Patients with
Endoprosthetic replacement (EPR) is an available option for the management of massive bone loss around failed knee implants. The aim of this study was to determine the results of knee EPRs performed for non-tumour indications. Since 2007, 85 EPRs were performed for in a single tertiary centre by seven surgeons. Mean age at surgery was 73.5 years (range:35–95) with infection as the most common indication (49%), followed by aseptic loosening (18%), complex primary replacement (16%), fracture (15%) and mechanical failure (2%). Mean follow up was 4 years (range:1–9). Functional outcome was determined using the Oxford Knee Score (OKS). At follow-up, 21 patients were deceased and 2 lost to follow-up. Complication rate was 19%. Of the 7 infected cases, 6 were treated with DAIR (debridement, antibiotics, and implant retention) and one underwent
Advances in military surgery have led to significant numbers of soldiers surviving with bilateral
Aim. Knee arthrodesis (KA) and
Aim. The purpose of this study was to report on outcomes after stabilization of large skeletal defects following radical debridement of hip or knee infections and staged reimplantation using segmental antibiotic mega-spacers. Method. From 1998–2018, 39 patients (18 male, 21 female) were treated for musculoskeletal infections at the hip (14) or knee (25). Patients were treated for infection after a procedure related to oncology (20), arthroplasty (16), or trauma (3). Following debridement, defects were stabilized with antibiotic impregnated PMMA and intramedullary nails. All patients underwent a standardized protocol: 6 weeks of intravenous antibiotics followed by 6 weeks of oral antibiotics guided by intraoperative cultures. After a 6-week holiday of antibiotics, repeat intraoperative cultures and inflammatory markers were analysed for infection resolution. Success was defined by reimplantation without additional infection-related complications or requirement of suppressive antibiotics at latest follow-up. Results. Mean age was 50.5±19.4 years. Mean defect size was 20.4cm. Mean time from surgery until infection was 34.5 months, with 74% of patients presenting with infection greater than one year after their most recent surgery. Mean follow-up was 110±68 months. Most common organisms of infection were Staphylococcus Epidermidis (11) and Staphylococcus Aureus (10). Mean defect size was significantly different among oncology (28±8 cm), trauma (19±5 cm) and arthroplasty (12±6 cm) patients (p<0.0001), though outcomes were comparable. Two patients with antibiotic spacers have not underwent attempted reimplantation – one patient with clinical and laboratory signs of resolved infection; one patient with recent spacer placement. One patient died of oncologic disease shortly after spacer placement. These three patients were excluded from outcomes analysis. Twenty-nine (81%) patients were successfully re-implanted with a segmental endoprosthesis. Eight patients required an additional procedure prior to infection resolution, including additional antibiotic spacer and debridement due to sustained inflammatory markers and clinical signs of infection (5), antibiotic spacer exchange due to mechanical failure (2), and polyethylene exchange 9 months after reimplantation (1). Two patients have remained on chronic suppressive antibiotics, but have retained their limb, prosthesis, and pain-free function. Four (11%) patients ultimately required an amputation for infection control (3
Aim. To assess the outcome and complication rate of rotating hinge knee prostheses in our unit. Method. From our knee database we have identified 137 consecutive rotating hinged TKRs (implanted 2004–2010) for severe instability, arthrofibrosis and severe bone loss in either primary or revision arthroplasty. Prospective pre-operative scores and post-operative scores were obtained. 23 had died or were lost to follow-up. This left 114 cases with complete outcome and complication data. Results. The mean preoperative American Knee Score of 30.4 improved to 85.5 at a mean follow up of 4.2 years. Complications included: re-revision (6), manipulation (3), infection (2 cases) and
Polymethyl methacrylate spacers are commonly used during staged revision knee arthroplasty for infection. In cases with extensive bone loss and ligament instability, such spacers may not preserve limb length, joint stability and motion. We report a retrospective case series of 19 consecutive patients using a custom-made cobalt chrome hinged spacer with antibiotic-loaded cement. The “SMILES spacer” was used at first-stage revision knee arthroplasty for chronic infection associated with a significant bone loss due to failed revision total knee replacement in 11 patients (58%), tumour endoprosthesis in four patients (21%), primary knee replacement in two patients (11%) and infected metalwork following fracture or osteotomy in a further two patients (11%). Mean follow-up was 38 months (range 24–70). In 12 (63%) patients, infection was eradicated, three patients (16%) had persistent infection and four (21%) developed further infection after initially successful second-stage surgery.
Periprosthetic infection is a challenging complication of total knee arthroplasty (TKA) which reported incidence varies from 1 to 2% in primary TKA and 3–5% in revision TKA. Persistent infection of TKA may benefit from knee arthrodesis when all reconstruction options have failed. Knee arthrodesis also demonstrated better functional results and pain relief than other salvage procedures such as above-knee amputation. The purpose of this study was to analyze treatment results in patients who underwent knee arthrodesis following infected TKA. Retrospective study with review of the data of all patients treated in our department with knee arthrodesis for chronic infection of knee arthroplasty between 2009 and 2014. Clinical and radiographic data were evaluated as well as several variables: technique used, fusion rate, time to fusion, need for further arthrodesis and complications. Patients with less than 8 months of follow-up were excluded from this study. 46 patients were treated with knee arthrodesis in our department from 2009 to 2014 for chronic infection of total knee arthroplasty. The sample included 26 (57%) women and 20 (43%) men, median age of 70 years. In 45 patients, the technique used was compressive external fixation, while an intramedullary modular nail was used in 1 patient. Mean follow-up of these patients was 35 months (8–57). Primary knee fusion was obtained in 32 (70%) patients with a mean time to fusion of 5,8 months (4–9). 9 (20%) patients needed rearthrodesis and 7 (15%) ultimately achieved fusion. 33 (72%) patients underwent knee arthrodesis in a single surgical procedure, while 13 (28%) firstly removed knee arthroplasty and used a spacer before arthrodesis. Overall complication rate was 35%; 7 (15%) patients experienced persistent infection and 4 (9%) of these undergone
The purpose of this study is to report a unique overgrowth syndrome and discuss the insights into the complex orthopaedic management. Written consent to report this case was granted. The patient's condition, wrongly diagnosed as Proteus syndrome, is characterised by a genetic mutation in PIK3CA, a critical regulator of cell growth. This lead to unregulated cellular division of fibroblasts isolated to the lower limbs. The legs weighed 117 kg, with a circumference of >110 cm. In addition to lower limb overgrowth, numerous musculoskeletal and organ pathologies have been encountered since birth requiring treatment from a wide variety of healthcare specialists and basic scientists. At 32 years, the patient developed septicaemia secondary to an infected foot ulcer. Amputation had been discussed in the elective setting, however the presence of sepsis expedited surgery. The
Squamous Cell Carcinoma (SCC) is a rare complication of chronic osteomyelitis (OM), arising in a sinus tract (Marjolin's Ulcer). We routinely send samples for histological analysis for all longstanding sinus tracts in patients with chronic osteomyelitis. We reviewed the clinical features and outcomes of patients with SCC arising from chronic osteomyellitis. A retrospective study was performed of patients with osteomyelitis between January 2004 and December 2014 in a single tertiary referral centre. Clinical notes, microbiology and histo-pathological records were reviewed for patients who had squamous cell carcinoma associated with OM. We treated 9 patients with chronic osteomyelitis related squamous cell carcinoma. The mean age at time of diagnosis was 51 years (range 41–81 years) with 4 females and 5 males. The mean duration of osteomyelitis was 16.5 years (3–30 years) before diagnosis of SCC. SCC arose in osteomyelitis of the ischium in 5 patients, sacrum in 1 patient, femur in 1 patient and tibia in 2 patients. Osteomyelitis was due to pressure ulceration in 7 patients and post-traumatic infection in 2 patients. The histology showed well differentiated SCC in 4 cases and moderately differentiated SCC in 2 cases with invasion. Two patients had SCC with involvement of bone. One patient had metastatic SCC to bowel. All patients had polymicrobial or Gram-negative cultures from microbiology samples. Four patients (57%) in our series died as result of their cancer despite wide resection. The mean survival after diagnosis of SCC was 1.3 years and mean age at time of death was 44.7 years. Two of these patients had ischial disease and were treated with hip disarticulation, hemi-pelvectomy and iliac node clearance. Five patients remain disease free at a mean of 3.4 years (range 0.1 – 7yrs) after excision surgery. One patient in this group underwent a through-hip amputation, one underwent an
Background. Although soft tissue sarcoma (STS) is a rare malignancy, myxofibrosarcoma is a common form diagnosed. Myxofibrosarcoma is complicated by a high local recurrence rate (18–54%) and significant morbidity following treatment, hence management can be challenging. Patients and Methods. Patients treated between 2003–2012 were identified via a database within the histopathology department and case notes were retrospectively assessed. All histology samples were reviewed by a senior histopathologist to ensure a correct diagnosis. Results. 29 patients (12 male, 17 female) with an average age of 61 years (range 19–89 years) underwent surgery at a single centre, with 24 patients receiving adjuvant and two receiving neo-adjuvant radiotherapy. 22 patients had lower limb and 7 had upper limb tumours. 3 were treated for secondary recurrence after having primary surgery elsewhere. 21 patients had Trojani Grade 2 or 3 tumours. All underwent limb-sparing surgery initially but six patients (20.7%) suffered local recurrence after an average follow-up of 28 months and all ultimately required
There are special circumstances in which revision total knee arthroplasty is not an option. The relative indications for the alternatives to revision TKA are: - Recurrent deep infection - Immunocompromised patient - Extensor mechanism loss - Extensive, non-reconstructable soft tissue loss - High functional demand, young age Remember the three A's as alternatives to revision TKA: arthrodesis, arthroplasty (resection), and amputation. Successful arthrodesis requires elimination of infection, coaptation of bone surfaces and rigid immobilisation. The proper position for arthrodesis is 15 degrees of knee flexion to allow foot clearance. If bone loss is greater than 3 cm fuse the knee in full extension. Avoid hyperextension. Achieve 5 degrees of valgus in correct rotation and use intramedullary instruments from TKA sets for best cuts. External fixation techniques as well as intramedullary internal fixation techniques will be described. Resection arthroplasty is indicated for salvage of an infected total knee when the patient is not a candidate for reimplantation. These patients usually have extensive soft and hard tissue loss. Procedure may be well tolerated and functional. Ancillary support with a long leg drop- lock KAFO increases stability and provides motion. Patients finding resection unacceptable are more likely to accept fusion or amputation; therefore resection may be a staging procedure. Amputation is indicated for failed multiple revisions, intractable or life threatening infection. Also should be indicated when there is a low chance of a successful arthrodesis. Ablate at the lowest level for infection eradication but good maintenance of function. Pedicle muscle flaps can be useful to fill dead spaces. Remember, elderly patients have limited ambulation potential because of high energy requirements of
Full-thickness burns around the knee can involve the extensor mechanism. The gastrocnemius flap is well described for soft tissue reconstruction around the knee. We describe a method where a Whichita Fusion Nail¯ knee arthrodesis, combined with a medial gastrocnemius muscle flap was used to salvage the knee and preserve the lower leg following a full-thickness contact burn. The gastrocnemius flap for wound coverage of an open knee joint was originally described in 1970 and remains the workhorse for soft tissue knee reconstruction. There are a number of local alternatives including the vastus lateralis, medialis and sartorius flap; and perforator flaps such as the medial sural artery perforator island flap and islanded posterior calf perforator flap, however many of these are unsuitable for larger defects. Full-thickness burns around the knee can put the extensor mechanism at risk and subsequent rupture is a possible consequence. The gastrocnemius flap has been used to cover a medial knee defect with exposed joint cavity following a burn and also been used in post burn contracture release around the knee. The primary indication for Wichita fusion nail is a failed total knee replacement. It allows intramedullary stabilization with compression at the arthrodesis site to stimulate bone union. With fusion rates reported up to 100% and low complication rates as compared to other methods of fusion, the technique has a useful role in limb salvage type procedures. While use of the gastrocnemius flap in knee burns has been described before we believe this is the first time that this combination of techniques, namely knee arthrodesis with soft tissue reconstruction using a gastrocnemius flap, has been reported. Combining these procedures with a multidisciplinary approach provides a useful alternative leading to limb salvage and avoiding the need for an
Despite our best efforts, occasionally, certain patients will have multiply operated, failed reconstructions after TKA. There are situations where further attempts at arthroplasty are unwise, for example, chronic infections with multiple failed staged reconstructions. A careful pre-operative evaluation of the patient is critical to guide decision-making. An assessment of medical comorbidity, functional demands, and expectations is important. Regarding the extremity, the severity of bone loss, soft tissue defects, ligamentous competency, and neurovascular status is important. The next step is to determine whether the knee is infected. The details of such a workup are covered in other lectures, however, the author prefers to aspirate all such knees and obtain C reactive protein and sedimentation rates. For equivocal cases, PCR may be helpful. If no infection is present, complex reconstruction is considered. Segmental megaprosthesis and hinged prostheses may be helpful. Often, soft tissue reconstruction with an extensor mechanism allograft or muscle flap is required. Obviously, these are massive undertakings and should be done by experienced surgeons. If a prosthesis is not a good option, other options include definitive resection, knee arthrodesis, or
Introduction. We aim to assess the functional outcome, patient perceived satisfaction and implant survival at a mean follow up of 13[10–16] years following revision knee replacement. Patients and Methods. Between 1995 and 2001, 243 revision knee replacements were performed in 230 patients using Endolink [Link, Hamburg] or TC3 [Depuy, Leeds] prosthesis at Wrightington hospital, Wrightington, were consented to take part in this study. Data was collected prospectively which includes complications and functional assessment by Oxford knee score, WOMAC, HSS, UCLA, SF12 scores, and patient satisfaction questioner. The scores were obtained pre-operatively and post-operatively at 1 year, 5 years and at the latest follow-up. The mean age was 69 yrs, 51% were males, TC3 prosthesis as used in 175 and Endolink in 68, the revision was for Infection in 71[29%], 53 patients had intra-operative positive culture, 35 had 2 stage revision. Results. At a mean follow up of 13 years [10–16] the survival of revision knee replacement in our patient group is 86%. Further surgery was performed in 35[14%], which includes 5 patients who had
Introduction. We aim to assess the functional outcome, patient satisfaction and implant survival at a mean follow up of 13[10–16] years following revision for infected total knee replacement. Patients and Methods. Between 1995 and 2001, 71 revision knee replacements were performed for infection, at Wrightington hospital, Wrightington. Data was collected prospectively which includes intra-operative cultures, complications and functional assessment by Oxford knee score, WOMAC, HSS, UCLA, SF12 scores, and patient satisfaction questioner. The scores were obtained pre-operatively and post-operatively at 1 year, 5 years and at the latest follow-up. Mean age was 69 yrs, 70% were Females, 31[44%] had 2 stage revisions and intra-operative culture was positive in 53 patients. Most common organism was staphylococcus aureus in 30% and staphylococcus epidermides in 18%. Results. At a mean follow up of 13[10–16] years, the survival of revision knee replacement for infection in our patient group is 82%. 4 patients had
Despite our best efforts, occasionally, certain patients will have multiply operated, failed reconstructions after TKA. There are situations where further attempts at arthroplasty are unwise, for example, chronic infections with multiple failed staged reconstructions. A careful preoperative evaluation of the patient is critical to guide decision-making. An assessment of medical comorbidity, functional demands, and expectations is important. Regarding the extremity, the severity of bone loss, soft tissue defects, ligamentous competency, and neurovascular status is important. The next step is to determine whether the knee is infected. The details of such a workup are covered in other lectures, however, the author prefers to aspirate all such knees and obtain C reactive protein and Sedimentation Rates. For equivocal cases, PCR may be helpful. If no infection is present, complex reconstruction is considered. Segmental megaprosthesis and hinged prostheses may be helpful. Often, soft tissue reconstruction with an extensor mechanism allograft or muscle flap is required. Obviously, these are massive undertakings and should be done by experienced surgeons. If a prosthesis is not a good option, other options include definitive resection, knee arthrodesis, or
TKA (Total Knee Arthroplasty) is a successful operation. Soft tissue problems with TKA are difficult to treat. Flap surgery is successful in treating this problem and salvaging the prostheses. We present results of flap surgery for complicated TKAs over a ten year period, performed by a single surgeon. Between 1996 and 2005, 31 patients (32 knees) underwent flap surgeries for TKAs. Four of these procedures were done prophylactically in patients with previous knee surgeries. Gastrocnemius, medial fasciocutaneous and anterior compartment flaps were used either solely or in combination based on the size of the defect. The data was collected retrospectively from case-notes and correspondence from the treating orthopaedic surgeons. All the knees included in the study had a minimum follow up of 6 months. The patients were aged between 50 and 94 years. Indication for primary TKA was osteoarthritis in 26 patients and rheumatoid arthritis in 5. The index orthopaedic surgery was a primary knee arthroplasty in 14 and revision in 13. The average duration between the TKA and flap surgery was 11 weeks (range 1 – 52). Gastrocnemius was the most commonly used local flap (17 cases). Anterior compartment flap was used in 5 cases and in the rest combination of flaps was used. Coagulase -ve Staph. aureus was the most commonly isolated organism from the perioperative wound swabs. Successful soft tissue cover was achieved in 29 of 32 knees (92%). Overall, TKA was salvaged in 23 of 32 knees (72%) and 3 knees (9.7%) underwent arthrodesis. Three (9.7%) patients had
Infection after knee arthroplasty is a devastating complication. Our aim is to present our outcomes of treating infected knee replacements at a tertiary referral centre. We performed a consecutive, retrospective case series of all revision knee arthroplasty for infection between January 2006 and December 2008. Case notes were reviewed and data collated on the date and institution of primary arthroplasty, procedures undertaken at our institution, microbiology and bone loss post first stage, serological markers (C-reactive protein, ESR) prior to second stage and outcome. During this three year period we performed 430 knee revision operations. 51 were in the presence of deep chronic infection. 90% were referred from other hospitals. Overall infection was successfully eradicated in 69%. Nineteen patients underwent repeat two-stage and overall eleven (58%) patients had successful eradication of infection with multiple two-stages. Of these 47% had F3/T3, the highest grading of Anderson Orthopaedic Research Institute bone loss indicating no metaphyseal bone. A further 12% had bicondylar deficiency on the tibia and no femoral metaphyseal bone (F3/T2b). Multidrug resistance present in 69% and 47% were infected with multiple organisms. All members of the unsuccessful outcome group had at least one multidrug resistant organism compared to 43% in the successful cohort (P=0.0002). Multiple organisms are associated with an unsuccessful outcome (P=0.056). Serological markers were not significantly different between the successful and unsuccessful outcome groups. Where the referring hospital had attempted revision and failed, the chance of eradicating infection dropped from 75% to 58% and the rate of
Patients with
