0, no pain, 10, maximum pain) was used for self-assessment. In addition patients were asked whether, in retrospect they would choose the same procedure again. THE BONE & JOINT JOURNAL
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Table I. Mean general health status, measured with the Short Form(SF)-36 at follow-up examinations SF-36
Current study
Benson et al28
Crockarell et al21
Fuchs and Mersmann29 Klinger et al34
De Vil et al40
Bierwagen et al30
Number Physical function Role-physical Bodily pain General health Vitality Social function Role-emotional Mental health
27 32.5 34.8 61.5 52.6 54.7 68.2 61.3 68.5
9 46.0 86.0 61.0 64.0 68.0 82.0 100 87.0
15 36.4 45.5 43.9 50.9 40.5 56.8 57.6 71.6
19 30.0 30.6 46.1 46.6 45.0 57.6 40.7 61.3
13 33.3 40.6 74.7 58.5 50.0 56.3 58.3 55.6
60 28.1 20.9 54.8 49.8 48.2 56.3 45.6 54.4
Results At follow-up, four patients had recurrent infections after arthrodesis (14.8%). Three of the four patients were treated with a further one-stage arthrodesis nail exchange. In one of these three patients there was aseptic loosening with a third single-stage exchange. Three of these patients had no clinical suspicion of infection and were doing well at the final follow-up. One patient underwent knee amputation owing to recurrent infection. At follow-up, 11 patients (40.7%) had no pain (VAS = 0) in the operated leg, three patients (11.1%) had a score of 1, six patients (22.2%) had a score of 2, five patients (18.5%) had a score 3, one patients (3.7%) had a score of 4, and one patient (3.7%) had a score of 5. The mean VAS score for pain was 1.44 (SD 1.48). All patients, including the amputee, who underwent arthrodesis stated that they would choose the same operation again. The mean SF-36 scores are presented in Table I.28-30 We experienced no complications related to the implant (e.g., fracture or decoupling of the nail). Discussion Knee arthrodesis is often employed as one of the last limb salvage procedures after failed PJI in TKA, without possibility for further revision.31 The major advantages of a successful knee arthrodesis include a low risk of reinfection8,10 and significantly less pain.5 However, patients must accept and live with an immobilised but stable limb. Most patients following a successful arthrodesis, when infection-related problems and pain disappear, describe problems with mobility and transport. However, comparisons between arthrodesis and amputation suggest that arthrodesis is more efficient than amputation.5,32 Therefore amputation should only be performed in special situations such as life-threatening infection, persistent infection, irreparable soft-tissue damage, or extensive bone loss. It is interesting that amputation is tolerated best by disabled patients who have low demands.33 The indication for an arthrodesis of the knee following PJI, in our clinic is limited and usually involves less than 1% of 200 patients with PJI that we treat in a year. The irreversible absence of the extensor mechanism following multiple septic revisions remains the main indication. Different procedures have been described for performing a knee arthrodesis.11,12,34 Salem et al11 described a longer time for bone fusion with external VOL. 97-B, No. 5, MAY 2015
20 32.1 30.8 47.4 46.9 43.1 56.4 46.7 58.3
fixation. When comparing external fixation with intramedullary fixation, lower complication rates have been found when using the intramedullary technique.6,19,22,35 In addition, greater axial and rotational stability are conferred, faster weight bearing is possible, and leg length discrepancy is reduced.36 However, leg-length discrepancy generally remains a problem regarding both techniques because of implant designs. Different authors describe leg-length discrepancies ranging from 2.5 cm to 6.4 cm after arthrodesis. Gurney et al37 described leg-length discrepancy as an important parameter for functional outcome, with a breakpoint of 2 cm to 3cm. We have used an intramedullary nail without bone fusion, with the remaining gap between the femur and tibia wrapped with antibiotic-impregnated cement. This part of the cement serves only as a seal and has no mechanical function, but allows for topical antibiotics to be released. In these patients, the implant behaves like an endoprosthesis. An advantage of the implant design is that it maintains the length of the leg or contributes to a reduction in the shrtening. Other authors performing knee arthrodesis with this implant have described very good outcomes concerning post-operative leg length discrepancy < 2 cm to 3 cm.16,38 Depending on the patient’s condition an external brace for blocking knee function in various degrees can be used, but it might cause damage to the softtissues and may not be so comfortable and practical in daily life. An alternative would be a hinged or rotating hinged knee endoprosthesis, which could be blocked in various degrees of flexion and full extension. Such a system would combine the advantages of hinged knee and arthrodesis, even in patients with lost extensor mechanisms. In general, the two-stage exchange has become the reference standard worldwide for treating PJI. However following Buchholz’s description of the single-stage procedure of mixing antibiotics into bone cement we have used the single-stage procedure in 85% of PJI.26 The major advantage of a cemented single-stage exchange concept is the need for only one operation, with decreased peri-operative risks, decreased functional impairment, improved financial benefits, shorter hospital stay, and shorter systemic antibiotic administration. Recurrence rates ranging from 0% to 20% have been described in patients undergoing knee arthrodesis after PJI.16-18,39,40I Most authors describe and recommend the two-stage procedure,5,10,16,19,34,35 although there are reports of successful and effective one-stage procedures
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with low recurrence rates.5,36,41 In contrast to those reports using the same implant, we used the cemented version of the nail. Based on cultures and the recommendations of the microbiologist, appropriate antibiotics were added to the cement to the femoral and tibial component and in between. We did not need to use prolonged post-operative antibiotic therapy in our patient’s cohort and although giving antibiotics for six weeks is common there is clear evidence of complications from prolonged antibiotic administration.42-44 The recurrence rate of infection in our cohort was 14.8%, which is comparable with results presented in other studies. All patients (including the patients who underwent revision) said that they would choose the arthrodesis and the single-stage procedure and their level of pain was comparable with those of other reports.16,17,19,21 We observed no implant-associated complications. Thus, for the carefully selected patient with realistic expectations, knee arthrodesis can relieve pain and avoid additional surgery or extensive post-operative rehabilitation despite the fact that knee function will be sacrificed. Supplementary material A table showing details of patients including bacteriological cultures, topical and systemic antibiotic treatment is available alongside the online version of this article at www.bjj.boneand joint.org.uk Author contributions: N. Hawi: study design, data collection, data analysis, writing the paper, ensured accuracy of data and analysis. D. Kendoff: study design, data analysis, writing the paper, ensured accuracy of data and analysis. M. Citak: data collection, data analysis, writing the paper, ensured accuracy of data and analysis. T. Gehrke: study design, data analysis, ensured accuracy of data and analysis C. Haasper: study design, data collection, data analysis, writing the paper, ensured accuracy of data and analysis. The author or one or more of the authors have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. In addition, benefits have been or will be directed to a research fund, foundation, educational institution, or other nonprofit organisation with which one or more of the authors are associated. This article was primary edited by S. Hughes and first proof edited by G. Scott.
References 1. Kurtz SM, Lau E, Schmier J, et al. Infection burden for hip and knee arthroplasty in the United States. J Arthroplasty 2008;23:984–991. 2. Segawa H, Tsukayama DT, Kyle RF, Becker DA, Gustilo RB. Infection after total knee arthroplasty. A retrospective study of the treatment of eighty-one infections. J Bone Joint Surg [Am] 1999;81-A:1434–1445. 3. 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-A:272–278. 4. Tibrewal S, Malagelada F, Jeyaseelan L, Posch F, Scott G. Single-stage revision for the infected total knee replacement: results from a single centre. Bone Joint J 2014;96-B:759–764. 5. Conway JD, Mont MA, Bezwada HP. Arthrodesis of the knee. J Bone Joint Surg [Am] 2004;86-A:835–848. 6. Wiedel JD. Salvage of infected total knee fusion: the last option. Clin Orthop Relat Res 2002;404:139–142. 7. 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. 8. Damron TA, McBeath AA. Arthrodesis following failed total knee arthroplasty: comprehensive review and meta-analysis of recent literature. Orthopedics 1995;18:361–368.
9. Wasielewski RC, Barden RM, Rosenberg AG. Results of different surgical procedures on total knee arthroplasty infections. J Arthroplasty 1996;11:931–938. 10. Knutson K, Hovelius L, Lindstrand A, Lidgren L. Arthrodesis after failed knee arthroplasty. A nationwide multicenter investigation of 91 cases. Clin Orthop Relat Res 1984;191:202–211. 11. Salem KH, Keppler P, Kinzl L, Schmelz A. Hybrid external fixation for arthrodesis in knee sepsis. Clin Orthop Relat Res 2006;451:113–120. 12. Oostenbroek HJ, van Roermund PM. Arthrodesis of the knee after an infected arthroplasty using the Ilizarov method. J Bone Joint Surg [Br] 2001;83-B:50–54. 13. 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-A:39– 45. 14. Nichols SJ, Landon GC, Tullos HS. Arthrodesis with dual plates after failed total knee arthroplasty. J Bone Joint Surg [Am] 1991;73-A:1020–1024. 15. Mabry TM, Jacofsky DJ, Haidukewych GJ, Hanssen AD. Comparison of intramedullary nailing and external fixation knee arthrodesis for the infected knee replacement. Clin Orthop Relat Res 2007;464:11–15. 16. Iacono F, Bruni D, Lo Presti M, et al. Knee arthrodesis with a press-fit modular intramedullary nail without bone-on-bone fusion after an infected revision TKA. Knee 2012;19:555–559. 17. Talmo CT, Bono JV, Figgie MP, et al. Intramedullary arthrodesis of the knee in the treatment of sepsis after TKR. HSS J 2007;3:83–88. 18. Vlasak R, Gearen PF, Petty W. Knee arthrodesis in the treatment of failed total knee replacement. Clin Orthop Relat Res 1995;321:138–144. 19. Waldman BJ, Mont MA, Payman KR, et al. Infected total knee arthroplasty treated with arthrodesis using a modular nail. Clin Orthop Relat Res 1999;367:230– 237. 20. Bargiotas K, Wohlrab D, Sewecke JJ, et al. 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-A:553–558. 21. Crockarell JR Jr, Mihalko MJ. Knee arthrodesis using an intramedullary nail. J Arthroplasty 2005;20:703–708. 22. McQueen DA, Cooke FW, Hahn DL. Knee arthrodesis with the Wichita Fusion Nail: an outcome comparison. Clin Orthop Relat Res 2006;446:132–139. 23. Neuerburg C, Bieger R, Jung S, et al. Bridging knee arthrodesis for limb salvage using an intramedullary cemented nail: a retrospective outcome analysis of a case series. Arch Orthop Trauma Surg 2012;132:1183–1189. 24. Iacono F, Raspugli GF, Bruni D, et al. Arthrodesis After Infected Revision TKA: Retrospective Comparison of Intramedullary Nailing and External Fixation. HSS J 2013;9:229–235. 25. Fink B, Makowiak C, Fuerst M, et al. The value of synovial biopsy, joint aspiration and C-reactive protein in the diagnosis of late peri-prosthetic infection of total knee replacements. J Bone Joint Surg [Br] 2008;90-B:874–878. 26. Gehrke T, Zahar A, Kendoff D. One-stage exchange: it all began here. Bone Joint J 2013;95-B:77–83. 27. Ware JE Jr, Gandek B. Overview of the SF-36 Health Survey and the International Quality of Life Assessment (IQOLA) Project. J Clin Epidemiol 1998;51:903–912. 28. Benson ER, Resine ST, Lewis CG. Functional outcome of arthrodesis for failed total knee arthroplasty. Orthopedics 1998;21:875–879. 29. Fuchs S, Mersmann A. Results of arthrodesis after knee prosthesis infection. Special reference to quality of life. Unfallchirurg 2000;103:626–631. (In German). 30. Bierwagen U, Walter G, Hoffmann R. Knee arthrodesis--quality of life and comparison of methods. Z Orthop Unfall 2010;148:566–572. (In German). 31. Ravikumar M, Kendoff D, Citak M, et al. One stage conversion of an infected fused knee to total knee replacement - a surgical challenge. Open Orthop J 2013;7:67–71. 32. Isiklar ZU, Landon GC, Tullos HS. Amputation after failed total knee arthroplasty. Clin Orthop Relat Res 1994;299:173–178. 33. Somayaji HS, Tsaggerides P, Ware HE, Dowd GS. Knee arthrodesis--a review. Knee. 2008;15:247–254. 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. 35. Ellingsen DE, Rand JA. Intramedullary arthrodesis of the knee after failed total knee arthroplasty. J Bone Joint Surg [Am] 1994;76-A:870–877. 36. Puranen J, Kortelainen P, Jalovaara P. Arthrodesis of the knee with intramedullary nail fixation. J Bone Joint Surg [Am] 1990;72-A:433–442. 37. Gurney B, Mermier C, Robergs R, Gibson A, Rivero D. Effects of limb-length discrepancy on gait economy and lower-extremity muscle activity in older adults. J Bone Joint Surg [Am] 2001;83-A:907–915. 38. Letartre R, Combes A, Autissier G, Bonnevialle N, Gougeon F. Knee arthrodesis using a modular customized intramedullary nail. Orthop Traumatol Surg Res 2009;95:520–528. THE BONE & JOINT JOURNAL
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39. Wilde AH, Stearns KL. Intramedullary fixation for arthrodesis of the knee after infected total knee arthroplasty. Clin Orthop Relat Res 1989;248:87–92. 40. De Vil J, Almqvist KF, Vanheeren P, Boone B, Verdonk R. Knee arthrodesis with an intramedullary nail: a retrospective study. Knee Surg Sports Traumatol Arthrosc 2008;16:645–650. 41. Lai KA, Shen WJ, Yang CY. Arthrodesis with a short Huckstep nail as a salvage procedure for failed total knee arthroplasty. J Bone Joint Surg [Am] 1998;80-A:380–388.
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42. 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 8. 43. Hoad-Reddick DA, Evans CR, Norman P, Stockley I. Is there a role for extended antibiotic therapy in a two-stage revision of the infected knee arthroplasty? J Bone Joint Surg [Br] 2005;87-B:171–174. 44. Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol 1999;20:250–278.
Septic single-stage knee arthrodesis after failed total knee arthroplasty using a cemented coupled nail N. Hawi, D. Kendoff, M. Citak, T. Gehrke, C. Haasper From Orthopaedic Surgery, Helios ENDO-Klinik, Hamburg, Germany
Knee arthrodesis is a potential salvage procedure for limb preservation after failure of total knee arthroplasty (TKA) due to infection. In this study, we evaluated the outcome of singlestage knee arthrodesis using an intramedullary cemented coupled nail without bone-onbone fusion after failed and infected TKA with extensor mechanism deficiency. Between 2002 and 2012, 27 patients (ten female, 17 male; mean age 68.8 years; 52 to 87) were treated with septic single-stage exchange. Mean follow-up duration was 67.1months (24 to 143, n = 27) (minimum follow-up 24 months) and for patients with a minimum follow-up of five years 104.9 (65 to 143,; n = 13). A subjective patient evaluation (Short Form (SF)-36) was obtained, in addition to the Visual Analogue Scale (VAS). The mean VAS score was 1.44 (SD 1.48). At final follow-up, four patients had recurrent infections after arthrodesis (14.8%). Of these, three patients were treated with a one-stage arthrodesis nail exchange; one of the three patients had an aseptic loosening with a third single-stage exchange, and one patient underwent knee amputation for uncontrolled sepsis at 108 months. All patients, including the amputee, indicated that they would choose arthrodesis again. Data indicate that a single-stage knee arthrodesis offers an acceptable salvage procedure after failed and infected TKA. Cite this article: Bone Joint J 2015;97-B:649–53.
N. Hawi, MD, Orthopaedic Surgeon, Trauma Department Hannover Medical School (MHH), Carl-Neuberg-Str. 1, 30625 Hannover, Germany. D. Kendoff , MD, Orthopaedic Surgeon, Professor, Orthopaedic Surgery M. Citak, MD, Orthopaedic Surgeon, Orthopaedic Surgery T. Gehrke, MD, Orthopaedic Surgeon, Professor, Orthopaedic Surgery C. Haasper, MD, Orthopaedic Surgeon, Professor, Orthopaedic Surgery Helios ENDO-Klinik, Hamburg, Holstenstr. 2, 22767 Hamburg, Germany. Correspondence should be sent to Dr N. Hawi; e-mail: [email protected] ©2015 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.97B5. 34902 $2.00 Bone Joint J 2015;97-B:649–53. Received 1 August 2014; Accepted after revision 8 December 2014
VOL. 97-B, No. 5, MAY 2015
Given the increasing absolute number of total knee arthroplasties (TKA), a corresponding increase in complications is to be expected.1 Despite recent gains in prosthetic design and surgical technique, complications such as infection, instability, persistent pain, or bone loss still occur.2,3 Infections are devastating and are often accompanied by prolonged treatment and recurrent surgical interventions. In general, single-stage or two-stage revisions are the treatment of choice and achieve adequate success rates for most patients.2-4 However, risks of failure include recurrent infections, ligamentous instability, extensor mechanism deficiency, extensive bone defects, and osteonecrosis. Alternative treatments include resection arthroplasty, amputation, or arthrodesis.5-9 In carefully selected patients with realistic expectations, knee arthrodesis can relieve pain and avoid additional surgery or extensive post-operative rehabilitation.8,10 Arthrodesis after prosthetic joint infection (PJI) is associated with a low risk of re-infection,8,10 with low levels of pain, and provides a stable limb. Several devices and techniques have been described to perform knee arthrodesis. Although external fixation is an effective technique, it is accompanied by high rates of
complication with variable outcomes.10-13 Plating with internal fusion is another option to obtain arthrodesis, but is less popular.14 Intramedullary devices have become more popular for knee arthrodesis because they are associated with lower rates of complication and earlier bony consolidation.6,15 However, limb shortening after knee arthrodesis using an intramedullary nail can range from 2.5 cm to 6.4 cm,5,16 and there are few publications that describe outcomes following using this technique for PJI.17-22 The best operative technique before performing an arthrodesis in PJI remains controversial.5,6,11 Most authors describe a two-stage procedure for the management of PJI in TKA16,17,23,24 The aim of this study was to evaluate the clinical and functional outcomes of single-stage arthrodesis after PJI with extensor mechanism deficiency using an intramedullary cemented coupled nail without bone-on-bone fusion.
Patients and Methods All patients with PJI after TKA, who were undergoing an arthrodesis had a one-stage exchange procedure. The indication for arthrodesis was extensor mechanism deficiency. 649
650
N. HAWI, D. KENDOFF, M. CITAK, T. GEHRKE, C. HAASPER
Fig. 1a
Fig. 1b
Anteroposterior radiographs of an a) 63 year-old and b) 87 year-old women with an infected revision total knee arthroplasty.
Fig. 2a
Fig. 2b
Anteroposterior radiographs of a) the same 63 year-old and b) 87 year-old women from Figure 1 treated with intermedullary nail arthrodesis.
Knowledge of the pathogenic organism and its antibiotic sensitivity were identified before performing a one-stage exchange. This was achieved by knee joint aspiration to obtain synovial fluid which was incubated for at least 14 days.25 Antibiotics were discontinued at least two weeks before knee joint aspiration. Operative treatment consisted of surgical debridement, removal of TKA components and the bone cement, obtaining fibrous tissue and bone samples, and insertion of the femoral and tibial cemented nail (Figs 1 and 2). Our technique of intramedullary nailing does not include bone-onbone fusion. We used the Link nail (Link, Hamburg, Germany), which consists of two separate and cemented femoral and tibial components, for the arthrodesis in all patients. Appropriate antibiotics were added to the cement, based on the cultures and the recommendations of the
Fig. 3 Intra-operative photograph showing the coupling mechanism.
microbiologist. The two components were coupled by reciprocal interlocking of their base-plates and two antero-posterior screws to lock the assembly. To prevent breaking out, each assembly screw has a hole (in the threaded section) in which to place an ultra-high molecular weight polyethylene peg before securing the screws (Fig. 3). The bone gap between the tibia and femur was also filled with cement containing the appropriate antibiotics. Once assembled, the nail has 5° valgus in the frontal plane and 5° flexion in the sagittal plane. Post-operative intravenous antibiotic therapy followed by oral antibiotic treatment was continued based on preoperative cultures, clinical signs, and monitoring of the C-reactive protein (CRP) and white blood cell count (WBC). Usually this consists of a mean antibiotic treatment of 17 days (14 to 23) (with the exception of Streptococcal infections).26 Between 2002 and 2012 there were 27 patients who underwent knee arthrodesis following PJI after TKA. All patients had extensor mechanism deficiency, so an arthrodesis was the last possible salvage procedure. Local Institutional Review Board approval and informed consent were obtained. In all ten patients were female and 17 patients were male with a mean age at arthrodesis of 68.8 years (52 to 87). The median number of previous operations was 7 (3 to 14) and the median number of previous infection-related operations was 4 (1 to 13). The mean follow-up time was 67.1 months (24 to 143) for all patients (n = 27) with a minimum follow-up of two years and a mean follow-up duration of 104.9 months (65 to 143) with a minimum follow-up of five years (n = 13). The end point was the need for further septic revision surgery. A subjective patient evaluation (Short Form (SF)-36) was employed to assess general health status.27 In addition, the Visual Analogue Scale (VAS; 0, no pain, 10, maximum pain) was used for self-assessment. In addition patients were asked whether, in retrospect they would choose the same procedure again. THE BONE & JOINT JOURNAL
SEPTIC SINGLE-STAGE KNEE ARTHRODESIS AFTER FAILED TOTAL KNEE ARTHROPLASTY USING A CEMENTED COUPLED NAIL
651
Table I. Mean general health status, measured with the Short Form(SF)-36 at follow-up examinations SF-36
Current study
Benson et al28
Crockarell et al21
Fuchs and Mersmann29 Klinger et al34
De Vil et al40
Bierwagen et al30
Number Physical function Role-physical Bodily pain General health Vitality Social function Role-emotional Mental health
27 32.5 34.8 61.5 52.6 54.7 68.2 61.3 68.5
9 46.0 86.0 61.0 64.0 68.0 82.0 100 87.0
15 36.4 45.5 43.9 50.9 40.5 56.8 57.6 71.6
19 30.0 30.6 46.1 46.6 45.0 57.6 40.7 61.3
13 33.3 40.6 74.7 58.5 50.0 56.3 58.3 55.6
60 28.1 20.9 54.8 49.8 48.2 56.3 45.6 54.4
Results At follow-up, four patients had recurrent infections after arthrodesis (14.8%). Three of the four patients were treated with a further one-stage arthrodesis nail exchange. In one of these three patients there was aseptic loosening with a third single-stage exchange. Three of these patients had no clinical suspicion of infection and were doing well at the final follow-up. One patient underwent knee amputation owing to recurrent infection. At follow-up, 11 patients (40.7%) had no pain (VAS = 0) in the operated leg, three patients (11.1%) had a score of 1, six patients (22.2%) had a score of 2, five patients (18.5%) had a score 3, one patients (3.7%) had a score of 4, and one patient (3.7%) had a score of 5. The mean VAS score for pain was 1.44 (SD 1.48). All patients, including the amputee, who underwent arthrodesis stated that they would choose the same operation again. The mean SF-36 scores are presented in Table I.28-30 We experienced no complications related to the implant (e.g., fracture or decoupling of the nail). Discussion Knee arthrodesis is often employed as one of the last limb salvage procedures after failed PJI in TKA, without possibility for further revision.31 The major advantages of a successful knee arthrodesis include a low risk of reinfection8,10 and significantly less pain.5 However, patients must accept and live with an immobilised but stable limb. Most patients following a successful arthrodesis, when infection-related problems and pain disappear, describe problems with mobility and transport. However, comparisons between arthrodesis and amputation suggest that arthrodesis is more efficient than amputation.5,32 Therefore amputation should only be performed in special situations such as life-threatening infection, persistent infection, irreparable soft-tissue damage, or extensive bone loss. It is interesting that amputation is tolerated best by disabled patients who have low demands.33 The indication for an arthrodesis of the knee following PJI, in our clinic is limited and usually involves less than 1% of 200 patients with PJI that we treat in a year. The irreversible absence of the extensor mechanism following multiple septic revisions remains the main indication. Different procedures have been described for performing a knee arthrodesis.11,12,34 Salem et al11 described a longer time for bone fusion with external VOL. 97-B, No. 5, MAY 2015
20 32.1 30.8 47.4 46.9 43.1 56.4 46.7 58.3
fixation. When comparing external fixation with intramedullary fixation, lower complication rates have been found when using the intramedullary technique.6,19,22,35 In addition, greater axial and rotational stability are conferred, faster weight bearing is possible, and leg length discrepancy is reduced.36 However, leg-length discrepancy generally remains a problem regarding both techniques because of implant designs. Different authors describe leg-length discrepancies ranging from 2.5 cm to 6.4 cm after arthrodesis. Gurney et al37 described leg-length discrepancy as an important parameter for functional outcome, with a breakpoint of 2 cm to 3cm. We have used an intramedullary nail without bone fusion, with the remaining gap between the femur and tibia wrapped with antibiotic-impregnated cement. This part of the cement serves only as a seal and has no mechanical function, but allows for topical antibiotics to be released. In these patients, the implant behaves like an endoprosthesis. An advantage of the implant design is that it maintains the length of the leg or contributes to a reduction in the shrtening. Other authors performing knee arthrodesis with this implant have described very good outcomes concerning post-operative leg length discrepancy < 2 cm to 3 cm.16,38 Depending on the patient’s condition an external brace for blocking knee function in various degrees can be used, but it might cause damage to the softtissues and may not be so comfortable and practical in daily life. An alternative would be a hinged or rotating hinged knee endoprosthesis, which could be blocked in various degrees of flexion and full extension. Such a system would combine the advantages of hinged knee and arthrodesis, even in patients with lost extensor mechanisms. In general, the two-stage exchange has become the reference standard worldwide for treating PJI. However following Buchholz’s description of the single-stage procedure of mixing antibiotics into bone cement we have used the single-stage procedure in 85% of PJI.26 The major advantage of a cemented single-stage exchange concept is the need for only one operation, with decreased peri-operative risks, decreased functional impairment, improved financial benefits, shorter hospital stay, and shorter systemic antibiotic administration. Recurrence rates ranging from 0% to 20% have been described in patients undergoing knee arthrodesis after PJI.16-18,39,40I Most authors describe and recommend the two-stage procedure,5,10,16,19,34,35 although there are reports of successful and effective one-stage procedures
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with low recurrence rates.5,36,41 In contrast to those reports using the same implant, we used the cemented version of the nail. Based on cultures and the recommendations of the microbiologist, appropriate antibiotics were added to the cement to the femoral and tibial component and in between. We did not need to use prolonged post-operative antibiotic therapy in our patient’s cohort and although giving antibiotics for six weeks is common there is clear evidence of complications from prolonged antibiotic administration.42-44 The recurrence rate of infection in our cohort was 14.8%, which is comparable with results presented in other studies. All patients (including the patients who underwent revision) said that they would choose the arthrodesis and the single-stage procedure and their level of pain was comparable with those of other reports.16,17,19,21 We observed no implant-associated complications. Thus, for the carefully selected patient with realistic expectations, knee arthrodesis can relieve pain and avoid additional surgery or extensive post-operative rehabilitation despite the fact that knee function will be sacrificed. Supplementary material A table showing details of patients including bacteriological cultures, topical and systemic antibiotic treatment is available alongside the online version of this article at www.bjj.boneand joint.org.uk Author contributions: N. Hawi: study design, data collection, data analysis, writing the paper, ensured accuracy of data and analysis. D. Kendoff: study design, data analysis, writing the paper, ensured accuracy of data and analysis. M. Citak: data collection, data analysis, writing the paper, ensured accuracy of data and analysis. T. Gehrke: study design, data analysis, ensured accuracy of data and analysis C. Haasper: study design, data collection, data analysis, writing the paper, ensured accuracy of data and analysis. The author or one or more of the authors have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. In addition, benefits have been or will be directed to a research fund, foundation, educational institution, or other nonprofit organisation with which one or more of the authors are associated. This article was primary edited by S. Hughes and first proof edited by G. Scott.
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