The December 2015 Knee Roundup360 looks at: Albumin and complications in knee arthroplasty; Tantalum: a knee fixation for all seasons?; Dynamic knee alignment; Tibial component design in UKA; Managing the tidal wave of revision knee arthroplasty; Scoring pain in TKR; Does anyone have a ‘normal’ tibial slope?; XLPE in TKR? A five-year clinical study; Spacers and infected revision arthroplasties; Dialysis and arthroplasty
In this paper we make the case for the use of
single-stage revision for infected knee arthroplasty.
Antibiotic impregnated articulating spacers are
used in two-stage revision total knee arthroplasty to deliver local antibiotic
therapy while preserving function. We have observed infection control
in greater than 95% of cases with functional outcomes approaching
those seen in revision for aseptic loosening. Higher failure has
been observed with methicillin resistant organisms.
Bactericidal levels of antibiotics are difficult
to achieve in infected total joint arthroplasty when intravenous antibiotics
or antibiotic-loaded cement spacers are used, but intra-articular
(IA) delivery of antibiotics has been effective in several studies.
This paper describes a protocol for IA delivery of antibiotics in
infected knee arthroplasty, and summarises the results of a pharmacokinetic
study and two clinical follow-up studies of especially difficult
groups: methicillin-resistant Cite this article:
The timing of total hip replacement (THR) in
patients with active tuberculosis (TB) of the hip is controversial, because
of the potential risk of reactivation of infection. There is little
information about the outcome of THR in these patients. We conducted
a systematic review of published studies that evaluated the outcome
of THR in patients with active TB of the hip. A review of multiple
databases referenced articles published between 1950 and 2012. A
total of six articles were identified, comprising 65 patients. TB
was confirmed histologically in all patients. The mean follow-up
was 53.2 months (24 to 108). Antituberculosis treatment continued
post-operatively for between six and 15 months, after debridement
and THR. One non-compliant patient had reactivation of infection.
At the final follow-up the mean Harris hip score was 91.7 (56 to
98). We conclude that THR in patients with active TB of the hip
is a safe procedure, providing symptomatic relief and functional
improvement if undertaken in association with extensive debridement
and appropriate antituberculosis treatment. Cite this article:
This was a retrospective analysis of the medium-
to long-term results of 46 TC3 Sigma revision total knee replacements
using long uncemented stems in press-fit mode. Clinical and radiological analysis took place pre-operatively,
at two years post-operatively, and at a mean follow-up of 8.5 years
(4 to 12). The mean pre-operative International Knee Society (IKS)
clinical score was 42 points (0 to 74), improving to 83.7 (52 to
100) by the final follow-up. The mean IKS score for function improved
from 34.3 points (0 to 80) to 64.2 (15 to 100) at the final follow-up.
At the final follow-up 30 knees (65.2%) had an excellent result, seven
(15.2%) a good result, one (2.2%) a medium and eight (17.4%) a poor
result. There were two failures, one with anteroposterior instability
and one with aseptic loosening. The TC3 revision knee system, when used with press-fit for long
intramedullary stems and cemented femoral and tibial components,
in both septic and aseptic revisions, results in a satisfactory
clinical and radiological outcome, and has a good medium- to long-term
survival rate.
This review summarises the opinions and conclusions
reached from a symposium on infected total knee replacement (TKR)
held at the British Association of Surgery of the Knee (BASK) annual
meeting in 2011. The National Joint Registry for England and Wales
reported 5082 revision TKRs in 2010, of which 1157 (23%) were caused
by infection. The diagnosis of infection beyond the acute post-operative
stage relies on the identification of the causative organism by
aspiration and analysis of material obtained at arthroscopy. Ideal
treatment then involves a two-stage surgical procedure with extensive
debridement and washout, followed by antibiotics. An articulating
or non-articulating drug-eluting cement spacer is used prior to
implantation of the revision prosthesis, guided by the serum level
of inflammatory markers. The use of a single-stage revision is gaining popularity
and we would advocate its use in certain patients where the causative
organism is known, no sinuses are present, the patient is not immunocompromised,
and there is no radiological evidence of component loosening or
osteitis. It is our opinion that single-stage revision produces high-quality
reproducible results and will soon achieve the same widespread acceptance
as it does in infected hip arthroplasty.
Periprosthetic infection following total hip replacement can be a catastrophic complication for the patient. The treatments available include single-stage exchange, and two-stage exchange. We present a series of 50 consecutive patients with a diagnosis of infected total hip replacement who were assessed according to a standardised protocol. Of these, 11 underwent single-stage revision arthroplasty with no recurrence of infection at a mean of 6.8 years follow-up (5.5 to 8.8). The remaining 39 underwent two-stage revision, with two recurrences of infection successfully treated by a second two-stage procedure. At five years, significant differences were found in the mean Harris Hip Scores (single-stage 87.8; two-stage 75.5; p = 0.0003) and in a visual analogue score for satisfaction (8.6; 6.9; p = 0.001) between the single- and two-stage groups. Single-stage exchange is successful in eradicating periprosthetic infection and results in excellent functional and satisfaction scores. Identification of patients suitable for the single-stage procedure allows individualisation of care and provides as many as possible with the correct strategy in successfully tackling their periprosthetic infection
We report the outcome at ten to 15 years of two-stage revision for hip infection in 99 patients using the Prostalac articulated hip spacer system. All the patients were contacted to determine their current functional and infection status using the Oxford-12, Short form-12, and Western Ontario and McMaster University Osteoarthritis Index questionnaires. A total of 11 of the 99 patients had a further infection, of whom seven responded to repeat surgery with no further sequelae. The mean interval between the stages was five months (1 to 36). We were able to review 48 living patients, with a mean age of 72 years (46 to 86), 34 (71%) of whom provided health-related quality-of-life outcome scores. The mean follow-up was 12 years (10 to 15). The long-term success rate was 89% and with additional surgery this rose to 96%. The mean global Western Ontario and McMaster University Osteoarthritis Index score was 80.6 ( Two-stage revision for hip infection using a Prostalac interim spacer offers a predictable and lasting solution for patients with this difficult problem.
Infection of a total hip replacement (THR) requires component removal and thorough local debridement. Usually, long-term antibiotic treatment in conjunction with a two-stage revision is required. This may take several months. One-stage revision using antibiotic-loaded cement has not gained widespread use, although the clinical and economic advantages are obvious. Allograft bone may be impregnated with high levels of antibiotics, and in revision of infected THR, act as a carrier providing a sustained high local concentration. We performed 37 one-stage revision of infected THRs, without the use of cement. There were three hips which required further revision because of recurrent infection, the remaining 34 hips (92%) stayed free from infection and stable at a mean follow-up of 4.4 years (2 to 8). No adverse effects were identified. Incorporation of bone graft was comparable with unimpregnated grafts. Antibiotic-impregnated allograft bone may enable reconstruction of bone stock, insertion of an uncemented implant and control of infection in a single operation in revision THR for infection.
We have carried out in 24 patients, a two-stage revision arthroplasty of the hip for infection with massive bone loss. We used a custom-made, antibiotic-loaded cement prosthesis as an interim spacer. Fifteen patients had acetabular deficiencies, eight had segmental femoral bone loss and one had a combined defect. There was no recurrence of infection at a mean follow-up of 4.2 years (2 to 7). A total of 21 patients remained mobile in the interim period. The mean Merle D’Aubigné and Postel hip score improved from 7.3 points before operation to 13.2 between stages and to 15.8 at the final follow-up. The allograft appeared to have incorporated into the host bone in all patients. Complications included two fractures and one dislocation of the cement prosthesis. The use of a temporary spacer maintains the function of the joint between stages even when there is extensive loss of bone. Allograft used in revision surgery after septic conditions restores bone stock without the risk of recurrent infection.