Knee arthrodesis after infected total knee arthroplasty using the Ilizarov method

Numerous treatments have been proposed for infected total knee arthroplasty. In selected patients, a knee arthrodesis is a well-recognized salvage procedure. However, there are no reports in the literature discussing the treatment of infected total knee arthroplasty using the Ilizarov method. The authors reviewed their experience with this technique in infected total knee arthroplasty, presenting six patients (four women, two men) treated between 1992 and 1998. The average age was 56.6 years (range, 23-70 years) and the mean number of previous surgical procedures was seven (range, 4-10 procedures). From the time of frame removal, the patients were followed up for a mean of 34.2 months (range, 12.4-87.5 months). Full weight-bearing was allowed 1 week after surgery if half-pins were used and after a mean of 2.6 months if Kirschner wires were used. Of the five patients who have completed treatment, all have obtained a stable knee arthrodesis after a mean external fixation time of 6.8 months without additional surgical procedures or bracing. All of the patients were satisfied with the treatment. The authors recommend knee arthrodesis by the Ilizarov method for infected total knee arthroplasty, particularly in patients with extensive bone loss, significant limb shortening or axial deformity or both, active infection, or previous failed arthrodesis.     

Infected total knee arthroplasty treated with arthrodesis using a modular nail.

Failed treatment of infected total knee replacement presents few attractive surgical options. Knee arthrodesis is challenging surgically and can be complicated by nonunion, malunion, or recurrent infection. Recently, a modular titanium intramedullary nail has been used in an attempt to reduce the incidence of nonunion and the rate of complications. In the present study, a review of the results of knee arthrodesis after infected total knee arthroplasty in 21 patients at three large academic institutions was performed. All patients were followed up for a mean of 2.4 years (range, 2-7.5 years). The mean age of the patients was 64 years. The mean number of previous operations was four (range, 2-9 operations). A solid arthrodesis was achieved without additional surgical treatment in 20 of 21 patients (95%). The mean time to fusion was 6.3 months. The one patient who suffered a nonunion achieved fusion after a subsequent bone grafting procedure. Based on the present study, intramedullary arthrodesis with a coupled titanium nail, is a reliable, effective method of achieving fusion after infection of a total knee arthroplasty. This procedure resulted in a high rate of fusion and a lower rate of complications when compared with traditional methods of arthrodesis.     

Knee arthrodesis using a customized intramedullary nail: 14 cases

We report our experience with knee arthrodesis using a customized intramedullary nail implanted in 14 patients. Indications for knee arthrodesis were: recurrent prosthesis infection (n=11), post-traumatic septic arthritis (n=1), aseptic loosening of a hinge prosthesis (n=1), and nonunion (n=1). A two-stage procedure was used for the 12 patients with infected joints. Mean follow-up was 19 months. Weight bearing began during the first week after arthrodesis in 13 patients. First intention bone healing was achieved in 13 patients. Mean time to healing was three months. All patients rapidly recovered full independence. Complications were: one misinsertion of the tibial stem, one nonunion which fused after repeated grafting, and two recurrent infections (controlled chronic fistulae) which required skin flaps for cover. We have found that this customized nail is a useful method for achieving bone fusion in patients with difficult indications for arthrodesis, particularly recurrent prosthesis infection.     

Kniearthrodesen

When arthrodesis of the knee is indicated, the operative procedure selected for fixation depends on the condition of the soft tissues, the bone stock, whether infection is present, and the age of the patient and his or her capacity for partial weight-bearing. In young patients with no infection or soft tissue problems, when adequate bone stock is present compression plating or the use of an intramedullary nail is possible and allows stable fixation. Soft tissue problems with defect(s) or infection are a good indication for the use of an external fixator. The most common indication for knee arthrodesis is a failed total knee prosthesis that has become infected. Deficient bone stock with osteopenic bone or a defect after failed total knee arthroplasty are problems that can be solved by the use of modular fusion nail systems, especially in older patients. These systems are more comfortable for the patient than external fixation devices and allow early full weight-bearing.     

Treatment of infected knee arthroplasty

Forty-eight patients with 51 infected knee arthroplasties were treated at the authors' institution between 1973 and 1986 and followed for 5.5 (range, 0-14) years. Six methods to treat the infections were employed: antibiotics only, soft-tissue surgery, removal of the prosthesis, revision arthroplasty, arthrodesis, and amputation. Failure of the initial surgical treatment led to second revision surgery in 20 patients. At the follow-up examination, three patients (five knees) had died from septic complications and two patients had had above-knee amputation. Two of 32 patients had been successfully treated with antibiotics with no additional surgery. Four patients had successful soft-tissue surgery. Following removal of the prosthesis, the infection healed in four patients. In 12 of 19 patients (13 knees) with revision arthroplasty the infection healed, but only seven of these had functioning prostheses. The infection healed in all but one of the 21 patients with arthrodeses, and all but two were fused. Infected compartmental prostheses with good bone stock can be treated with an exchange arthroplasty using a two-stage procedure with tricompartmental revision prostheses. Otherwise, an arthrodesis using a two-stage procedure is recommended for the treatment of infected knee arthroplasty.     

Management of wounds of exposed or infected knee prostheses.

Skin damage after total knee arthroplasty may jeopardise the functional benefit of the prosthesis. In such cases standard treatment is aimed at avoiding arthrodesis, sometimes replacing the implant and, in exceptional cases, amputation. In most cases early and adequate coverage of the soft tissue defect may make it possible to salvage the prosthesis. Ten patients with skin damage after total knee arthroplasty were treated by debridement of the wound, which was then covered with a pedicled gastrocnemius muscle flap. This was supported by local irrigation and systemic antibiotics. Seven patients were reviewed after a mean follow-up of 28 months (range 14-59). Six patients kept their prostheses and one had a relapse caused by infection at 22 months, which required removal of the prosthesis and secondary arthrodesis. The gastrocnemius muscle flap provides good quality coverage, permits early mobilisation and fast rehabilitation, and reduces the rate of arthrodesis after failure of total knee arthroplasty.     

Limb Salvage After Infected Knee Arthroplasty With Bone Loss and Extensor Mechanism Deficiency Using a Modular Segmental Replacement System

Multiple total knee arthroplasty revisions pose significant surgical challenges, such as bone loss and soft tissue compromise. For patients with bone loss and extensor mechanism insufficiency after total knee arthroplasty, arthrodesis is a treatment option for the avoidance of amputation. However, arthrodesis is both difficult to achieve in situations with massive bone loss and potentially undesirable due to the dramatic shortening that follows. Although intramedullary nailing for knee arthrodesis has been widely reported, this technique has traditionally relied on the achievement of bony union. We report a case of a patient with massive segmental bone loss in which a modular intercalary prosthesis was used for arthrodesis to preserve limb length without bony union.     

Two-stage conversion of fused knee to total knee arthroplasty

We report 2 cases of conversion of fused knee to total knee arthroplasty (TKA) by way of soft-tissue expansion. Case 1 had had multiple operations on the infected total knee, which was arthrodesed 7 months before conversion. Case 2 had had knee arthrodesis for an intra-articular comminuted fracture 5 years and 10 months before conversion. In both patients, a tissue expander was placed subcutaneously upon the patella and the patellar tendon to gradually expand the anterior knee skin for later coverage and knee flexion. After takedown of the arthrodesis, a fully constrained rotating-hinge prosthesis was implanted as the second-stage procedure. The final range of flexion was 95 degrees in both knees with patients' subjective satisfaction.     

人工全膝关节置换术后感染的治疗

目的：探讨人工全膝关节置换术后感染的治疗方法及效果。方法：6例TKA术后感染患者。感染发生时间为TKA术后1个月－11年,2例为早期感染,4例迟发性感染,平均4年2月。其中骨关节炎4例,类风湿性关节炎2例。单纯清创、抗感染治疗3例;清创、一期假体再置术1例;清创、二期假体再置换术1例;关节融合术1例。结果：在3例单纯清创、抗感染治疗中,1例经5次清创后痊愈,1例2次清创后感染未控制,改行关节融合术,1例3次清创,感染未愈;2例关节再置换术病例痊愈,功能恢复满意;2例关节融合术后痊愈。所有病例平均随访4年,除1例失去随访外,其余感染均未复发。结论：对全膝关节置换术后感染可行的治疗包括：单纯清创、抗感染治疗;清创、一期或二期假体再置换术;关节融合术等方法。每种方法都有其适应证,应根据患者的具体病情采用合适的治疗方法。     

Arthrodesis for failed knee arthroplasty. A report of 20 cases

Twenty consecutive patients treated by arthrodesis for failed knee arthroplasty are reviewed. Eight hinged, five stabilised and seven compartmental prostheses were removed, for infection (15 cases), loosening (4) and instability (1). One patient refused a second-stage operation but the remainder gained sound fusion. Infected knees had a two-stage procedure with temporary insertion of gentamicin-loaded beads after removal of the prosthesis; all infections healed. Six arthrodeses using a Hoffmann-Vidal external fixator resulted in two temporary failures. One Ace-Fischer external fixation was successful. Of 10 primary attempts at arthrodesis with an intramedullary Küntscher nail, nine were successful; the tenth fused after two more attempts by the same method. The two failures of external fixation and two failures after Charnley single-frame compression done elsewhere were successfully fused with intramedullary nails. Delayed union in three cases fused after prolonged fixation and repeated bone grafts. The indications for and methods of arthrodesis after failed knee arthroplasty are discussed.     

Knee arthrodesis with simultaneous lengthening using the Ilizarov method

OBJECTIVE: To determine whether knee arthrodesis with simultaneous lengthening using the Ilizarov method for a nonreconstructable knee joint with bone loss and infection is a successful salvage procedure. DESIGN: Retrospective review of patients. SETTING: University hospital-based orthopaedic practice. PATIENTS: From 1999 to 2001, 4 consecutive patients with a nonreconstructable knee joint, bone loss, and infection after trauma underwent knee arthrodesis with simultaneous lengthening. INTERVENTION: Arthrodesis of the knee with simultaneous limb lengthening through an osteotomy of the tibia and/or femur and the use of an Ilizarov frame. External bone stimulation was used at the knee arthrodesis site and the lengthening sites. Application of this device began during the early distraction phase and continued until frame removal. MAIN OUTCOME MEASURES: Bony union at the arthrodesis and bone lengthening sites, alignment of the lower extremity, limb length discrepancy, infection, pain, and outcome scales (SF-36 scores and American Academy of Orthopaedic Surgeons lower limb modules). RESULTS: Bony union of the knee arthrodesis and lengthening sites and good alignment were achieved in all 4 patients. Mean amount of lengthening was 5.4 cm (range 2.5-11.5 cm). Average time in frame was 11 months (range 6-17 months). Limb length discrepancy after treatment averaged 1.8 cm (range 0.6-3.7 cm). Mean duration of follow-up after frame removal was 35 months (range 28-48 months). At follow-up, infection had not recurred, pain was not present, and assistive devices were not needed for ambulation. Average SF-36 scores improved in all 8 categories, and the average American Academy of Orthopaedic Surgeons lower limb modules improved from a mean of 33 (range 11-37) to a mean of 68 (range 51-76). CONCLUSION: Knee arthrodesis with simultaneous lengthening can be performed successfully using the Ilizarov method. It enables surgeons to optimize limb length during knee arthrodesis. The use of external fixation and the avoidance of internal implants may be advantageous in the presence of or history of infection. The Ilizarov frame provides stability that allows weight bearing during treatment.     

Arthrodesis following knee arthroplasty

In 44 failed total arthroplasties of the knee joint, arthrodesis was attempted (1970-1986). The interval between implantation of the total knee arthroplasty and diagnosis of infection was more than 2 years on average. Removal of the arthroplasty and arthrodesis was performed about 1 year later. In 80% of the knees, compression arthrodesis using an AO plate was used 34 times, with solid fusion occurring after 6 months. External fixation was used in 10 patients; rate of solid fusion was only 60%. The reasons for delayed union or failure had to do with reduced bone stock in the metaphysis with poor bone quality, inadequate fixation, and uncontrolled infections.     

Arthrodesis of the knee following failed total knee arthroplasty.

In forty-five patients, who had an arthrodesis because of failed total knee arthroplasty, the cause was infection in forty, instability in two, failure of the prosthesis in two, and loosening in one. The arthrodesis succeeded in twenty-nine (81%) of thirty-six patients who had had a minimally or partially constrained arthroplasty and in five (56%) of nine who had had a hinge-type prosthesis inserted. The reasons for failure were severe bone loss, persistent sepsis, and loss of bone apposition after manipulation. The technique of arthrodesis did not seem to influence the final result. External fixation most commonly had to be used because of the infections and the device was kept in place for an average of ten weeks, after which immobilization in a cast was used until the arthrodesis healed.     

Intramedullary fixation for arthrodesis of the knee after infected total knee arthroplasty

Knee arthrodesis with curved intramedullary rods was performed in 12 patients after infected total knee arthroplasty. The underlying pathologic condition was osteoarthritis in nine patients and rheumatoid arthritis in three patients. Nine patients with a postoperative follow-up time of greater than two years (average, 34 months; median, 29 months; longest, 55 months) were evaluated for functional results. Six patients obtained a satisfactory knee fusion in an average of 6.6 months (range, three to 11 months; median, five months). Those patients without massive bone loss preoperatively attained a fusion rate of 66.6%. Two thirds of the patients with massive bone loss attained fusion. Indications for surgery in addition to infection included massive bone loss, mixed infection with multiple organisms, infrapatellar tendon rupture, ligamentous instability, and severe valgus deformity with tibial fracture nonunion. Failure occurred in three cases. One was associated with rod breakage; another was due to massive bone resorption; and the third was in a diabetic female with infrapatellar tendon rupture. All patients with successful arthrodesis reported an absence of pain and the ability to ambulate with, at most, a walker. The use of curved intramedullary rods is a convenient technique for obtaining successful arthrodesis after infected total knee arthroplasty.     

Arthrodesis of the knee with a long intramedullary nail following the failure of a total knee arthroplasty as the result of infection

BACKGROUND: Knee arthrodesis can be an effective treatment option for relieving pain and restoring some function after the failure of a total knee arthroplasty as the result of infection. The purpose of the present study was to review the outcome of a staged approach for arthrodesis of the knee with a long intramedullary nail after the failure of a total knee arthroplasty as the result of infection. METHODS: We reviewed the results for twelve patients who underwent knee arthrodesis after the removal of a prosthesis because of infection. The study group included seven women and five men who had an average age of sixty-eight years at the time of the arthrodesis. All patients were managed with a staged protocol. Implant removal, débridement, and insertion of antibiotic cement spacers was followed by the administration of systemic antibiotics. Provided that clinical and laboratory data suggested eradication of the infection, arthrodesis of the affected knee with use of a long intramedullary nail was carried out. Clinical and laboratory evaluation and radiographic analysis were performed after an average duration of follow-up of 4.1 years. RESULTS: Solid union was achieved in ten of the twelve knees. The average time to union was 5.5 months. One patient had an above-the-knee amputation because of recurrence of infection. In another patient, nail breakage occurred three years following implantation. The average limb-length discrepancy was 5.5 cm. The mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score improved from 41 to 64 points. None of the seven patients who underwent arthrodesis with a technique involving convex-to-concave reamers had a complication, and the average time to union for these seven patients was shorter than that for the remaining five patients (4.3 compared with 7.4 months). CONCLUSIONS: We believe that obtaining large surfaces of bleeding contact bone during arthrodesis following staged treatment of an infection at the site of a failed total knee arthroplasty contributes to stability and enhances bone-healing. Staged arthrodesis with use of a long intramedullary nail and convex-to-concave preparation of bone ends provided a painless functional gait with low complication and reoperation rates in this challenging group of patients.     

Infection after total knee arthroplasty. A retrospective study of the treatment of eighty-one infections.

BACKGROUND: The clinical presentation of an infection at the site of a total knee arthroplasty can be used as a guide to treatment, including the decision as to whether the prosthesis should be retained or removed. We reviewed the results of treatment of infection after total knee arthroplasty to evaluate the effectiveness of four treatment protocols based on the clinical setting of the infection. METHODS: We retrospectively evaluated the results of treatment of eighty-one infections in seventy-six consecutive patients who either had an infection after a total knee arthroplasty or had multiple positive intraoperative cultures of specimens of periprosthetic tissue obtained during a revision total knee arthroplasty performed because of presumed aseptic loosening. The patients were managed according to one of four protocols. Five infections in five patients who had positive intraoperative cultures were treated with antibiotic therapy alone. Twenty-three early postoperative infections in twenty-one patients were treated with débridement, antibiotic therapy, and retention of the prosthesis. Twenty-nine late chronic infections in twenty-eight patients were treated with a delayed-exchange arthroplasty after a course of antibiotics. Seven acute hematogenous infections in six patients were treated with débridement, antibiotic therapy, and retention of the prosthesis. Seventeen infections in seventeen patients were not treated according to one of the four protocols. Sixteen late chronic infections were treated either with an arthrodesis (five infections) or with débridement, antibiotic therapy, and retention of the prosthesis (eleven infections). One acute hematogenous infection was treated with resection arthroplasty because of life-threatening sepsis. RESULTS: The mean duration of follow-up was 4.0 years (range, 0.3 to 14.0 years). Eleven patients who had an arthrodesis, a resection arthroplasty, or an above-the-knee amputation after less than two years of follow-up were included in the study as individuals who had a failure of treatment. In the group of patients who were managed according to protocol, the initial course of treatment was successful for all five infections that were diagnosed on the basis of positive intraoperative cultures, five of the ten deep early infections, all thirteen superficial early infections, twenty-four of the twenty-nine late chronic infections, and five of the seven acute hematogenous infections. Only one of eleven prostheses in patients who had a late chronic infection that was not treated according to protocol was successfully retained after débridement. CONCLUSIONS: Our treatment protocols, which were based on the clinical setting of the infection, were successful for most patients. A major factor associated with treatment failure was a compromised immune status. Bone loss and necrosis of the soft tissues around the joint also complicated the treatment of these infections.     

Use of an intramedullary rod in knee arthrodesis following failed total knee arthroplasty

A retrospective review was conducted of 20 consecutive patients (10 men and 10 women) with failed total knee arthroplasty (TKA) who underwent arthrodesis using an intramedullary rod. Average patient age was 70.5 years. One patient was lost to follow-up, and the remaining 19 patients were evaluated an average of 4.5 years postoperatively (range: 1-24 years). Three patients without infections achieved a solid arthrodesis without complications. In 16 patients, the indication for fusion was an infection, and 12 of these patients had an uncomplicated postoperative course and achieved a solid arthrodesis. Of the remaining 4 patients, 1 required revision for a nonunion, 1 a skin graft, and 2 had recurrence of their infections in the postoperative period. Both patients had positive cultures at attempted arthrodesis. One patient underwent debridement at 3 months, and a solid fusion was obtained. The other patient required rod removal and currently has a nonunion, uses a brace, and is on suppressive antibiotic treatment. An intramedullary rod is the ideal fixation choice for knee arthrodesis in patients with a failed, noninfected TKA; however, in patients with an infection, the infection must be eradicated prior to rod use.     

人工全膝关节置换术后深部感染的一期假体再置换

人工膝关节置换术后深部感染的处理非常棘手,作者采用一期人工膝关节再置换术治疗８例患者,其中包括晚期感染７例,占８７．５％。平均随访２０．１个月,患者疼痛症状明显缓解,无１例感染复发,但功能恢复欠佳。作者认为：（１）一期再置换术是治疗深部感染的一种可选择方法;（２）使用抗生素骨水泥固定,链霉素粉剂埋入关节腔及软组织内,有助于减少术后感染复发;（３）深部感染明确后,应尽早行一期再置换,以减少骨组织的进一步破坏;（４）一期再置换术的长期疗效尚需进一步观察和随访。     

Advanced concepts in knee arthrodesis

The aim is to describe advanced strategies that can be used to diagnose and treat complications after knee arthrodesis and to describe temporary knee arthrodesis to treat infected knee arthroplasty. Potential difficult complications include nonunited knee arthrodesis, limb length discrepancy after knee arthrodesis, and united but infected knee arthrodesis. If a nonunited knee arthrodesis shows evidence of implant loosening or failure, then bone grafting the nonunion site as well as exchange intramedullary nailing and/or supplemental plate fixation are recommended. If symptomatic limb length discrepancy cannot be satisfactorily treated with a shoe lift, then the patient should undergo tibial lengthening over nail with a monolateral fixator or exchange nailing with a femoral internal lengthening device. If a united knee arthrodesis is infected, the nail must be removed. Then the surgeon has the option of replacing it with a long, antibiotic cement-coated nail. The authors also describe temporary knee arthrodesis for infected knee arthroplasty in patients who have the potential to undergo insertion of a new implant. The procedure has two goals: eradication of infection and stabilization of the knee. A temporary knee fusion can be accomplished by inserting both an antibiotic cement-coated knee fusion nail and a static antibiotic cement-coated spacer. These advanced techniques can be helpful when treating difficult complications after knee arthrodesis and treating cases of infected knee arthroplasty.     

Outcome of infected total knee arthroplasty

The results of 44 cases of deep infection after total knee arthroplasty were reviewed. The average age of the patients was 62 years (range, 31–81 years), and all had positive bacterial cultures from deep aspiration or tissue biopsy. Osteitis was revealed in 22 cases. One case was initially treated with antibiotics only, 27 cases were treated with surgical debridement and antibiotics, and 16 cases had immediate removal of the prosthesis. In 21 cases, failed debridement was followed by removal of the prosthesis. Revision arthroplasty was attempted in 15 of the 37 cases in which the prosthesis was removed; the infection was cured in 11 cases. A total of 25 cases that underwent removal of the prosthesis had an arthrodesis performed, and 4 ultimately underwent amputation. In no case of osteitis was the infection cured merely by dedridement and antibiotics, and the index prostheses were retained mainly in cases in which osteitis did not develop.