J Korean Orthop Assoc.  2014 Feb;49(1):79-84. 10.4055/jkoa.2014.49.1.79.

Artificial Fusion of Infected Total Knee Arthroplasty Using a Flexible Intramedullary Rod Bundle and an Antibiotic-Loaded Cement Spacer

• Lee DH
• Shin YS
• Park JH
• Nha KW
• Yoon JR
• Han SB

• KMID: 2185263
• DOI: http://doi.org/10.4055/jkoa.2014.49.1.79

Abstract

Multiple total knee arthroplasty (TKA) failure resulting from a recurrent infection is a challenging problem. Knee arthrodesis is one treatment option that normally involves the application of an external fixator, plate fixation, and intramedullary nailing. However, these approaches are not always successful, and a reinfection is a risk, particularly in older, medically compromised patients. This paper reports a new arthrodesis technique that uses a bundle of flexible intramedullary rods and an antibiotic-loaded cement spacer. This technique was used in two cases of multiple TKA failure that resulted from a recurrent infection. The procedure was successful in both cases with no evidence of rod or cement failure. Two advantages of this procedure are infection eradication and mechanical strength. However, this procedure should only be used for medically compromised elderly patients at high risk of rerevision TKA failure resulting from persistent periprosthetic infection because rod fracture or loosening can occur with time.

Keyword

total knee arthroplasty; infection; artificial fusion; antibiotic-loaded cement spacer

MeSH Terms

Aged
Arthrodesis
Arthroplasty*
External Fixators
Fracture Fixation, Intramedullary
Humans
Knee*

Figure

• 

  Figure 1 (A) Flexible rods were inserted retrogradely until they filled the femur medullary cavity, after which they were trimmed at the level of the articular bony defect of the proximal tibia. (B) Flexible rods were inserted antegradely until they filled the tibial cavity, after which they were trimmed at the level of the distal femur bony defect to allow sufficient overlap with rods from the femoral side. (C) Overlapping rod ends from the femoral and tibial sides were interdigitated and fixed using cerclage wires. (D) During the dough time period, antibiotic-loaded cement was placed within the knee and molded to the irregular contours of the bony defects of the distal femur and proximal tibia.

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  Figure 2 Knee anteroposterior (A) and lateral (B) radiographs at postoperative 40 months showing the flexible rod bundle with cerclage wires crossing from the femur to the tibia, and antibiotic-loaded cement used to compensate for bone loss. Note the lack of evidence of rod or cement spacer failure.

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  Figure 3 Immediate postoperative radiographs showing inserted flexible rods avoiding the distal dynamic hip screw.

Reference

1. Hart WJ, Jones RS. Two-stage revision of infected total knee replacements using articulating cement spacers and short-term antibiotic therapy. J Bone Joint Surg Br. 2006; 88:1011–1015.

2. Senior CJ, da Assunção RE, Barlow IW. Knee arthrodesis for limb salvage with an intramedullary coupled nail. Arch Orthop Trauma Surg. 2008; 128:683–687.

3. 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.

4. Campanacci M, Costa P. Total resection of distal femur or proximal tibia for bone tumours. Autogenous bone grafts and arthrodesis in twenty-six cases. J Bone Joint Surg Br. 1979; 61-B:455–463.

5. Sundgren K. Cemented modular intramedullary nail in failed knee arthroplasty--a report of 2 cases. Acta Orthop Scand. 1999; 70:305–307.

6. 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.

7. Persson BM, Rydholm A. Artificial fusion of the knee joint with intramedullary nail and acrylic cementation following radical excision for tumor. Arch Orthop Trauma Surg. 1984; 102:260–263.

8. Capanna R, Biagini R, Ruggieri P, Bettelli G, Casadei R, Campanacci M. Temporary resection-arthrodesis of the knee using an intramedullary rod and bone cement. Int Orthop. 1989; 13:253–258.

9. Hsieh PH, Tai CL, Lee PC, Chang YH. Liquid gentamicin and vancomycin in bone cement: a potentially more cost-effective regimen. J Arthroplasty. 2009; 24:125–130.

10. Ha CW. A technique for intraoperative construction of antibiotic spacers. Clin Orthop Relat Res. 2006; 445:204–209.