Aims. Intra-articular administration of antibiotics during primary total knee arthroplasty (TKA) may represent a safe, cost-effective strategy to reduce the risk of acute periprosthetic joint infection (PJI).
Aims. 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
Aims. The aim of this study was to determine if the local delivery of
Aims. The management of periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) is challenging. The correct antibiotic management remains elusive due to differences in epidemiology and resistance between countries, and reports in the literature. Before the efficacy of surgical treatment is investigated, it is crucial to analyze the bacterial strains causing PJI, especially for patients in whom no organisms are grown. Methods. A review of all revision TKAs which were undertaken between 2006 and 2018 in a tertiary referral centre was performed, including all those meeting the consensus criteria for PJI, in which organisms were identified. Using a cluster analysis, three chronological time periods were created. We then evaluated the antibiotic resistance of the identified bacteria between these three clusters and the effectiveness of our antibiotic regime. Results. We identified 129 PJIs with 161 culture identified bacteria in 97 patients. Coagulase-negative staphylococci (CNS) were identified in 46.6% cultures, followed by Staphylococcus aureus in 19.8%. The overall resistance to antibiotics did not increase significantly during the study period (p = 0.454). However, CNS resistance to teicoplanin (p < 0.001), fosfomycin (p = 0.016), and tetracycline (p = 0.014) increased significantly.
Aims. The aims of this study were to compare the mean duration of antibiotic release and the mean zone of inhibition between vancomycin-loaded porous tantalum cylinders and antibiotic-loaded bone cement at intervals, and to evaluate potential intrinsic antimicrobial properties of tantalum in an in vitro medium environment against methicillin-sensitive Staphylococcus aureus (MSSA). Materials and Methods. Ten porous tantalum cylinders and ten cylinders of cement were used. The tantalum cylinders were impregnated with
Aims. Despite recent literature questioning their use,
Aims. Debridement, antibiotics, and implant retention (DAIR) remains one option for the treatment of acute periprosthetic joint infection (PJI) despite imperfect success rates. Intraosseous (IO) administration of
Aims. The aim of this study was to compare the ability of tantalum, 3D porous titanium, antibiotic-loaded bone cement, and smooth titanium alloy to inhibit staphylococci in an in vitro environment, based on the evaluation of the zone of inhibition (ZOI). The hypothesis was that there would be no significant difference in the inhibition of methicillin-sensitive or methicillin-resistant Staphylococcus aureus (MSSA/MRSA) between the two groups. Methods. A total of 30 beads made of three different materials (tantalum/3D porous titanium and smooth titanium alloy) were bathed for one hour in a solution of 1 g
Two-stage revision surgery for infected total knee replacement offers the highest rate of success for the elimination of infection. The use of articulating antibiotic-laden cement spacers during the first stage to eradicate infection also allows protection of the soft tissues against excessive scarring and stiffness. We have investigated the effect of cyclical loading of cement spacers on the elution of antibiotics. Femoral and tibial spacers containing
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. We reviewed our institutional joint arthroplasty database and identified 41 patients diagnosed with fungal PJIs and treated with two-stage exchange arthroplasty after primary total knee arthroplasty (TKA) between January 2001 and December 2020, and compared them with those who had non-fungal PJIs during the same period. After propensity score matching based on age, sex, BMI, American Society of Anesthesiologists grade, and Charlson Comorbidity Index, 40 patients in each group were successfully matched. The surgical and antimicrobial treatment, patient demographic and clinical characteristics, recurrent infections, survival rates, and relevant risk factors that affected joint survivorship were analyzed. We defined treatment success as a well-functioning arthroplasty without any signs of a PJI, and without antimicrobial suppression, at a minimum follow-up of two years from the time of reimplantation.Aims
Methods
Single-stage revision total knee arthroplasty (rTKA) is gaining popularity in treating chronic periprosthetic joint infections (PJIs). We have introduced this approach to our clinical practice and sought to evaluate rates of reinfection and re-revision, along with predictors of failure of both single- and two-stage rTKA for chronic PJI. A retrospective comparative cohort study of all rTKAs for chronic PJI between 1 April 2003 and 31 December 2018 was undertaken using prospective databases. Patients with acute infections were excluded; rTKAs were classified as single-stage, stage 1, or stage 2 of two-stage revision. The primary outcome measure was failure to eradicate or recurrent infection. Variables evaluated for failure by regression analysis included age, BMI, American Society of Anesthesiologists grade, infecting organisms, and the presence of a sinus. Patient survivorship was also compared between the groups.Aims
Methods
We propose a state-of-the-art temporary spacer, consisting of a cobalt-chrome (CoCr) femoral component and a gentamicin-eluting ultra-high molecular weight polyethylene (UHMWPE) tibial insert, which can provide therapeutic delivery of gentamicin, while retaining excellent mechanical properties. The proposed implant is designed to replace conventional spacers made from bone cement. Gentamicin-loaded UHMWPE was prepared using phase-separated compression moulding, and its drug elution kinetics, antibacterial, mechanical, and wear properties were compared with those of conventional gentamicin-loaded bone cement.Aims
Methods
Our objective is to describe our early and mid-term results with the use of a new simple primary knee prosthesis as an articulating spacer in planned two-stage management for infected knee arthroplasty. As a second objective, we compared outcomes between the group with a retained first stage and those with a complete two-stage revision. We included 47 patients (48 knees) with positive criteria for infection, with a minimum two-year follow-up, in which a two-stage approach with an articulating spacer with new implants was used. Patients with infection control, and a stable and functional knee were allowed to retain the initial first-stage components. Outcomes recorded included: infection control rate, reoperations, final range of motion (ROM), and quality of life assessment (QoL) including Western Ontario and McMaster Universities osteoarthritis index, Knee Injury and Osteoarthritis Outcome Score, Oxford Knee Score, 12-Item Short-Form Health Survey questionnaire, and University of California Los Angeles (UCLA) activity score and satisfaction score. These outcomes were evaluated and compared to additional cohorts of patients with retained first-stage interventions and those with a complete two-stage revision. Mean follow-up was 3.7 years (2.0 to 6.5).Aims
Methods
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. 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/m2 (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%).Aims
Methods
Metaphyseal fixation during revision total knee arthroplasty (TKA) is important, but potentially difficult when using historical designs of cone. Material and manufacturing innovations have improved the size and shape of the cones which are available, and simplified the required bone preparation. In a large series, we assessed the implant survivorship, radiological results, and clinical outcomes of new porous 3D-printed titanium metaphyseal cones featuring a reamer-based system. We reviewed 142 revision TKAs in 139 patients using 202 cones (134 tibial, 68 femoral) which were undertaken between 2015 and 2016. A total of 60 involved tibial and femoral cones. Most cones (149 of 202; 74%) were used for Type 2B or 3 bone loss. The mean age of the patients was 66 years (44 to 88), and 76 (55 %) were female. The mean body mass index (BMI) was 34 kg/m2 (18 to 60). The patients had a mean of 2.4 (1 to 8) previous operations on the knee, and 68 (48%) had a history of prosthetic infection. The mean follow-up was 2.4 years (2 to 3.6).Aims
Methods
The aim of this study was to assess the effects of transferring patients to a specialized arthroplasty centre between the first and second stages (interstage) of prosthetic joint infection (PJI) of the knee. A search of our institutional database was performed to identify patients having undergone two-stage revision total knee arthroplasty (TKA) for PJI. Two cohorts were created: continuous care (CC) and transferred care (TC). Baseline characteristics and outcomes were collected and compared between cohorts.Aims
Patients and Methods
The rate of peri-prosthetic infection following
total joint replacement continues to rise, and attempts to curb
this trend have included the use of antibiotic-loaded bone cement
at the time of primary surgery. We have investigated the clinical-
and cost-effectiveness of the use of antibiotic-loaded cement for
primary total knee replacement (TKR) by comparing the rate of infection
in 3048 TKRs performed without loaded cement over a three-year period The absolute rate of infection increased when antibiotic-loaded
cement was used in TKR. However, this rate of increase was less
than the rate of increase in infection following uncemented THR
during the same period. If the rise in the rate of infection observed
in THR were extrapolated to the TKR cohort, 18 additional cases
of infection would have been expected to occur in the cohort receiving
antibiotic-loaded cement, compared with the number observed. Depending
on the type of antibiotic-loaded cement that is used, its cost in
all primary TKRs ranges between USD $2112.72 and USD $112 606.67
per case of infection that is prevented. Cite this article:
The aim of this study was to identify risk factors for prosthetic
joint infection (PJI) following total knee arthroplasty (TKA). The New Zealand Joint Registry database was analysed, using revision
surgery for PJI at six and 12 months after surgery as primary outcome
measures. Statistical associations between revision for infection,
with common and definable surgical and patient factors were tested.Aims
Patients and Methods
Structural allografts may be used to manage uncontained
bone defects in revision total knee replacement (TKR). However,
the availability of cadaver grafts is limited in some areas of Asia.
The aim of this study was to evaluate the mid-term outcome of the
use of femoral head allografts for the reconstruction of uncontained
defects in revision TKR, focusing on complications related to the
graft. We retrospectively reviewed 28 patients (30 TKRs) with Anderson
Orthopaedic Research Institute (AORI) type 3 bone defects, who underwent
revision using femoral head allografts and stemmed components. The
mean number of femoral heads used was 1.7 (1 to 3). The allograft–host
junctions were packed with cancellous autograft. At a mean follow-up of 76 months (38 to 136) the mean American
Knee Society knee score improved from 37.2 (17 to 60) pre-operatively
to 90 (83 to 100) (p <
0.001). The mean function score improved
from 26.5 (0 to 50) pre-operatively to 81 (60 to 100) (p <
0.001).
All the grafts healed to the host bone. The mean time to healing
of the graft was 6.6 months
(4 to 16). There have been no complications of collapse of the graft,
nonunion, infection or implant loosening. No revision surgery was
required. The use of femoral head allografts in conjunction with a stemmed
component and autogenous bone graft in revision TKR in patients
with uncontained bone defects resulted in a high rate of healing
of the graft with minimal complications and a satisfactory outcome.
Longer follow-up is needed to observe the evolution of the graft. Cite this article:
A soft-tissue defect over an infected total knee
replacement (TKR) presents a difficult technical problem that can
be treated with a gastrocnemius flap, which is rotated over the
defect during the first-stage of a revision procedure. This facilitates
wound healing and the safe introduction of a prosthesis at the second
stage. We describe the outcome at a mean follow-up of 4.5 years
(1 to 10) in 24 patients with an infected TKR who underwent this procedure.
A total of 22 (92%) eventually obtained a satisfactory result. The
mean Knee Society score improved from 53 pre-operatively to 103
at the latest follow-up (p <
0.001). The mean Western Ontario
and McMaster Universities osteoarthritis index and Short-Form 12
score also improved significantly (p <
0.001). This form of treatment can be used reliably and safely to treat
many of these complex cases where control of infection, retention
of the components and acceptable functional recovery are the primary
goals. Cite this article:
In this paper we make the case for the use of
single-stage revision for infected knee arthroplasty.
All major studies have incorporated the use of prolonged courses of parenteral or oral antibiotic therapy in the management of two-stage revision of an infected total knee arthroplasty. We present a series of 59 consecutive patients, all with microbiologically-proven deep infection of a total knee arthroplasty, in whom a prolonged course of antibiotic therapy was not routinely used. The mean follow-up was 56.4 months (24 to 114). Of the 38 patients who underwent a staged exchange, infection was successfully eradicated in 34 (89%) but recurrent or persistent infection was present in four (11%). Our rate of cure for infection is similar to that reported elsewhere. We conclude that a prolonged course of antibiotic therapy seems not to alter the incidence of recurrent or persistent infection. The costs of the administration of antibiotics are high and such a regime may be unnecessary.
Satisfactory primary wound healing following
total joint replacement is essential. Wound healing problems can
have devastating consequences for patients. Assessment of their healing
capacity is useful in predicting complications. Local factors that
influence wound healing include multiple previous incisions, extensive
scarring, lymphoedema, and poor vascular perfusion. Systemic factors
include diabetes mellitus, inflammatory arthropathy, renal or liver
disease, immune compromise, corticosteroid therapy, smoking, and
poor nutrition. Modifications in the surgical technique are necessary
in selected cases to minimise potential wound complications. Prompt
and systematic intervention is necessary to address any wound healing
problems to reduce the risks of infection and other potential complications. Cite this article:
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.
We present a series of 48 patients with infected total knee replacements managed by the use of articulating cement spacers and short-term parenteral antibiotic therapy in the postoperative period. All patients had microbiological and/or histological confirmation of infection at the first stage of their revision. They all underwent re-implantation and had a mean follow-up of 48.5 months (26 to 85). Infection was successfully eradicated in 42 of the 48 patients (88%). Six had persistent infection which led to recurrence of symptoms and further surgery was successful in eliminating infection in four patients. These rates of success are similar to those of other comparable series. We conclude that protracted courses of intravenous antibiotic treatment may not be necessary in the management of the infected total knee replacement. In addition, we analysed the microbiological, histological and serological results obtained at the time of re-implantation of the definitive prosthesis, but could not identify a single test which alone would accurately predict a successful outcome.
This retrospective study evaluated the midterm clinical and radiographic outcomes of a second-generation total knee replacement system. In a multicentre consecutive series of 1512 patients, 1970 knees were treated with the PFC Sigma knee system (Depuy, Warsaw, Indiana). The patients were reviewed for functional outcome, and underwent independent radiographic evaluation at a mean follow-up of 7.3 years (5 to 10). A total of 40 knees (2%) required revision, 17 (0.9%) for infection. The incidence of osteolysis was 2.2%. The ten-year survival with revision for any cause other than infection as the endpoint was 97.2% (95% CI 95.4 to 99.1). The PFC Sigma knee system appears to provide excellent results in the medium term.
It is unclear whether there is a limit to the amount of distal bone required to support fixation of supracondylar periprosthetic femoral fractures. This retrospective multicentre study evaluated lateral locked plating of periprosthetic supracondylar femoral fractures and compared the results according to extension of the fracture distal with the proximal border of the femoral prosthetic component. Between 1999 and 2008, 89 patients underwent lateral locked plating of a supracondylar periprosthetic femoral fracture, of whom 61 patients with a mean age of 72 years (42 to 96) comprising 53 women, were available after a minimum follow-up of six months or until fracture healing. Patients were grouped into those with fractures located proximally (28) and those with fractures that extended distal to the proximal border of the femoral component (33). Delayed healing and nonunion occurred respectively in five (18%) and three (11%) of more proximal fractures, and in two (6%) and five (15%) of the fractures with distal extension (p = 0.23 for delayed healing; p = 0.72 for nonunion, Fisher’s exact test). Four construct failures (14%) occurred in more proximal fractures, and three (9%) in fractures with distal extension (p = 0.51). Of the two deep infections that occurred in each group, one resolved after surgical debridement and antibiotics, and one progressed to a nonunion. Extreme distal periprosthetic supracondylar fractures of the femur are not a contra-indication to lateral locked plating. These fractures can be managed with internal fixation, with predictable results, similar to those seen in more proximal fractures.