Aims. The aim of this study was to characterize the factors leading to transfemoral amputation after total knee arthroplasty (TKA), as well as the rates of mortality and functional independence after this procedure in these patients. Patients and Methods. This was a multicentre retrospective review with a prospective telephone survey for the assessment of function. All patients with a TKA who subsequently required transfemoral amputation between January 2001 and December 2015 were included. Demographic information, medical comorbidities, and postoperative mortality data were collected. A 19-item survey was used for the assessment of function in surviving patients. Results. A total of 111 patients were included. Their mean age was 61.0 years (42.0 to 88.0) at the time of TKA, with a subsequent mean of 3.7 operations (0 to 15) over a mean period of 6.1 years (0.05 to 30.1) before amputation. The indication for amputation was chronic infection in 97 patients (87.4%). The rate of five-year survival was 51.7%, and advanced age (p = 0.001) and renal failure (p = 0.045) were associated with an increased risk of mortality. Of the 62 surviving patients, 34 completed the survey; 32 (94.1%) owned a prosthesis but only 19 (55.9%) used it; 19 (55.9%) primarily used a wheelchair for mobility; 27 (79.5%) had phantom pain; and 16 (47.1%) required chronic pain medication. Only 18 patients (52.9%) were satisfied with the quality of life. Conclusion. Patients with complications after TKA, in whom transfemoral amputation is considered, should be made aware of the high rate of mortality and the poor functional outcome in the survivors. Alternative forms of treatment including arthrodesis of the knee should be investigated

Aims. In cases of severe periprosthetic joint infection (PJI) of the knee, salvage procedures such as knee arthrodesis (KA) or above-knee amputation (AKA) must be considered. As both treatments result in limitations in quality of life (QoL), we aimed to compare outcomes and factors influencing complication rates, mortality, and mobility. Methods. Patients with PJI of the knee and subsequent KA or AKA between June 2011 and May 2021 were included. Demographic data, comorbidities, and patient history were analyzed. Functional outcomes and QoL were prospectively assessed in both groups with additional treatment-specific scores after AKA. Outcomes, complications, and mortality were evaluated. Results. A total of 98 patients were included, 52 treated with arthrodesis and 47 with AKA. The mean number of revision surgeries between primary arthroplasty and arthrodesis or AKA was 7.85 (SD 5.39). Mean follow-up was 77.7 months (SD 30.9), with a minimum follow-up of two years. Complications requiring further revision surgery occurred in 11.5% of patients after arthrodesis and in 37.0% of AKA patients. Positive intraoperative tissue cultures obtained during AKA was significantly associated with the risk of further surgical revision. Two-year mortality rate of arthrodesis was significantly lower compared to AKA (3.8% vs 28.3%), with age as an independent risk factor in the AKA group. Functional outcomes and QoL were better after arthrodesis compared to AKA. Neuropathic pain was reported by 19 patients after AKA, and only 45.7% of patients were fitted or were intended to be fitted with a prosthesis. One-year infection-free survival after arthrodesis was 88.5%, compared to 78.5% after AKA. Conclusion. Above-knee amputation in PJI results in high complication and mortality rates and poorer functional outcome compared to arthrodesis. Mortality rates after AKA depend on patient age and mobility, with most patients not able to be fitted with a prosthesis. Therefore, arthrodesis should be preferred whenever possible if salvage procedures are indicated. Cite this article: Bone Joint J 2024;106-B(7):669–679

Aims. Arthrodesis is rarely used as a salvage procedure for patients with a chronically infected total knee arthroplasty (TKA), and little information is available about the outcome. The aim of this study was to assess the reliability, durability, and safety of this procedure as the definitive treatment for complex, chronically infected TKA, in a current series of patients. Methods. We retrospectively identified 41 patients (41 TKAs) with a complex infected TKA, who were treated between 2002 and 2016 using a deliberate, two-stage knee arthrodesis. Their mean age was 64 years (34 to 88) and their mean body mass index (BMI) was 39 kg/m. 2. (25 to 79). The mean follow-up was four years (2 to 9). The extensor mechanism (EM) was deficient in 27 patients (66%) and flap cover was required in 14 (34%). Most patients were host grade B (56%) or C (29%), and limb grade 3 (71%), according to the classification of McPherson et al. A total of 12 patients (29%) had polymicrobial infections and 20 (49%) had multi-drug resistant organisms; fixation involved an intramedullary nail in 25 (61%), an external fixator in ten (24%), and dual plates in six (15%). Results. Survivorship free from amputation, persistent infection, and reoperation, other than removal of an external fixator, at five years was 95% (95% confidence interval (CI) 89% to 100%), 85% (95% CI 75% to 95%), and 64% (95% CI 46% to 82%), respectively. Reoperation, other than removal of an external fixator, occurred in 13 patients (32%). After the initial treatment, radiological nonunion developed in ten knees (24%). Nonunion was significantly correlated with persistent infection (p = 0.006) and external fixation (p = 0.005). Of those patients who achieved limb salvage, 34 (87%) remained mobile and 31 (79%) had ‘absent’ or ‘minimal’ pain ratings. Conclusion. Knee arthrodesis using a two-stage protocol achieved a survivorship free from amputation for persistent infection of 95% at five years with 87% of patients were mobile at final follow-up. However, early reoperation was common (32%). This is not surprising as this series included worst-case infected TKAs in which two-thirds of the patients had a disrupted EM, one-third required flap cover, and most had polymicrobial or multi-drug resistant organisms. Cite this article: Bone Joint J 2020;102-B(6 Supple A):170–175

Abstract. Aims. The primary aim of this study was to evaluate the outcomes of fungal knee periprosthetic joint infection following knee arthroplasty. The secondary aim was to evaluate risk factors for acquiring a fungal PJI. Patients and Methods. This was a retrospective analysis of patients presenting with a confirmed fungal PJI of the knee in two tertiary centres. There were a total of 45 cases. Isolated fungal infections along with mixed bacterial and fungal infections were included. Mean follow up was 40 months (range 3–118). Results. The mean age at presentation was 69 years (range 46 to 87) and mean BMI was 31 kg/m2 (range 20 to 44). The median number of procedures that patients had on the affected limb from the index primary arthroplasty procedure was 6 (range 2–17). The median procedure number at which a fungal infection was identified was 5 (range 2–10). A history of prolonged antibiotic therapy (above 6 months total) was present in 37 patients (88%). During the study period 22 patients were infection free, 14 treated with lifelong suppression, 7 had above knee amputations and 6 had died. Overall infection cure rate was 49%. Conclusions. Patients with fungal PJI are generally poor hosts with multiple co-morbidities, long term exposure to antibiotics and high rates of open wounds and sinuses. The poor outcome associated with fungal PJI relative to bacterial PJI should be shared with patients in order to manage the expectations of this complex cohort

Abstract. Introduction. Knee arthrodesis is one of the treatment options for limb salvage of a failed total knee replacement (TKR) when further revisions were contraindicated. The aim of this study is to determine patient outcomes after knee arthrodesis (KA) following a failed TKR. Methodology. A literature search was conducted for studies published from January 2000 through January 2022 via Medline, Web of Science, Embase and Cochrane databases. Only primary research studies were included with independent extraction of articles by two reviewers. Results were synthesised by narrative review according to PRISMA guidelines, with full tabulation of all included study results. Results. A total of 34 studies with 1,034 patients were included in the review; all were longitudinal observational studies, and none were conducted as randomised controlled trials. Reporting methods were very inconsistent in the included studies, and this heterogeneity led to pooled data totals that varied widely in different categories. The mean follow-up was 3.5 years. Overall, 72.0% (167 of 232) of patients used a walking stick and 12.5% (36 of 287) remained non-ambulatory after KA. Only 7.7% (58 of 752) of patients subsequently underwent above-knee amputation. Conclusion. KA is a potential limb salvage procedure after revision arthroplasties have been attempted in cases of failed TKR. Most patients were able to ambulate both at home and in the community, although with an increased rate of using a walking stick after the operation. However, in the absence of randomised controlled trials, these data may allow for a more accurate counselling and decision making

Aims. Our purpose was to describe an unusual series of 21 patients with fungal osteomyelitis after an anterior cruciate ligament reconstruction (ACL-R). Methods. We present a case-series of consecutive patients treated at our institution due to a severe fungal osteomyelitis after an arthroscopic ACL-R from November 2005 to March 2015. Patients were referred to our institution from different areas of our country. We evaluated the amount of bone resection required, type of final reconstructive procedure performed, and Musculoskeletal Tumor Society (MSTS) functional score. Results. A total of 21 consecutive patients were included in the study; 19 were male with median age of 28 years (IQR 25 to 32). All ACL-R were performed with hamstrings autografts with different fixation techniques. An oncological-type debridement was needed to control persistent infection symptoms. There were no recurrences of fungal infection after median of four surgical debridements (IQR 3 to 6). Five patients underwent an extensive curettage due to the presence of large cavitary lesions and were reconstructed with hemicylindrical intercalary allografts (HIAs), preserving the epiphysis. An open surgical debridement was performed resecting the affected epiphysis in 15 patients, with a median bone loss of 11 cm (IQR 11.5 to 15.6). From these 15 cases, eight patients were reconstructed with allograft prosthesis composites (APC); six with tumour-type prosthesis (TTP) and one required a femoral TTP in combination with a tibial APC. One underwent an above-the-knee amputation. The median MSTS functional score was 20 points at a median of seven years (IQR 5 to 9) of follow-up. Conclusion. This study suggests that mucormycosis infection after an ACL-R is a serious complication. Diagnosis is usually delayed until major bone destructive lesions are present. This may originate additional massive reconstructive surgeries with severe functional limitations for the patients. Level of evidence: IV. Cite this article: Bone Joint Open 2020;2(1):3–8

Aims. The integrity of the soft tissue envelope is crucial for successful treatment of infected total knee arthroplasty (TKA). The purpose of this study was to evaluate the rate of limb salvage, infection control, and clinical function following microvascular free flap coverage for salvage of the infected TKA. Methods. We retrospectively reviewed 23 microvascular free tissue transfers for management of soft tissue defects in infected TKA. There were 16 men and seven women with a mean age of 61.2 years (39 to 81). The median number of procedures performed prior to soft tissue coverage was five (2 to 9) and all patients had failed at least one two-stage reimplantation procedure. Clinical outcomes were measured using the Knee Society Scoring system for pain and function. Results. In all, one patient was lost to follow-up prior to 12 months. The remaining 22 patients were followed for a mean of 46 months (12 to 92). At latest follow-up, four patients (18%) had undergone amputation for failure of treatment and persistent infection. For the other 18 patients, 11 patients (50%) had maintained a knee prosthesis in place while seven patients had undergone resections for persistent infection but retained their limbs (32%). Reoperations were common following coverage and reimplantation. The median number of additional procedures was two (0 to 6). Clinical function was poor in patients who underwent reimplantation and retained a knee prosthesis following free flap coverage with a mean KSS score for pain and function of 44 (0 to 70) and 30 (0 to 65), respectively. All patients required an assistive device. Extensor mechanism problems and extensor lag requiring bracing were common following limb salvage and prosthesis reimplantation. Conclusion. Microvascular tissue transfer for management of infected TKA can be successful in limb salvage (82%) but clinical outcomes in salvaged limbs were poor. Cite this article: Bone Joint J 2020;102-B(6 Supple A):176–180

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Periprosthetic joint infection (PJI) is a challenging complication of any arthroplasty procedure. We reviewed our use of static antibiotic-loaded cement spacers (ABLCSs) for staged management of PJI where segmental bone loss, ligamentous instability, or soft-tissue defects necessitate a static construct. We reviewed factors contributing to their failure and techniques to avoid these complications when using ABLCSs in this context.

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To map literature on prognostic factors related to outcomes of revision total knee arthroplasty (rTKA), to identify extensively studied factors and to guide future research into what domains need further exploration.

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Achievement of accurate microbiological diagnosis prior to revision is key to reducing the high rates of persistent infection after revision knee surgery. The effect of change in the microorganism between the first- and second-stage revision of total knee arthroplasty for periprosthetic joint infection (PJI) on the success of management is not clear.

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Fungal periprosthetic joint infections (PJIs) are rare, but their diagnosis and treatment are highly challenging. The purpose of this study was to investigate the clinical outcomes of patients with fungal PJIs treated with two-stage exchange knee arthroplasty combined with prolonged antifungal therapy.

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Tibial tubercle osteotomy (TTO) facilitates surgical exposure and protects the extensor mechanism during revision total knee arthroplasty (rTKA). The purpose of this study was to determine the rates of bony union, complications, and reoperations following TTO during rTKA, to assess the functional outcomes of rTKA with TTO at two years’ minimum follow-up, and to identify the risk factors of failure.

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This study aims to determine the rate of and risk factors for total knee arthroplasty (TKA) after operative management of tibial plateau fractures (TPFs) in older adults.

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Endoprosthetic reconstruction with a distal femoral arthroplasty (DFA) can be used to treat distal femoral bone loss from oncological and non-oncological causes. This study reports the short-term implant survivorship, complications, and risk factors for patients who underwent DFA for non-neoplastic indications.

Introduction. Infection following TKA can be a catastrophic complication that can cause significant pain, morbidity and jeopardize limb viability. The integrity of the soft tissue envelope is critical to successful treatment and infection control. While local tissue flaps can provide adequate coverage for most soft tissue defects around the knee, there are cases that require salvage using microvascular free tissue transfers. The purpose of this study is to evaluate the 1) rate of limb salvage; 2) infection control; and 3) clinical function following free flap coverage for salvage of the infected TKA. Materials and Methods. We retrospectively reviewed 23 microvascular free tissue transfers for management of soft tissue defects in infected TKA. There were 16 men and 7 women with a mean age of 61.2 years (range 39–81). The median number of procedures performed prior to soft tissue coverage was 5 (range 2–9) and all patients had failed at least one 2 stage reimplantation procedure. Clinical outcomes were measured using the Knee Society Scoring system for pain and function. The rate of limb salvage and infection control were recorded. Results. One patient was lost to follow up prior to 12 months. The remainder 22 patients were followed for a mean of 46 months (range 12–92 months). At latest follow up, 4 patients (18%) had undergone amputation for failure of treatment and persistent infection. For the remainder 18 patients, 11 patients (50%) have maintained a knee prosthesis in place while 7 patients had undergone resections for persistent infection but maintained their limbs (32%). Reoperations were common following coverage and reimplantation procedure. The median number of additional procedures was 2 (range 0–6). Clinical function was poor in patients who were reimplanted and retained a knee prosthesis following free flap coverage with a mean KSS score for pain and function of 44 (range 0–70) and 30 (range 0–65). All patients required an assistive device. Extensor mechanism problems and extensor lag requiring bracing were common following limb salvage and prosthesis reimplantation. Conclusions. Microvascular tissue transfer for management of infected TKA can be successful in limb salvage (81%) but clinical outcomes in salvaged limbs were poor. The data should be used to counsel patients when contemplating limb salvage in these severe, end-stage cases. For figures, tables, or references, please contact authors directly

Introduction. While knee arthrodesis is a salvage option for recalcitrant total knee arthroplasty (TKA) periprosthetic joint infection (PJI) it is used relatively uncommonly and contemporary data are limited. We sought to determine the reliability, durability and safety of knee arthrodesis as the definitive treatment for complex, persistently infected TKA in a modern series of patients. Methods. We retrospectively identified 41 knees treated from 2002–2016 with a deliberate, two-stage knee arthrodesis protocol (TKA resection, high-dose antibiotic spacer, targeted IV antibiotics and followed by subsequent knee arthrodesis) in patients with complex TKA PJI. Mean age was 64 years & mean BMI was 39 kg/m. 2. Mean follow-up was 4 years. The extensor mechanism was deficient in 66% of knees, and flap coverage was required in 34% of knees. The majority of patients were host grade B (56%) or C (29%), and extremity grade of 3 (71%). Twenty-nine percent had poly-microbial infections, and 49% had multi-drug resistant organisms. Fixation included intramedullary nail (61%), external fixator (24%), and dual plating (15%). Results. Two patients (5%) required amputation for persistently infected non-unions; therefore, limb salvage was accomplished in 95% of patients. After initial treatment, there were non-unions in 24% and persistent infection in 17%. Non-union was significantly correlated with persistent infection, with 50% of non-unions having persistent infection compared with just 6% of united knees (p=0.006). External fixation was a significant risk factor for non-union (70%) compared to intramedullary fixation (8%; p=0.005). Overall, twenty-seven complications occurred in 20 patients and 31% required reoperation other than external fixator removal. Intramedullary fixation led to a 90% rate of both infection control and radiographic union. Conclusion. Two-stage knee arthrodesis using a deliberate protocol (resection, high-dose abx spacer, targeted IV abx, and subsequent arthrodesis) ultimately achieved successful limb salvage in 95% of patients with complex infected TKA. One or more complications occurred in nearly half the patients and reoperation was required for 1-in-3. That substantial risk of complications is not surprising as this large contemporary series included complex, worst-case infected TKA in which: 2/3 had disrupted extensor mechanism, 1/3 required flap coverage, and the majority had poly-microbial or multi-drug resistant organisms. Summary. For contemporary patients with very complex, infected TKA a two-stage knee arthrodesis was reliable in achieving limb salvage (95%) at the cost of a high initial complication and reoperation rate. For figures, tables, or references, please contact authors directly

Knee arthrodesis is a potential salvage procedure for limb preservation after failure of total knee arthroplasty (TKA) due to infection. In this study, we evaluated the outcome of single-stage knee arthrodesis using an intramedullary cemented coupled nail without bone-on-bone fusion after failed and infected TKA with extensor mechanism deficiency. Between 2002 and 2012, 27 patients (ten female, 17 male; mean age 68.8 years; 52 to 87) were treated with septic single-stage exchange. Mean follow-up duration was 67.1months (24 to 143, n = 27) (minimum follow-up 24 months) and for patients with a minimum follow-up of five years 104.9 (65 to 143,; n = 13). A subjective patient evaluation (Short Form (SF)-36) was obtained, in addition to the Visual Analogue Scale (VAS). The mean VAS score was 1.44 (SD 1.48). At final follow-up, four patients had recurrent infections after arthrodesis (14.8%). Of these, three patients were treated with a one-stage arthrodesis nail exchange; one of the three patients had an aseptic loosening with a third single-stage exchange, and one patient underwent knee amputation for uncontrolled sepsis at 108 months. All patients, including the amputee, indicated that they would choose arthrodesis again. Data indicate that a single-stage knee arthrodesis offers an acceptable salvage procedure after failed and infected TKA. Cite this article: Bone Joint J 2015;97-B:649–53

Introduction. Total Knee Arthroplasty (TKA) in high risk patients may result in numerous post-operative complications that may ultimately lead to above knee amputation (AKA). There is a paucity of literature regarding AKA in patients with prior TKA. We sought to characterize the factors leading to AKA, as well as patient functional and clinical outcomes post-operatively, with the hypothesis that minimal activity would be achieved. Methods. This is a multicenter retrospective review for patient identification, with prospective telephone survey completion for assessment of functional status. All patients from January 2001 to December 2015 with AKA and prior TKA at two academic centers were included for possible survey enrollment. Demographic information and medical comorbidities were collected, in addition to perioperative and post-operative mortality data. A 23-item survey was provided to all available patients and analyzed for patient functional status. Results. 112 patients with AKA following TKA were included for analysis with mean age 60.6 (11.5) years at TKA, with 3.7 (3.14) surgeries over 6.0 (6.3) years prior to AKA. The most common medical comorbidities were cardiac disease (64.3%), renal insufficiency (34.8%), and atherosclerosis (26.8%). Indications for AKA were multifactorial, however, were primarily driven by infection (87.5%) and vascular disease (10.7%). At the time of the survey, 49 (43.8%) patients were deceased and the 5-year survival rate was 60.2% (figure I). 34 (30.4%) patients were enrolled for survey completion. Of the respondents, 32 (94.1%) reported owning a prosthesis but only 19 (55.9%) reported wearing it, and 19 (55.9%) primarily used a wheelchair for mobility. 27 (79.5%) noted phantom pain with 16 (47.1%) requiring chronic medication. Overall, only 18 patients (52.9%) were satisfied with their quality of life. Discussion and Conclusion. TKA patients often undergo multiple surgeries over many years prior to AKA. Following this procedure, there is a high mortality rate; for patients surviving, almost half are dissatisfied with their quality of life, and low functional status is observed. TKA patients that might be considered candidates for AKA should be made aware the expected clinical and functional outcomes. For any figures or tables, please contact authors directly

Most patients (95%) with fibular hemimelia have an absent anterior cruciate ligament (ACL). The purpose of this study was to assess the long-term outcome of such patients with respect to pain and knee function. We performed a retrospective review of patients with fibular hemimelia and associated ACL deficiency previously treated at our institution. Of a possible 66 patients, 23 were sent the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) questionnaire and Lysholm knee score to complete. In all, 11 patients completed the MODEMS and nine completed the Lysholm score questionnaire. Their mean age was 37 years (27 to 57) at review. Five patients had undergone an ipsilateral Symes amputation. There was no significant difference in any subsections of the Short-Form 36 scores of our patients compared with age-matched controls. The mean Lysholm knee score was 90.2 (82 to 100). A slight limp was reported in six patients. No patients had episodes of locking of the knee or required a supportive device for walking. Four had occasional instability with sporting activities. . These results suggest that patients with fibular hemimelia and ACL deficiency can live active lives with a similar health status to age-matched controls

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Infection complicating primary total knee arthroplasty (TKA) is a common reason for revision surgery, hospital readmission, patient morbidity, and mortality. Increasing incidence of methicillin-resistant Staphylococcus aureus (MRSA) is a particular concern. The use of vancomycin as prophylactic agent alone or in combination with cephalosporin has not demonstrated lower periprosthetic joint infection (PJI) rates, partly due to timing and dosing of intravenous (IV) vancomycin administration, which have proven important factors in effectiveness. This is a retrospective review of a consecutive series of primary TKAs examining incidence of PJI, adverse reactions, and complications using IV versus intraosseous (IO) vancomycin at 30-day, 90-day, and one-year follow-up.