How I do it — Second stage revision total knee arthroplasty

BackgroundInfection is a potentially devastating complication following primary total knee arthroplasty, and the traditional gold-standard treatment for chronic prosthetic joint infection has been in the form of a two-stage revision total knee arthroplasty. This involves a first stage – removal of all implants and infected material, with implantation of a temporary spacer – followed by a second stage which includes reimplantation with a definitive prosthesis.IndicationsAlthough the outcomes of single-stage and two-stage revision arthroplasty surgeries are similar, there are certain indications such as atypical or more virulent organisms, patient factors and soft tissue factors that would favour a two-stage approach.Surgical techniqueThe second stage revision procedure consists of explantation of the spacer with a debridement and synovectomy. Further samples are sent for microbiological analysis. Once the surgical field is clean and lavaged, the definitive prosthesis is implanted.ConclusionsA second stage revision total knee arthroplasty is a reliable procedure for the treatment of chronic prosthetic joint infection. There is a significant re-revision rate, predominantly due to recurrent deep infection.     

Reactivation of ancient joint tuberculosis of the knee following total knee arthroplasty after 61 years: a case report

The prevalence of pulmonary tuberculosis is increasing and is associated with a rise in skeletal tuberculosis. Even after appropriate anti-tuberculosis therapy, reactivation of the infection may occur, even after many years. In this case report we describe a patient who had a reactivation of tuberculosis in the knee after total knee arthroplasty. At the age of 14 years, the patient had isolated tuberculosis arthritis of the left knee. Reactivation occurred after total knee arthroplasty 61 years later, at the age of 75. The patient was treated with a combined therapy; first the joint was irrigated with povidine-iodine and saline solution, and gentamicin beads were left behind. When the cultures revealed Mycobacterium tuberculosis, drug therapy of isoniazid, rifampicin, ethambutol and pyrazinamide was started and was continued for 9 months postoperatively. At a recent follow-up, the patient is doing well, with good range of motion in the knee.     

Metal hypersensitivity in total knee arthroplasty: revision surgery using a ceramic femoral component - a case report

We present a case involving the revision of a total knee arthroplasty with a metal femoral component using a ceramic implant due to metal hypersensitivity. A 58-year-old female patient underwent total knee arthroplasty (TKA) with a standard metal bicondylar knee system. She suffered from persistent pain and strong limitations in her range of motion (ROM) associated with flexion during the early postoperative period. Arthroscopic arthrolysis of the knee joint and intensive active and passive physical treatment, in combination with a cortisone regime, temporarily increased the ROM and reduced pain. No signs of low grade infection or other causes of implant failure were evident. Histology of synovial tissue revealed lymphoplasmacellular fibrinous tissue, consistent with a type IV allergic reaction. Allergometry (skin reaction) revealed type IV hypersensitivity against nickel-II-sulfate and palladium chloride. Revision surgery of the metal components was performed with a cemented ceramic femoral component (same bicondylar design) and a cemented titanium alloy tibial component. Postoperative evaluations were performed 10days, and 3 and 12months after the revision surgery. There was an increased ROM in flexion to 90° at the 12month follow-up. No swelling or effusion was observed at all clinical examinations after the revision surgery. No pain at rest and moderate walking pain were evident. The presented case demonstrates that ceramic implants are a promising solution for patients suffering from hypersensitivity to metal ions in total knee arthroplasty.     

全膝关节置换中的改良截骨

背景：近年来全膝关节置换在临床应用普遍,置换技术及假体设计理念均获得极大改善和提高,但尚无截骨顺序方面的研究。 目的：探讨改良截骨方法在全膝关节置换过程中应用的临床效果。 方法：对60例患者的60膝行全膝关节置换,原发疾病包括骨关节炎52例,类风湿性关节炎6例,创伤性关节炎2例,均为后稳定型膝关节,应用强生PFC-Sigma PS型假体或LINK Gemini PS型假体。在极度屈膝下,先行股骨截骨,包括股骨远端前方后方斜面截骨(某些类型还包括股骨髁间截骨)。髌骨不常规置换,再行胫骨平台截骨。记录手术时间,置换后引流量,置换前及置换后6,12周膝关节活动度及美国特种外科医院膝关节评分,并进行统计学分析。 结果与结论：60例患者均获得随访,随访时间3-14个月。手术时间平均(51.3±12.5) min,置换后引流量平均(302±39) mL。置换后6,12周患者膝关节活动度及美国特种外科医院膝关节评分均较置换前明显改善(P < 0.01)。2例患者置换后1个月出现低度感染,经抗感染治疗后好转,未出现假体排异反应。提示全膝关节置换过程中先行股骨截骨可以为胫骨的操作获得更大的空间,方便切除半月板,并可安全地进一步松解周围软组织。操作简便,可以缩短手术时间,减少术中失血,具有良好的修复效果。     

Does intraarticular steroid infiltration increase the rate of infection in subsequent total knee replacements?

Steroid injection into the arthritic joint is a well-known treatment. Its efficacy is well documented. An increase in the incidence of infection secondary to steroid injection has been reported in recent literature. Based on the current literature we carried out a retrospective study to evaluate the incidence of infection in primary total knee arthroplasty as a result of previous steroid infiltration into the knee joint.In our study, 440 patients underwent total knee replacement between 1997 and 2005. Only 90 patients had intraarticular steroid injection prior to surgery, of which 45 patients had injection within 1 year prior to surgery. A matched cohort of 180 patients who had total knee replacement without steroid injection was used as control group to compare the infection rate. All patients had at least 1 year follow up. Two cases of superficial infection were noted in the study group and five cases of superficial infection in the control group. No cases of deep infection were noted in either group. Statistical analysis showed no significant difference in incidence of infection in either group (P value 1.0).This study showed no increase in the incidence of infection in patients with total knee arthroplasty with prior steroid injection.     

Miliary tuberculosis with delayed-onset total knee arthroplasty Mycobacteria tuberculosis infection successfully treated with medical therapy alone: A case report and literature review

Tuberculosis (TB) affecting a prosthetic knee is an unusual and diagnostically challenging presentation of this disease. This study reported a case of an 80-year-old man with a left total knee arthroplasty (TKA) performed eight years before his presentation. He presented with left knee swelling and pain for one month. Knee X-rays showed a normal joint space with no loosening of his prosthesis. His chest X-ray showed miliary disease, and microbiological studies of his sputum and synovial fluid aspirate grew Mycobacteria tuberculosis complex. He was successfully medically treated with anti-tuberculous therapy alone for one year. His knee hardware was retained, and he did not require debridement, resection, or revision. It is believed that this is the first reported case of miliary TB with delayed-onset TKA prosthetic joint infection (PJI) in which the prosthesis was successfully retained. Thirty-eight published TB TKA PJI cases in medical literature were also reviewed.     

Infection rates in patients undergoing primary knee arthroplasty with pre-existing orthopaedic fixation-devices

BackgroundPrior knee surgery in the setting of knee arthroplasty (KA) can influence the overall outcome of the procedure and render the operation more technically challenging.The effects of residual fixation devices on subsequent procedures about the knee are ill-defined. Some authors claim an increase in periprosthetic infection in this cohort of patients. The objective of this study was to evaluate the overall incidence of periprosthetic infections in patients undergoing primary KA with pre-existing osteosynthetic hardware in situ.MethodsThe current investigators retrospectively reviewed 124 patients undergoing knee arthroplasty and removal of orthopaedic fixation devices, due to prior high tibial osteotomies, fracture fixation or cruciate ligament reconstruction. The exclusion criterion was a prior history of infection of the fixation device. The mean follow-up time was 5.4 years (range 15 months to 9 years). Nine patients were lost to follow-up.ResultsJoint aspiration was performed two weeks prior to surgery in 53 patients (42.4%) and intra-operative samples were obtained in 106 patients (84.8%), which did not show any bacterial growth. A subacute periprosthetic infection occurred after seven months in only one patient.ConclusionThe results of the current study demonstrate that previously implanted osteosynthetic fixation devices do not significantly increase the risk of developing periprosthetic knee infections. A two-stage procedure with implant retrieval prior to total knee arthroplasty is not clinically indicated in the cohort described, amongst whom an infection rate of 0.9% was revealed.     

保留假体清创治疗人工关节置换后的急性感染

文题释义： 保留假体清创：是用于治疗关节置换后感染的一种方法，主要应用于早期治疗，对于感染的关节只是进行垫片或者内衬的更换，清除关节腔内感染及疑似感染的组织，不取出假体，对患者来说是一种痛苦小、花费少的治疗方法。 人工全膝关节置换：用于治疗重度关节磨损、严重关节畸形的患者，用金属假体代替股骨关节面和胫骨关节面并在关节面之间加聚乙烯衬垫，是近代发展非常快的手术，解决了患者膝关节疼痛，纠正了力线，提高了患者生活质量。 背景：与翻修手术比较，保留假体清创治疗假体周围感染具有创伤小、耗时短、花费低等优势，但是关于保留假体清创的适应证和围术期管理还存在争议。 目的：综述清创保留假体手术应用于假体周围感染的术前适应证、术中操作及术后抗生素应用。 方法：英文文献检索PubMed、Web of Science、Embase、The Cochrane Library数据库，年限为2000至2018年，检索关键词为“total knee arthroplasty、periprosthetic joint infection、Diagnose、treatment”。中文文献检索中国知网、万方数据库，检索年限为2000至2018年，检索关键词为“关节置换术、术后感染、保留假体清创术”。筛选相关文献，统计文献保留假体治疗关节置换后感染的成功率，总结最为准确的诊断标准及治疗最有效的方法经验。 结果与结论：目前关于关节置换后感染的诊断国际上没有统一的标准，有很多组织提出了一些共识和指南，其中Parvizi等综合其他共识和指南提出了新的假体周围感染诊断标准，其敏感性和特异性都较高，得到了大多数人的认可。保留假体清创适用于稳定且固定良好的假体、症状持续时间短、软组织良好且无窦道形成的患者。术中应该彻底清除感染坏死组织及疑似感染的组织，碘伏水浸泡半小时，更换新的垫片，清创完全后对重新消毒铺巾更换一套新的手术工具。术后应根据培养结果联合应用敏感的抗生素，院外口服利福平4个月。保留假体清创是治疗早期急性关节置换后感染的最佳方法，具有患者痛苦小、花费少、接受度高、避免翻修等优势。 ORCID: 0000-0002-2784-1542(徐长波) 中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程        

Cost analysis of debridement and retention for management of prosthetic joint infection

Prosthetic joint infection remains one of the most devastating complications of arthroplasty. Debridement and retention of the prosthesis is an attractive management option in carefully selected patients. Despite this, there are no data investigating the cost of this management modality for prosthetic joint infections. The aim of this case–control study was to calculate the cost associated with debridement and retention for management of prosthetic joint infection compared with primary joint replacement surgery without prosthetic joint infection. From 1 January 2008 to 30 June 2010, there were 21 prosthetic joint infections matched to 42 control patients. Controls were matched to cases according to the arthroplasty site, age and sex. Cases had a greater number of unplanned readmissions (100% vs. 7.1%; p <0.001), more additional surgery (3.3 vs. 0.07; p <0.001) and longer total bed days (31.6 vs. 7.9 days; p <0.001). In addition they had more inpatient, outpatient and emergency department visits (p <0.001, respectively). For patients with prosthetic joint infection the total cost, including index operation and costs of management of the prosthetic joint infection, was 3.1 times the cost of primary arthoplasty; the mean cost for cases was Australian dollars (AUD) $69 414 (±29 869) compared with $22 085 (±8147) (p <0.001). The demand for arthroplasty continues to grow and with that, the number of prosthetic joint infections will also increase, placing significant burden on the health system. Our study adds significantly to the growing body of evidence highlighting the substantial costs associated with prosthetic joint infection.     

Prosthetic joint infection caused by Helcococcus kunzii

Helcococcus kunzii was isolated by sonication and conventional cultures obtained from a case of infection following total knee prosthesis in an immunocompetent patient. The patient recovered uneventfully. This is the first known case of an H. kunzii prosthetic joint infection.     

Challenges in periprosthetic knee-joint infection

The number of knee arthroplasty procedures is growing and projected to further increase. The risk for periprosthetic joint infection (PJI) is estimated to be low (<1%). However, considering the increasing number of total knee arthroplasty, the increasing number of patients with multiple comorbidities, and the lifelong risk for acquiring hematogenous infection, the total number of PJI will further increase. Despite existing treatment concepts for PJI of the knee, there are still questions to solve, such as type of debridement surgery in case of implant retention, the role of a spacer from a microbiological perspective, and the optimal duration of antimicrobial therapy. In this REVIEW, these questions will be analyzed according to the available literature and the experience of the authors. Moreover, we REVIEW the most recent data on infection, risk factors, and microbiology of PJI.     

Debridement,antibiotics and implant retention (DAIR) for the management of knee prosthetic joint infection

BackgroundWhile two-stage revision arthroplasty is viewed as the gold standard for the treatment of knee periprosthetic joint infection (PJI) in terms of infection eradication, it is associated with significant cost along with patient morbidity and mortality. Debridement, antibiotics, and implant retention (DAIR) is an attractive option as it has demonstrated better patient outcomes, comparable implant longevity to primary arthroplasty, and significantly reduced cost when successful. Given the heterogeneity of what is defined as a DAIR the literature is highly variable in terms of its efficacy from the perspective of infection eradication.MethodsIn the setting of a previously well-functioning, well-fixed arthroplasty with an acceptable soft tissue envelope and a treatable organism we report our methods for proceeding with a DAIR procedure, both unicompartmental and total knee.ResultsWith the above methods we have demonstrated improved patient outcomes when compared to one- or two-stage arthroplasty with lower patient morbidity. Implant longevity in the setting of a successful DAIR is equivalent to those of a primary arthroplasty.ConclusionsWith appropriate indications and good surgical technique as described we believe DAIR is an excellent option in the treatment of periprosthetic joint infection. We hope that with a well-defined protocol as outlined we can gain a better understanding of the efficacy of DAIR procedure with more homogeneity to the procedure to better define when they are most successful while improving patient outcomes and reducing cost.     

Two-stage TKA for tuberculosis septic arthritis of the knee masquerading as pigmented villonodular synovitis: A case report

A 25-year-old female presented with left knee pain following arthroscopic synovectomy for presumed pigmented villonodular synovitis (PVNS). Radiographs and magnetic resonance imaging demonstrated tricompartmental arthritic changes. She underwent a two-stage procedure first involving antibiotic spacer implantation, followed 1 week later by spacer removal and definitive total knee arthroplasty (TKA) once initial intraoperative culture results were negative. Subsequent cultures confirmed tuberculosis septic arthritis. Repeat evaluation 1 year postoperatively showed no complications and patient satisfaction with left knee function. This is a unique case report in the United States describing 1-year outcomes following staged TKA for tuberculosis septic arthritis masquerading as PVNS.     

Phenotypic characteristics of joint fluid cells from patients with continuous joint effusion after total knee arthroplasty

Joint effusion after total joint arthroplasty (TJA) is a manifestation of inflammatory reactions within the prosthetic joint. Among the various causes for joint effusion following TJA, deep infection (DI), wear particle-induced synovitis (PS) and metal sensitivity to the implant should be excluded as soon as possible, as these may result in the failure of TJA. The present study analyzed joint fluid cells from patients after total knee arthroplasty (TKA) using fluorescence-activated cell sorter (FACS), and examined the feasibility of using FACS to exclude the possibility of biomaterial-related complication. A total of 72TKAs from 64 patients suffering from joint effusion were examined in this study. Joint fluid was aspirated in outpatient clinics and applied to FACS. The results indicated that patients could be clearly classified into four types based on forward/side scatter profiles. Analysis of specific CD markers revealed that leukocytes were selectively recruited from blood to inflamed prosthetic joints. Dominant cell types were CD16+neutrophils in DI and increased rheumatoid activity, CD14+macrophages in PS, and CD3+CD45RO+T cells in metal sensitivity. These findings suggest the feasibility of diagnosing joint effusion by analyzing dominant cell type recruited using FACS. In conclusion, FACS may offer a useful tool for analyzing joint fluid cells from post-TJA patients and for excluding biomaterial-related complication following TJA.     

A randomised RSA study of Peri-Apatite HA coating of a total knee prosthesis

BACKGROUND: In total knee replacement, sound early fixation of the prosthesis is crucial for achieving a good long-term result and for minimising the risk of loosening. Various types of prosthetic material, different surface textures and shapes and the incorporation of screws or pegs have been used to achieve good fixation, particularly in the uncemented knee. Hydroxyapatite (HA) coating of prosthetic joint components is another technique used to enhance early stability and so to improve the longevity of the prosthesis-bone fixation. HA ceramic coatings are mostly plasma sprayed onto the fixation surface of the implant. Plasma spraying is largely a 'line of sight' technique and as such there are difficulties involved when covering three-dimensional planes, such as porous beaded fixation surfaces typically found on several knee prostheses. The objective of this study was to assess the clinical performance of the solution-deposited HA coating, Peri-Apatite , with regard to its ability to stimulate an endurable and stable implant fixation. PATIENTS AND METHODS: We randomised 60 patients into two groups; one group received the porous coated prosthesis with solution-deposited HA, and the other group received a prosthesis without HA. Radiostereometric examination was used as the primary tool for measuring migration in the prosthetic components. RESULTS: There was a lower incidence of early subsidence in the Peri-Apatite group. At 24 months there were no differences in clinical scorings or maximal total point motion. CONCLUSION: Addition of solution-deposited HA coating appears to provide better early stable fixation in a porous coated knee prosthesis.     

Ureaplasma parvum Prosthetic Joint Infection Detected by PCR

We describe the first reported case of Ureaplasma parvum prosthetic joint infection (PJI) detected by PCR. Ureaplasma species do not possess a cell wall and are usually associated with colonization and infection of mucosal surfaces (not prosthetic material). U. parvum is a relatively new species name for certain serovars of Ureaplasma urealyticum, and PCR is useful for species determination. Our patient presented with late infection of his right total knee arthroplasty. Intraoperative fluid and tissue cultures and pre- and postoperative synovial fluid cultures were all negative. To discern the pathogen, we employed PCR coupled with electrospray ionization mass spectrometry (PCR/ESI-MS). Our patient''s failure to respond to empirical antimicrobial treatment and our previous experience with PCR/ESI-MS in culture-negative cases of infection prompted us to use this approach over other diagnostic modalities. PCR/ESI-MS detected U. parvum in all samples. U. parvum-specific PCR testing was performed on all synovial fluid samples to confirm the U. parvum detection.     

Clostridium infection in a knee extensor mechanism allograft: case report and review

An unusual case of Clostridium perfringens infection after an allograft reconstruction of an extensor mechanism in a multiply revised total knee arthroplasty is reported. The case occurred in an elderly patient with an underlying bleeding dyscrasia who had previously undergone two revision total knee arthroplasties. The patient was treated by open irrigation, debridement, removal of allograft and prosthesis, intravenous antibiotics, and implantation of an antibiotic impregnated cement spacer utilizing an intramedullary rod.     

全膝关节置换后关节后方复合松解的可行性评价

背景：临床对于膝骨关节炎患者可以实施全膝关节置换治疗,为提高修复效果,促进功能恢复,要采取有效措施改善置换过程中的关节间隙以及置换后的关节活动度。 目的：探讨全膝关节置换后行关节后方复合松解的有效性及可行性。 方法：从两家三甲医院2009年12月至2013年12月收治的行单侧全膝关节置换的膝骨关节炎患者中选择118例进行研究,随机分为对照组和观察组,每组59例。在患者全膝关节置换过程中完成截骨之后,对照组行常规后髁增生骨清理,观察组行关节后方复合松解。观察两组患者置换后伸、屈膝间隙情况和主动屈膝90°和120°所需时间,记录3个月随访时的膝关节功能美国纽约特种外科医院评分以及最大屈膝角度,并进行比较。 结果与结论：经统计和比较,两组患者在屈膝间隙方面差异无显著性意义(P > 0.05);但在伸膝间隙、主动屈膝90°、120°所需时间以及最大屈膝角度方面,两组差异均有显著性意义,观察组优于对照组(P均< 0.05)。比较置换后3个月两组患者的膝关节功能美国纽约特种外科医院评分,可得观察组的各项指标得分以及总分均显著高于对照组,差异均有显著性意义(P均 < 0.05)。表明全膝关节置换后行关节后方复合松解具有一定的有效性和可行性,可以有效改善置换过程中伸膝间隙以及置换后膝关节活动度,但对置换过程中屈膝间隙方面无明显影响。中国组织工程研究杂志出版内容重点：人工关节;骨植入物;脊柱;骨折;内固定;数字化骨科;组织工程     

Optimizing patellofemoral arthroplasty

Patellofemoral arthroplasty (PFA) has been an option for patients with symptomatic patellofemoral osteoarthritis since the 1950's. Many of the early failures resulted from a combination of implant design and surgeon technique. The goal of this overview is not to review the history of PFA, but rather to explore options for surgeons to optimize long-term outcomes and improve patient knee function, while highlighting the differing techniques required in PFA with those routinely adopted in total knee arthroplasty (TKA).     

Prosthetic joint infection due toCandida parapsilosis in the UK: Case report and literature review

Candida infection of joint replacements is a rare but increasingly reported phenomenon. A case ofCandida parapsilosis prosthetic knee joint infection occurring in the UK is described. Cure followed removal of the prosthesis and treatment, first with a combination of amphotericin and 5-fluorocytosine, then ketoconazole.