Clin Orthop Surg.  2013 Sep;5(3):180-187. 10.4055/cios.2013.5.3.180.

Revision of Infected Total Knee Arthroplasty: Two-Stage Reimplantation Using an Antibiotic-Impregnated Static Spacer

Affiliations
  • 1Department of Orthopaedic Surgery, Clinic Hospital of Valencia, Valencia, Spain. Antonio.Silvestre@uv.es
  • 2Department of Surgery, Orthopaedic Valencia University School of Medicine, Valencia, Spain.

Abstract

BACKGROUND
A two-stage revision remains as the "gold standard" treatment for chronically infected total knee arthroplasties.
METHODS
Forty-five septic knee prostheses were revised with a minimum follow-up of 5 years. Static antibiotic-impregnated cement spacers were used in all cases. Intravenous antibiotics according to sensitivity test of the culture were applied during patients' hospital stay. Oral antibiotics were given for another 5 weeks. Second-stage surgery was undertaken after control of infection with normal erythrocyte sedimentation rate and C-reactive protein values. Extensile techniques were used if needed and metallic augments were employed for bone loss in 32 femoral and 29 tibial revisions.
RESULTS
The average interval between the first-stage resection and reimplantation was 4.4 months. Significant improvement was obtained with respect to visual analog scale pain and clinical and functional scores, and infection was eradicated in 95.6% of cases following a two-stage revision total knee arthroplasty. Radiographic evaluation showed suitable alignment without signs of mechanical loosening.
CONCLUSIONS
This technique is a reasonable procedure to eradicate chronic infection in knee arthroplasty and provides proper functional and clinical results. However, it sometimes requires extensile surgical approaches that could imply arduous surgeries. Metallic augments with cementless stems available in most of the knee revision systems are a suitable alternative to handle bone deficiencies, avoiding the use of bone allografts with its complications.

Keyword

Two-stage revision; Chronically infected knee arthroplasty; Extensile approach; Metallic augments

MeSH Terms

Aged
Aged, 80 and over
Anti-Bacterial Agents/*administration & dosage
Arthroplasty, Replacement, Knee/*adverse effects
Female
Humans
Knee Joint/physiology/radiography/surgery
*Knee Prosthesis
Male
Middle Aged
Prosthesis Design
Prosthesis-Related Infections/*therapy
Range of Motion, Articular
Replantation/adverse effects/instrumentation/*methods
Retrospective Studies
Treatment Outcome
Anti-Bacterial Agents

Figure

  • Fig. 1 (A) A two-stage revision of a chronically infected knee. Antibiotic-impregnated cement beads acting as static spacer with a short cement stem to minimize cement block migration. (B) In the other images, we can see the knee after revision with a semi-constrained prosthesis with the stems (Performance Avant, Biomet).

  • Fig. 2 (A) A revision of multi-operated infected knee with sinus tract. First stage after removing the prosthesis. Static spacer adapted to the defect created. In this case we added Septopal-30 to increase the levels of gentamicin locally. (B) Stability was not achieved with semi-constrained prosthesis, so rotating-hinge prosthesis was employed in this case (RHK, Biomet).


Reference

1. Bozic KJ, Kurtz SM, Lau E, et al. The epidemiology of revision total knee arthroplasty in the United States. Clin Orthop Relat Res. 2010; 468(1):45–51.
Article
2. Hsu CS, Hsu CC, Wang JW, Lin PC. Two-stage revision of infected total knee arthroplasty using an antibiotic-impregnated static cement-spacer. Chang Gung Med J. 2008; 31(6):583–591.
3. Insall JN, Thompson FM, Brause BD. Two-stage reimplantation for the salvage of infected total knee arthroplasty. J Bone Joint Surg Am. 1983; 65(8):1087–1098.
Article
4. Volin SJ, Hinrichs SH, Garvin KL. Two-stage reimplantation of total joint infections: a comparison of resistant and nonresistant organisms. Clin Orthop Relat Res. 2004; (427):94–100.
5. Jamsen E, Stogiannidis I, Malmivaara A, Pajamaki J, Puolakka T, Konttinen YT. Outcome of prosthesis exchange for infected knee arthroplasty: the effect of treatment approach. Acta Orthop. 2009; 80(1):67–77.
Article
6. Cohen JC, Hozack WJ, Cuckler JM, Booth RE Jr. Two-stage reimplantation of septic total knee arthroplasty: report of three cases using an antibiotic-PMMAspacer block. J Arthroplasty. 1988; 3(4):369–377.
7. Engh GA, Ammeen DJ. Bone loss with revision total knee arthroplasty: defect classification and alternatives for reconstruction. Instr Course Lect. 1999; 48:167–175.
8. Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res. 1989; (248):13–14.
Article
9. Ghanem E, Azzam K, Seeley M, Joshi A, Parvizi J. Staged revision for knee arthroplasty infection: what is the role of serologic tests before reimplantation? Clin Orthop Relat Res. 2009; 467(7):1699–1705.
Article
10. Piper KE, Fernandez-Sampedro M, Steckelberg KE, et al. C-reactive protein, erythrocyte sedimentation rate and orthopedic implant infection. PLoS One. 2010; 5(2):e9358.
Article
11. Borowski M, Kusz D, Wojciechowski P, Cielinski L. Treatment for periprosthetic infection with two-stage revision arthroplasty with a gentamicin loaded spacer: the clinical outcomes. Ortop Traumatol Rehabil. 2012; 14(1):41–54.
Article
12. Hardeman F, Londers J, Favril A, Witvrouw E, Bellemans J, Victor J. Predisposing factors which are relevant for the clinical outcome after revision total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2012; 20(6):1049–1056.
Article
13. Burnett RS, Kelly MA, Hanssen AD, Barrack RL. Technique and timing of two-stage exchange for infection in TKA. Clin Orthop Relat Res. 2007; 464:164–178.
Article
14. Kohl S, Evangelopoulos DS, Kohlhof H, et al. An intraoperatively moulded PMMA prostheses like spacer for two-stage revision of infected total knee arthroplasty. Knee. 2011; 18(6):464–469.
Article
15. Qiu XS, Sun X, Chen DY, Xu ZH, Jiang Q. Application of an articulating spacer in two-stage revision for severe infection after total knee arthroplasty. Orthop Surg. 2010; 2(4):299–304.
Article
16. Johnson AJ, Sayeed SA, Naziri Q, Khanuja HS, Mont MA. Minimizing dynamic knee spacer complications in infected revision arthroplasty. Clin Orthop Relat Res. 2012; 470(1):220–227.
Article
17. Wang CJ, Hsieh MC, Huang TW, Wang JW, Chen HS, Liu CY. Clinical outcome and patient satisfaction in aseptic and septic revision total knee arthroplasty. Knee. 2004; 11(1):45–49.
Article
18. Nickinson RS, Board TN, Gambhir AK, Porter ML, Kay PR. Two stage revision knee arthroplasty for infection with massive bone loss: a technique to achieve spacer stability. Knee. 2012; 19(1):24–27.
Article
19. Hofmann AA, Goldberg TD, Tanner AM, Cook TM. Ten-year experience using an articulating antibiotic cement hip spacer for the treatment of chronically infected total hip. J Arthroplasty. 2005; 20(7):874–879.
Article
20. Stefansdottir A, Johansson D, Knutson K, Lidgren L, Robertsson O. Microbiology of the infected knee arthroplasty: report from the Swedish Knee Arthroplasty Register on 426 surgically revised cases. Scand J Infect Dis. 2009; 41(11-12):831–840.
Article
21. Macheras GA, Kateros K, Galanakos SP, Koutsostathis SD, Kontou E, Papadakis SA. The long-term results of a two-stage protocol for revision of an infected total knee replacement. J Bone Joint Surg Br. 2011; 93(11):1487–1492.
Article
22. Mortazavi SM, Vegari D, Ho A, Zmistowski B, Parvizi J. Two-stage exchange arthroplasty for infected total knee arthroplasty: predictors of failure. Clin Orthop Relat Res. 2011; 469(11):3049–3054.
Article
23. Barrack RL, Smith P, Munn B, Engh G, Rorabeck C. The Ranawat Award: comparison of surgical approaches in total knee arthroplasty. Clin Orthop Relat Res. 1998; (356):16–21.
24. Chalidis BE, Ries MD. Does repeat tibial tubercle osteotomy or intramedullary extension affect the union rate in revision total knee arthroplasty? Aretrospective study of 74 patients. Acta Orthop. 2009; 80(4):426–431.
Article
25. Mulhall KJ, Ghomrawi HM, Engh GA, Clark CR, Lotke P, Saleh KJ. Radiographic prediction of intraoperative bone loss in knee arthroplasty revision. Clin Orthop Relat Res. 2006; 446:51–58.
Article
26. Fehring TK, Christie MJ, Lavernia C, et al. Revision total knee arthroplasty: planning, management, and controversies. Instr Course Lect. 2008; 57:341–363.
27. Haidukewych GJ, Hanssen A, Jones RD. Metaphyseal fixation in revision total knee arthroplasty: indications and techniques. J Am Acad Orthop Surg. 2011; 19(6):311–318.
Article
28. Springer BD, Sim FH, Hanssen AD, Lewallen DG. The modular segmental kinematic rotating hinge for nonneoplastic limb salvage. Clin Orthop Relat Res. 2004; (421):181–187.
Article
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